Post-exposure prophylaxis (PEP) for HIV

Question 1

When to start?

Answer 1

Available as 2–3 agents for those at significant risk, e.g. contaminated needle-stick injury.

Must be started within 72 hours of an episode of risk.

Question 2

PEP Assessment

Answer 2

History – ask about:

• exposure.
• exposed patient.
• source person.
• factors that can increase risk of transmission or acquisition.

Estimate risk of transmission.

Decide if exposure was high risk.

Check whether PEP is never recommended for the situation.

Check if the patient is eligible for funded PEP.

Baseline investigations by the provider, ID, or Sexual Health.

Question 3

PEP, History of exposure

Answer 3

Date and time (was it

Type, including blood or body fluid involved, trauma, and first aid measures applied

If sexual exposure:

• vaginal, anal, or oral
• receptive or insertive
• ejaculation
• condom use
• consensual or not

If non-occupational needle-stick injury:

• blood contamination of needle or syringe
• estimated age of needle or syringe
• depth of injury

Question 4

PEP, Hx of Exposed patient

Answer 4

• Most recent HIV test and result
• Potential exposures within last 3 m or since last HIV test
• Previous PEP use
• Current PrEP use
• Current STI symptoms
• Hepatitis B and C infection
• Immunisations, e.g. hepatitis A (HAV), hepatitis B (HBV), human papilloma virus (HPV)
• Pregnancy risk, contraception, or lactation
• Medical history, e.g. renal disease, current medication and allergies, psychiatric history, recreational drug and alcohol use
• Up‑to‑date contact details.

Question 5

PEP, Hx of the Source person

Answer 5

Be aware that pt may not have access to information about the source person.

If known:

• HIV status. If HIV positive:
• Are they on treatment?
• Is their viral load undetectable?
• Current STIs, hepatitis B and C status
• Demographic factors, e.g. from a country with a high HIV prevalence

Question 6

Factors that can increase risk of transmission or acquisition

Answer 6

STI in the source person, esp genital ulcer disease and symptomatic gonococcal infections.

A breach in genital mucosal integrity, e.g. trauma, genital piercing or genital tract infection.

A breach in oral mucosal integrity when performing oral sex, e.g. trauma, mouth ulcers.

Direct IV or intra-arterial injection with a needle or syringe containing HIV infected blood.

Uncircumcised status of the insertive HIV negative partner.

Question 7

Risk of transmission prior to PEP

Answer 7

See Auckland DHB – Post-exposure Prophylaxis After Non-occupational Exposure to HIV Table:

and Risk of Transmission Per Exposure From a Known HIV Positive Person, Not on Treatment.

1. PEP is recommended if risk of transmission can be calculated as > 1 in 1000.
2. Pts may wish to consider PEP if risk is 1 in 1,000 to 1 in 10,000, particularly if risk is close to 1 in 1,000 or there are factors that increase risk.

Question 8

Decide if exposure was high risk prior to PEP

Answer 8

MSM who have had recent condomless anal sex or shared injecting equipment with a person who is:

• known to be HIV +ve and is not on treatment, or is on Ry with a detectable or unknown viral load.
• of unknown HIV serostatus.

Pts who have had recent sexual contact or shared injecting equipment with a person who is:

• from a country with a high HIV prevalence.
• known to be HIV +ve and not on treatment, or on Ry with a detectable or unknown viral load.

Question 9

PEP is never recommended if:

Answer 9

Pt presents longer than 72 hours after exposure

Exposure consists solely of:

• receptive or insertive oral intercourse
• blood or body fluid splashed onto intact skin
• bite injury or saliva onto skin or mucous membrane (e.g. eye)

Needle-stick injury from a discarded needle (e.g. in park, on beach) of uncertain age and from unknown source, or from known source with unknown HIV status

Pt has been taking prescribed ( if been poorly adherent to PrEP, can have PEP).

Question 10

PEP is funded by Pharmac in the following situations:

Answer 10

It is adequate if pt states that the source person told them they had HIV infection and it cannot be confirmed that they have an undetectable viral load.

Condomless receptive anal intercourse with known HIV +ve person

Sharing of IV equipment with known HIV +ve person

Non-consensual intercourse with risk indicating need for prophylaxis

Apply for special authority (sexual health or infectious diseases).

Question 11

PEP Management

Answer 11

1. Ensure PEP is initiated ASAP after exposure (preferably within 24 hours, absolutely within 72 hours)

A). If sexual assault:

• pt aged
• aged ≥ 18 years, follow the Recent Sexual Assault pathway.

B). If pt is eligible for funded PEP:

• request acute sexual health assessment or acute ID assessment.
• after hours, request acute ID assessment and advise pt to attend the nearest hospital emergency department.

C). If high-risk exposure and pt is not eligible for funded PEP, offer referral for self-funded treatment.

• If pt accepts, request assessment as for a pt eligible for funded PEP.
• If pt does not accept, seek ID advice during consultation.

2. Seek ID advice for all other pts presenting for PEP.
3. If pregnancy risk, consider emergency contraception.
4. Arrange follow-up to:

• ensure that pt has been offered appropriate intervention and f/u testing.
• reinforce preventative practices (e.g. safe sexual and injecting behaviour) until the pt’s seronegative status is confirmed at follow-up.
• support any psychological distress.
• offer vaccinations (HAV, HBV, HPV) as appropriate.

Question 12

PEP, Request acute sexual health assessment or acute infectious diseases assessment if:

Answer 12

High-risk exposure

Pt would like specialist advice.

Seek advice by phone for all other pts presenting at GP for PEP.