Approach to HIV nPEP: Source with unknown HIV status

This algorithm describes our suggested approach to nonoccupational post-exposure prophylaxis (nPEP) in persons after a sexual or percutaneous exposure to a person with HIV and should be used in conjunction with UpToDate content on nPEP. A shared decision making approach should be used with all patients since the risks, benefits, costs, and barriers will vary for each individual. Pre-exposure prophylaxis should also be discussed with those who have repeated exposures that put them at risk for acquiring HIV.

ART: antiretroviral therapy; HIV: human immunodeficiency virus; nPEP: nonoccupational post-exposure prophylaxis; TAF/FTC: tenofovir alafenamide-emtricitabine; TDF/FTC: tenofovir disoproxil fumarate-emtricitabine.

* An example of a high-prevalence area is the World Health Organization African Region. Detailed information on the prevalence of HIV in different geographic areas can be found on the WHO website.

¶ Alternative regimens should be considered in certain settings. These include:

Reduced kidney function (estimated glomerular filtration rate [GFR] of <60 mL/min/1.73 m²) or creatinine clearance [CrCl] <50 mL/min) - For nPEP, TDF/FTC should be avoided in persons with reduced kidney function if there are other reasonable alternatives. If the CrCl is between 30 and 50 mL/min and the exposure was through anal sex or injection drug use (IDU), we prefer a TAF/FTC-containing regimen. For those with vaginal exposure or a CrCl <30 mL/min not on dialysis, we typically avoid TAF (uncertain efficacy and potential safety issues, respectively) and instead use dose reduced TDF and FTC in combination with dolutegravir or boosted darunavir. However, the optimal approach is uncertain and infectious diseases consultation may be helpful in these settings. For dose adjustments, refer to the tenofovir disoproxil fumarate and emtricitabine separate drug information topics within UpToDate.
Exposure to a person with drug-resistant HIV - In this setting boosted darunavir (in combination with TAF/FTC or TDF/FTC) can be considered. This regimen is associated with more side effects than integrase strand transfer inhibitor (INSTI)-containing regimens.
TAF/FTC-containing regimens are generally avoided in persons assigned female at birth due to reduced drug concentration in vaginal mucosa.

Δ Some patients may choose to initiate nPEP if the source's risk factors are unknown, depending upon the type of exposure.

◊ A variety of symptoms and signs may be seen in association with acute HIV infection. The most common findings are fever, lymphadenopathy, sore throat, rash, myalgia/arthralgia, and headache. Refer to UpToDate topics that discuss clinical manifestations and diagnosis of acute HIV for additional information.

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Approach to HIV nPEP: Source with unknown HIV status