Approach to HIV nPEP: Source with known HIV

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.

* 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. 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 inhibitors (INSTI)-containing regimens.
TAF/FTC-containing regimens are generally avoided in persons assigned female at birth due to reduced drug concentration in vaginal mucosa.

¶ Discontinuing nPEP is reasonable in this setting since clinical trials have found that sexual transmission of HIV is unlikley if a persons with HIV is on ART and has a viral load <1000 copies/mL, particularly if the viral load is <200 copies/mL. However, some patients may still choose to continue nPEP after reviewing the risks and benefits. There are no data evaluating viral load thresholds for HIV transmission when the exposure was through IDU.

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Approach to HIV nPEP: Source with known HIV