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nPEP Quick Guide for Providers

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Assessment, treatment, and follow-up recommendations for people with known or potential exposures to HIV and other infections. Health care providers should evaluate persons rapidly for nPEP when care is sought ≤72 hours after an exposure that presents a substantial risk for HIV acquisition.

Risk Assessment

Risk Assessment Algorithm
*Some clinicians would offer nPEP on a case-by-case basis

Substantial Risk for HIV Acquisition

Exposure of: vagina, penis, rectum, eye, mouth or other mucous membrane, non-intact skin, or percutaneous contact
With: blood, semen, vaginal secretions, rectal secretions, breast milk, any body fluid that is visibly contaminated with blood
When: the source is known to have HIV

Negligible Risk for HIV Acquisition

Exposure of: vagina, penis, rectum, eye, mouth or other mucous membrane, non-intact skin, or percutaneous contact
With: urine, nasal secretions, saliva, sweat, tears (if visible blood, see “Substantial Risk for HIV Acquisition”)
When: regardless of the known or suspected HIV status of the source

Laboratory Assessment

  • HIV Ag/Ab: Rapid (point of care) 4th generation (Ag/Ab) test is preferred, but if not available, a rapid Ab test or a non-rapid lab-based HIV test should be done. If non-rapid testing is done, start nPEP immediately and arrange follow-up in 1-2 days for HIV results.
    • If the rapid HIV test is reactive (positive), the person should NOT be given nPEP, but should be offered imme­diate antiretroviral therapy (before being discharged) and should be linked to ongoing HIV care.
  • Gonorrhea (GC) and chlamydia (CT) NAAT: Offer tests according to sites of sexual contact (e.g., swabs for oropharyngeal, rectal, vaginal sites; urine for urethral site).
    • For post-sexual assault patients, STI testing should be considered; empiric treatment should be provided whether or not STI testing is done.
  • Syphilis test: RPR/VDRL or treponemal test
    • For post-sexual assault patients, STI testing should be considered; empiric treatment should be provided whether or not STI testing is done.
  • Urine pregnancy test for persons at risk of pregnancy
  • Serum creatinine, ALT, AST
  • Hepatitis B sAb, cAb, Ag
  • Hepatitis C Ab

Treatment

Adults and adolescents (≥ 13 years) see below. Regimens for children and people with reduced renal function are also available.

If rapid HIV testing result is negative (non-reactive), or if lab-based test is sent and is pending, offer nPEP and as appropriate, STI treatment, emergency contraception, hepatitis B prophylaxis, and HPV vaccination:

HIV prophylaxis: Administer first dose of nPEP on site as soon as possible after a negative rapid HIV test result is obtained or a non-rapid HIV test is sent.

  • Tenofovir disoproxil fumarate (TDF)/emtricitabine (FTC) (Truvada) 300/200 mg + dolutegravir (Tivicay) 50 mg – 1 tablet of each PO daily x 28 days (2016 Guidelines)
    • Many providers prescribe tenofovir alafenamide (TAF)/FTC (Descovy) in place of TDF/FTC, and bictegravir in place of dolutegravir. Bictegravir is available as a coformulation with TAF/FTC (bictegravir/TAF/FTC, Biktarvy).
  • If client is in the first trimester of pregnancy OR may become pregnant within the next 28 days: TDF/ FTC (Truvada) 300/200 mg 1 tab PO daily + EITHER dolutegravir (Tivicay) 50 mg 1 PO daily OR raltegravir (Isentress) 400 mg 1 tab PO twice a day.
    • The use of dolutegravir at conception and in very early pregnancy has been associated with a small, but not statistically significant, increase in the risk of fetal neural tube defects (see package insert).
  • Truvada should not be used for those with CrCl less than 60 mL/min; an alternative regimen must be used in those circumstances.

Sexually transmitted GC, CT, and trichomonas empiric treatment: offer to all with sexual exposures (oral, vaginal, or rectal exposures)

  • GC: Ceftriaxone (500 mg IM x 1 [1,000 mg IM for persons weighing ≥ 150 kg]) is the recommended treatment for GC and should not be substituted with another antibiotic unless there are clear contraindications (see CDC 2021 STI Treatment Guidelines for alternative).
  • CT: doxycycline 100 mg PO twice/day x 7 days (or if pregnant, azithromycin 1 gram PO x 1)
  • If risk of vaginitis: metronidazole 2 grams PO x 1
  • Emergency contraception: Offer to persons at risk of pregnancy with a negative pregnancy test.
  • Hepatitis B prophylaxis: Administer 1 dose of hepatitis B vaccine to persons not previously vaccinated or incom­pletely vaccinated. If the exposure source is available for testing and is HBsAg positive, unvaccinated exposed persons should be given both hepatitis B vaccine and hepatitis B immune globulin during the initial nPEP evalu­ation. Follow-up dose(s) of hepatitis B vaccine should be administered according to the vaccine prescribing informa­tion. Previously vaccinated exposed persons who did not receive postvaccination testing should be provided a single hepatitis B vaccine booster dose.
  • Prophylaxis against hepatitis C is not recommended.
  • HPV vaccination: For those aged 9 to 45 years inclusively, offer HPV vaccination dose if not adequately vaccinated previously (see Gardasil package insert).

Patient Education

  • Possible nPEP drug side effects: nausea, GI upset, ;headache, myalgias
  • Possible nPEP drug interactions: antacids, calcium, iron supplements
  • Stress the importance of adherence to the nPEP regimen for 28 days, without interruption
  • For those with ongoing risk of HIV infection, offer PrEP initiation immediately after completion of the 28-day course of nPEP

Follow-up

  • Follow-up should be scheduled at 72 hours and 4-6 weeks after initiating nPEP
  • HIV Ag/Ab test after initial non-reactive test
  • Syphilis test at 4-6 weeks and 3-6 months after exposure
  • HBV and HCV serology tests at 6 months after initial non-reactive test if susceptible at baseline

References and Resources

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