Post-Exposure Prophylaxis for HIV-Infected Needle Stick Injury
Immediate Action Protocol
- The CDC recommends initiating bictegravir/emtricitabine/tenofovir alafenamide (BIC/FTC/TAF) as a single tablet once daily for 28 days immediately after an HIV-infected needle stick, starting within 1-2 hours if possible, but no later than 72 hours post-exposure 1, 2, 3
- The American College of Physicians and other medical societies advise to start PEP immediately—do not delay for any reason, as efficacy decreases significantly with each passing hour 1, 2, 3
Preferred Medication Regimens
- The CDC's preferred choice is bictegravir 50mg/emtricitabine 200mg/tenofovir alafenamide 25mg (BIC/FTC/TAF) - one tablet once daily for 28 days, which maximizes adherence 1, 2, 3
- An alternative regimen is dolutegravir (DTG) 50mg once daily PLUS emtricitabine/tenofovir alafenamide (FTC/TAF) 200mg/25mg once daily for 28 days 1, 2, 3
Baseline Assessment and Testing
- Before administering the first PEP dose, perform a rapid or laboratory-based HIV antigen/antibody combination test, baseline renal function (creatinine, eGFR) before any tenofovir-based regimen, and review current medications for potential drug interactions 1, 2, 3
Follow-Up Testing Schedule
- Evaluate the exposed person within 72 hours after starting PEP, and monitor for drug toxicity for at least 2 weeks 3, 5, 6
- Perform HIV antigen/antibody test PLUS HIV nucleic acid test (NAT) at 4-6 weeks post-exposure, and laboratory-based HIV antigen/antibody combination immunoassay AND HIV nucleic acid test (NAT) at 12 weeks post-exposure 2, 3
Duration and Adherence
- Complete the full 28-day course regardless of subsequent information about the source patient, as incomplete adherence significantly reduces effectiveness 1, 2, 3
Special Populations and Considerations
- For patients with impaired renal function, use tenofovir alafenamide (TAF) instead of tenofovir disoproxil fumarate (TDF) due to improved renal safety 1, 3
- Pregnancy does not preclude the use of optimal PEP regimens and should not be a reason to deny PEP, but expert consultation is advised 7, 8
Counseling and Secondary Transmission Prevention
- Advise the exposed person to use precautions to prevent secondary transmission during the follow-up period, and seek immediate medical evaluation for any acute illness during follow-up 5, 6, 7