NEED HELP?

POST-EXPOSURE PROPHYLAXIS (PEP) Contact the TOLL-FREE National HIV & TB

Health Care Worker Hotline
Occupational and Non-occupational 0800 212 506 / 021 406 6782
Published July 2024, Version 4 Alternatively “WhatsApp” or send an SMS or “Please Call Me” to 071 840 1572
www.mic.uct.ac.za

TABLE 1: PEP DECISION TOOL TABLE 3: HIV PEP REGIMENS

HIV exposure is a medical emergency TYPE OF EXPOSURE TIMEFRAME
EXPOSURE TO BLOOD OR OTHER INFECTIOUS MATERIAL2
PREFERRED REGIMEN
and HIV PEP must be initiated immediately. TYPE OF
VIA MUCOUS MEMBRANE OR NON-INTACT SKIN3
WITHIN WHICH PEP
Adults and adolescents Children < 10 years and < 30 kg:
PROPHYLAXIS SEXUAL IS MOST LIKELY TO
Do not wait for confirmatory results before including splash or contact with open wound and/or
percutaneous exposure (needle stick)
BE EFFECTIVE ≥ 10 years and ≥ 30 kg:
AZT + 3TC + DTG
initiating PEP. A step-wise approach is required. HIV PROPHYLAXIS ✓ Within 72 hours ✓ TDF 300 mg + 3TC 300 mg + DTG 50 mg for 28 days
Within 7 days of
HEPATITIS B perinatal and needle (TLD) once a day for 28 days Refer to paediatric dosing chart for dosing
VIRUS ✓ ✓ stick exposures ALTERNATIVE OPTIONS:
PROPHYLAXIS1 Within 14 days of sexual
A three-drug regimen should be used in all cases. If a drug is not tolerated, substitute with a suitable
STEP 1: IMMEDIATE MANAGEMENT exposure
As soon as possible, but alternative and continue the non-offending antiretrovirals.
EMERGENCY • TDF is better tolerated than AZT. TAF or AZT can be used as an alternative in adults and adolescents who have
✓ within 5 days of
• Assess eligibility for PEP (Table 1). CONTRACEPTION unprotected intercourse poor kidney function or who are not tolerating TDF.
• Start HIV PEP immediately (refer to Table 3). Do not wait for laboratory results before STI PROPHYLAXIS ✓ Within 72 hours • DTG can be substituted for a protease inhibitor (LPV/r or ATV/r or DRV/r).
1
Human bites that draw blood require HBV prophylaxis, antibiotic prophylaxis with amoxicillin/clavulanic acid and tetanus
initiating. Provide a full 28 day supply of antiretrovirals. prophylaxis (refer to Standard Treatment Guidelines). SPECIAL PRESCRIBER’S POINTS:
• Don’t delay initiating HIV PEP if unsure about appropriate regimen as this can be modified 2
INFECTIOUS MATERIAL • Always check for drug-drug interactions. ATV/r and DRV/r are contra-indicated with rifampicin. ATV/r is also con-
after consultation with an expert. • Blood or any bloodstained fluids, tissue or other material traindicated with proton-pump inhibitors e.g. omeprazole, lansoprazole. Polyvalent cations (Mg2+, Fe2+, Ca2+, Al3+,
• Rectal fluid, vaginal secretions, or penile pre-ejaculate and semen Zn2+) interact with DTG. Please check how to administer correctly. If you need help contact the Hotline (0800 212
• Fluid from any body cavity such as pleural, pericardial, amniotic, peritoneal, synovial and cerebrospinal fluids 506).
• Breast milk
STEP 2: BASELINE MONITORING AND OTHER PROPHYLAXIS • If the source patient is on a failing or third line regimen, consult with an Infectious Disease Specialist or the Hotline.
NON-INFECTIOUS MATERIAL • NVP should be avoided in PEP due to risk of hypersensitivity reactions.
Saliva/sputum, tears, vomitus, faeces/stool, sweat and urine pose no risk of HIV, unless contaminated with infectious materials • ABC should only be used if there is NO alternative as there is a risk of a hypersensitivity reaction to ABC. Phone
• Do necessary baseline tests: Table 2. Remember to provide thorough, confidential, e.g. blood. the hotline to discuss.
pre-test counselling before HIV testing. Post-test counselling and results should be 3
Intact skin exposed to infectious or non-infectious materials poses no risk for acquiring HIV or HBV. • For the paediatric dosing chart contact the hotline or visit the website (www.mic.uct.ac.za).
handled in strict confidence.
• Start appropriate prophylaxis (refer to Table 1 for maximum timeframe): TABLE 2: TESTING (BASELINE AND FOLLOW-UP) TABLE 4: HEPATITIS B PEP
• Hepatitis B PEP: Table 4. SOURCE
EXPOSED PATIENT Vaccination status and Source patient
PATIENT
• Emergency contraception: Table 5. antibody response of exposed
BASE-
• STI prophylaxis: Table 6. BASELINE 6 WEEKS4 4 MONTHS patient HBsAg positive or unknown HBsAg negative
LINE 6
HIV5 HIV test HIV test HIV test HIV test Unvaccinated OR vaccination • HBIG, IM, 500 units Initiate Hep B vaccination
Surface incomplete • Hep B vaccine (3 doses at monthly intervals) (month 0, 1 and 6)
STEP 3: TEST SOURCE PATIENT, IF POSSIBLE Hepatitis B
Surface Surface antibody - antigen Vaccinated AND known to have
antigen HBV testing in exposed can be omitted if known to be protected No treatment No treatment
HBsAb titre ≥ 10 units/mL7
• Refer to Table 2. (natural immunity or vaccination) or source is negative
PCR Vaccinated AND HBsAb < 10 units/mL • HBIG, IM, 500 units6
• Offer source patient comprehensive and confidential pre-test counselling and ensure Antibody No treatment
Only if high risk for HCV, or if Only if source antibody - OR unknown • Hep B vaccine (3 doses at monthly intervals)
Hepatitis C Antibody
informed voluntary consent is obtained. If consent for HIV testing is refused the source is positive or unknown positive and health care 6
Refer to secondary level of care for HBIG, IM. HBIG should be given as soon as possible, preferably within 24-72 hours
following options can be considered: worker antibody negative
after exposure (or within 7 days);
Serum 7
If obtaining HBsAb titre takes more than 24 hours, initiate treatment as for vaccinated with HBsAb ≤ 10 units/mL.
 HIV test can be offered anonymously. - If TDF part of PEP - -
creatinine Note: Repeat HBsAb 1-2 months after last vaccine dose to ensure adequate immune response (i.e. HBsAb > 10 units/mL)
 In cases of sexual assault, the law makes provision for HIV testing in alleged If AZT part of PEP: at baseline
FBC and diff - and repeat at 2 weeks - -
offenders. The victim, or an interested person, can apply for this to be done within TABLE 5: EMERGENCY TABLE 6: STI PROPHYLAXIS
For sexual exposures include the following tests:
90 days of the alleged offence.
• If source patient is unknown or refuses testing, the health care worker/patient must be
Pregnancy
-
Baseline: Beta hCG; repeat if normal menstrual period did not occur within 4 CONTRACEPTION (WITHIN 5 DAYS) Adults and adolescents:
test weeks of exposure Ceftriaxone 250 mg IM AND azithromycin 1 g oral stat
treated as if the source is HIV-positive and HBsAg-positive. RPR/TP Levonorgestrel 1.5 mg oral stat AND metronidazole8 2 g oral stat
Syphillis antibody Baseline: RPR/TP antibody 8
First-trimester of pregnancy: metronidazole 400mg twice daily for 7 days
Provide double the levonorgestrel dose in the preferred over stat dose in combination with ceftriaxone and azithromycin
STEP 4: FOLLOW-UP AND MONITORING 4
If the patient is transitioning to PrEP, do these tests at 4 weeks. following situations:
• Patients on enzyme inducing medicines (including Children:
5
WHICH HIV TEST TO DO: efavirenz, rifampicin and carbamazepine), as they Ceftriaxone (< 25 kg: 125 mg IM, ≥ 25 kg 250 mg IM)
• Ensure all baseline laboratory results have been received and acted upon within 72 hours. significantly reduce levonorgestrel levels. AND
ADULTS: As per the HTS national guideline
• Follow-up testing and monitoring: refer to Table 2. • Women > 80 kg or BMI ≥ 30. Azithromycin single oral dose
CHILDREN: (< 45 kg: 20 mg/kg; ≥ 45 kg: 1g)
• Enquire about any adverse effects of ART and manage appropriately (see Table 7). • < 18 months of age: HIV PCR Special prescriber’s points: AND
• Exposed patient should be counselled to practice safe sex (use condoms) for • 18 to 24 months: HIV Rapid test. Confirm with HIV PCR or HIV VL • Provide antiemetic to prevent nausea and Metronidazole
at least 4 months after the exposure to protect sexual partners. • > 24 months: as for adults vomiting: metoclopramide 10 mg 8 hourly as • 1-3 years: 50 mg tds for 7 days or 500 mg oral stat
needed. • 4-7 years: 100 mg bd for 7 days or 600-800 mg oral stat
Children can provide consent for HIV testing if ≥ 12 years of age; or if < 12 years and of “sufficient maturity”; • If vomiting occurs within 2 hours of taking • 8-10 years: 100 mg tds for 7 days or 1 g oral stat
SPECIAL CONSIDERATIONS or if < 12 years and not sufficiently mature: parent, caregiver, or the Provincial Head of the Department of levonorgestrel, repeat the dose. • > 10 years: metronidazole 2 g oral stat or
• Alternative options (e.g. Copper IUD) can be metronidazole 400 mg bd orally for 7 days (preferred for
Pregnancy: PEP is not contra-indicated in pregnancy. Pregnant health care workers/patients should receive Social Development may give consent.
considered. children)
the same prophylaxis as adults, except for emergency contraception. Do not wait for laboratory result before initiating HIV PEP. PEP can be stopped if laboratory HIV test is
Breastfeeding: Although antiretrovirals are transmitted through the breastmilk, it is not considered to be negative and there are no signs of seroconversion illness
TABLE 7: POSSIBLE ADVERSE EFFECTS OF ANTIRETROVIRAL TREATMENT
harmful to the breastfed child. If the health care worker/patient is however infected with HIV, the risk of 3TC = lamivudine; ABC = abacavir; ART = antiretroviral therapy; ATV/r = atazanavir and ritonavir; AZT = zidovudine; BMI = body mass index; DTG = dolutegravir; Atazanavir/ritonavir Generally well tolerated. Benign jaundice with unconjugated
transmitting HIV to the baby during this early stage of infection should be considered. DRV/r = darunavir and ritonavir; ELISA = enzyme-linked immunosorbent assay; FBC and diff = Full blood count and differential; HBV = hepatitis B virus; HCV = hepati-
tis C virus; HBIG = hepatitis B immunoglobulin; HBsAb = hepatitis B surface antibody; HBsAg = hepatitis B surface antigen; hCG = human chorionic gonadotropin; HIV hyperbilirubinaemia occurs commonly. Hepatitis (uncommon).
Interrupt breastfeeding for 12-24 hours after stat metronidazole dose. = human immunodeficiency virus; IM = intramuscular; IUD = intrauterine device; LPV/r = lopinavir and ritonavir; NVP = nevirapine; PCR = polymerase chain reaction; Darunavir/ritonavir Gastrointestinal upset, rash, hepatitis (uncommon). Contains sulphonamide
Window period: HIV PEP is not indicated if the source patient is HIV-negative confirmed by laboratory STI = sexually transmitted infection; TAF = tenofovir alafenamide; TDF = tenofovir disoproxil fumarate; TLD = tenofovir + lamivudine + dolutegravir; VL = viral load moiety (use with caution in patients with sulphonamide allergy).
ELISA test, unless acute antiretroviral syndrome is suspected (symptoms include: fever, lymphadenopathy, Based on the National Clinical Guidelines for post-exposure Dolutegravir Generally well tolerated. Occasional insomnia.
sore throat, rash, myalgia, arthralgia, headache). prophylaxis (PEP) in occupational and
Emtricitabine/Lamivudine Generally well tolerated.
non-occupational exposure, South African Department of
Exposed person who is known to be HBsAg positive at baseline: If TDF part of PEP regimen, refer to higher Health, Published 2020 Lopinavir/ritonavir Diarrhoea, nausea, vomiting, hepatitis.
level of care to assess continuing or discontinuing of TDF. This publication was supported under funding provided by the Global Fund to Fight AIDS, Tuberculosis and Malaria through the National Department of Health
of South Africa and the NDoH Pharmacovigilance Centre for Public Health Programmes. Its contents are solely the responsibility of the authors and do not Tenofovir Generally well tolerated. Nausea, diarrhoea, vomiting, nephrotoxicity.
Exposed person HBsAg positive during follow-up testing: Refer for further assessment. necessarily represent the official views of the Global Fund or the National Department of Health of South Africa
Zidovudine Nausea, vomiting, headache, fatigue, anaemia, neutropenia.