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10. Post Exposure Prophylaxis (PEP) in HIV/AIDS

Objective: Prevent infection with HIV and HBV.
Exposure to blood or other potentially infectious body fluid is a medical emergency.

Steps for Managing an Exposure

  1. First Aid - Immediately wash the wound and surrounding skin/mucous membrane with water.
  2. Assess HIV Risk - Determine exposure risk by HIV status of source and nature of body fluid.
  3. Counsel the exposed individual and reduce anxiety.
  4. Give Prophylaxis - Administer HBV vaccine and/or immunoglobulins based on exposure type, source status, and immune status.
  5. Informed Consent + Pre-test Counselling - Test for HIV, HBV, and HCV status.
  6. Follow Up at 6 weeks, 12 weeks, and 6 months for HIV, HBV, and HCV status.

Step-by-Step PEP Protocol

StepTimingActionDetails
10 hr / 0 minManage exposure siteWash wound with water + soap; irrigate eye with water/normal saline; rinse mouth with water/saline; refer to physician
2ASAPEstablish eligibility for PEPAssess exposure + source code; exposure within 72 hrs; determine risk of transmission
3-Counsel for PEPProvide info on HIV/PEP; obtain consent; offer special leave
4Ideally within 2 hrs, not more than 72 hrsPrescribe PEPAssess source HIV status; check pregnancy (females); explain ARV side effects; explain post-exposure measures for HBV/HCV
5-Laboratory evaluationHIV pre-test counselling; check Hep B immunization; offer HIV, HBV, HCV tests; CBC + LFT if needed; HIV post-test counselling
66 monthsFollow up & monitor adherenceRecord keeping; clinical assessment at 2 weeks; Hep B vaccination if needed; HIV test at 3 and 6 months

When to Start PEP

Start PEP if high-risk exposure to blood or infectious body fluids occurs due to:
  1. Needle stick injury
  2. Splashing of blood on mucous membranes (eye or mouth)
  3. Blood contact with non-intact skin (abrasions, cuts, open wound, or dermatitis)

PEP for HIV - Exposure & Source Codes

HIV Exposure Code

Type of ExposureConditionExposure Code
Mucous membrane / compromised skin (volume or duration)Small volume / few drops / short durationEC1
Large volume / major splash / long durationEC2
Percutaneous (severity)Less severeEC2
More severeEC3

HIV Source Code

HIV StatusDefinitionSource Code
HIV NegativeSource not HIV+, but consider HBV/HCVNo PEP required
HIV PositiveLow viral titre, asymptomatic, high CD4HIV SC 1
HIV PositiveHigh viral titre, advanced disease, low CD4HIV SC 2
HIV Status UnknownRisk in generalized HIV epidemic / key affected populationHIV SC Unknown

NACO PEP Recommendations (Based on Exposure + Source Codes)

Exposure CodeSource CodePEP RecommendationDuration
11Not warranted-
12Recommended28 days
21Recommended28 days
22Recommended28 days
31 or 2Recommended28 days
2/3UnknownConsider PEP if HIV prevalence is high in given population28 days

When PEP is NOT Needed

  • Exposed individual tests HIV positive at baseline - start ART, not prophylaxis
  • Source is established HIV negative
  • Exposure to body fluid with no significant risk: tears, non-blood-stained saliva, urine, sweat
  • Exposure on intact skin

Recommended PEP Regimens (Adults)

RegimenAdministration
Preferred: TDF (300mg) + 3TC (300mg) + DTG (50mg) FDC1 tab within 2 hrs of exposure; next day 1 tab OD - continue for 4 weeks
Alternate 1: TDF (300mg) + 3TC (300mg) FDC1 tab within 2 hrs; next day 1 tab OD
Alternate 2: LPV/r (200/50mg) FDC2 tabs within 2 hrs; then 2 tabs BD - continue for 4 weeks
Alternate 3: TDF (300mg) + 3TC (300mg) + EFV (600mg) FDC1 tab immediately; next day 1 tab OD - continue for 4 weeks
As per upcoming NACO guidelines (subject to change)
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