Quick guidance for those initiating PEP

If the patient is under 16 contact the on-call paediatrician.

• Pregnancy is not a contraindication to PEP.
• Pregnant women are at increased risk of HIV transmission and the high viraemia associated with primary infection would lead to a high likelihood of intrauterine infection.
• A thorough risk assessment should be undertaken in all women of childbearing age considering PEP, including a contraceptive history & pregnancy testing.
• Patients should be counselled that a negative urine pregnancy test at baseline may be too early to exclude pregnancy conceived within the previous three weeks.
• Refer for further guidance to BASHH guideline.

• Advise patient if they notice a rash, muscle pain or jaundice whilst taking PEP they must phone 01387 241787 and ask to speak to a member of the Infection Disease Team.
• If they cannot contact a member of the Infection Disease Team they should contact the Emergency Department and not take further doses of PEP until they have been assessed.

• Explain that full PEP course is 28
• Explain the HIV drugs prescribed are not licensed for use as PEP and PEP is not 100% effective
• Ensure no significant drug interactions (see www.hiv-druginteractions.org for interactive charts)
• Discuss potential side effects and their management (see PEP – Patient Information Leaflet)
• Explain base line blood tests (see below) & the possible need for further tests to assess tolerability of PEP and possible toxicity (routine renal and liver function test monitoring after initiation not necessary unless clinically indicated or if baseline tests are abnormal)
• Explain importance of poor adherence makes it less likely that PEP will work.
  • forget to take a dose, take it as soon as it is remembered
  • if it is time for the next dose skip the missed dose and go back to the regular schedule
  • do not take a double dose to make up for a forgotten dose
  • if more than 48 hours has elapsed since the last dose then discontinue PEP and contact the Infectious Disease Team

• The need for an HIV test prior to commencing PEP should not be delayed whilst waiting for result. It will be discontinued if baseline HIV positive.
• The need to have a follow-up HIV test no sooner that 45 days after completion of the PEP If the 28-day PEP course is completed this is 73 days (10.5 weeks) post exposure. This may be delayed to 12 weeks post exposure to align with syphilis testing.
• Ensure emergency contraception (if applicable) & follow up pregnancy testing.
• Hep B immunisation – administer a single dose of hepatitis B vaccination unless patient is known to have completed a course.
• Baseline investigations (see above)
• Promote condom use/avoidance of blood donation until all results at end of follow up are available and negative.
• Explore issues around disclosure/responsibilities (including legalities) to protect sexual partners from infection.
• Discuss coping strategies.
• Discuss testing for sexually transmitted infections commencing 2 weeks post exposure (this maybe offered as part of follow up with Infectious Diseases but patients can self refer to Sexual Health).
• Advise patients to seek advice about any acute illness especially suggestive of seroconversion whilst taking PEP and in the follow up period.

• HIV
• hepatitis B core antibody/surface antigen/surface antibody titre
• hepatitis C antibody
• syphilis serology
• creatinine
• eGFR 
• alanine transaminase

Refer to BASHH guideline if patient found to have chronic hepatitis B infection.

• Issue tenofovir disporil 245mg/emtricitable 200mg and raltegravir 1200mg (2x600mg) once daily for 28 days.
• Raltegravir 600mg is provided by pharmacy in quantities of 60 tablets - 4 tabs will need to be discarded by the clinician or patient
• If pregnant: raltegravir 400mg twice daily is preferred as the third agent. Where accessing raltegravir 400mg might cause delay use raltegravir 600mg twice daily with switching at the earliest opportunity.
• If index case has a past or current history of antiretroviral (ARV) treatment failure, seek advice from the Infectious Disease Team.

• Advise patient to arrange a follow up appointment with the Infectious Disease Team by phoning 01387 241787 on the next working day.
• Share patient details with the Infectious Disease Team (see Arranging follow up form)