PEPSE protocol

This guideline is for use primarily by healthcare professionals in the emergency
department, primary care and GP Out of Hours, for the assessment of individuals aged over 16 presenting following a potential sexual/non-occupational exposure to HIV.

Table of abbreviations

3.1 Overview of PEPSE

• PEPSE reduces the risk of transmission of HIV by almost 80%.
• It is generally given where transmission risk approaches/exceeds 0.1%.
• PEPSE is most effective if given within 24h of exposure but can be
  administered up to 72h. Beyond 72h, PEPSE is not effective.
• PEPSE is available at BSH, Emergency departments at BGH.

3.2 Risk of HIV transmission

Risk of transmission varies with:

• Nature of sexual contact
• HIV serostatus of source (and viral load)
  
  • If serostatus unknown, background prevalence of HIV in source risk
    group (e.g. MSM/Heterosexual, ethnicity, PWID etc.)
• Number of exposures within a 72h period (risk is cumulative)

Use tables 1 & 2 below, together with the flowchart above, to determine if PEPSE is
indicated.

3.3 Table 1: Source is known HIV+

If source is known HIV+ get details (NB: often the patient is in contact with the source, and can find out these details during the consultation):

• Consultant
• Treatment centre
• Treatment history (including details of drug resistance)
• HIV viral load (90% of patients on treatment have an undetectable viral load)

Undetectable = Untransmissible: Patients with viral load <40 CANNOT transmit HIV.

3.4 Table 2: Source HIV status unknown

• The percentages in this table are to help you calculate cumulative risk from
  multiple sexual exposures.
• High-risk exposures (in red) should be given PEPSE based on ONE sexual
  encounter, regardless of % risk.
• If source is on PrEP, DO NOT GIVE PEPSE.

NB: In Scotland in 2017 the only new HIV diagnoses in PWID were in GGC & Lanarkshire.

3.5 Special situations where it is appropriate to prescribe PEPSE despite calculated risk

• MSM who have had receptive anal intercourse (See Table 2)
• Multiple sexual encounters (within previous 72h) where cumulative risk likely exceeds 0.1% (Use Table 2 to calculate this risk)
• Sexual assault, involving female patient, receptive anal sex or traumatic vaginal sex, where the source is from a country of high HIV prevalence* (traumatic intercourse may increase transmission rates).
• Extreme anxiety from the patient (prescribe PEPSE and refer to sexual health clinic for further discussion).

* See “Blood Borne Viruses – Background Information for Risk Assessment”

• Provide 7-day PEPSE pack if indicated:
  
  • Emtricitabine/Tenofovir 200/245mg one tablet daily
  • Raltegravir 400mg twice daily.
• This is a starter pack: full treatment course is 28 days.
• Patient should be advised to seek review at BSH within 3 days.
• Pregnant women: There is limited experience of using PEPSE in this patient group, but nominally PEPSE appears to be well-tolerated and safe.

4.1 Extending PEPSE

If high-risk sex occurs during the last 2 days of the PEPSE course, extend the course for 48h after the exposure.

4.2 Missed doses

4.3 Adverse effects and interactions

Common adverse effects (may affect >10% patients)

• Nausea, vomiting, diarrhoea
• Headache
• Dizziness
• Rash
• Feeling weak

Drug-specific concerns:

• Emtricitabine/tenofovir
  
  • Renal Impairment: If baseline CrCl <80 mL/min, consider if the benefits of
    PEPSE outweigh the risks
• Raltegravir
  
  • Avoid Cytochrome P450 enzyme inducing medication (e.g. Rifampicin)
  • Do not take multivitamins/antacids containing Calcium, iron, magnesium or aluminium at the same time as Raltegravir (limits absorption; leave 4h either side)

This is done at Borders Sexual Health Clinic. Preferably the patient will be told to
telephone BSH to make an appointment within 3 days of being prescribed PEPSE.

• Web: www.borderssexualhealth.org.uk
• Email (Health professionals only): sexual.health2@borders.scot.nhs.uk
• Telephone: 01896 663700

All cases of suspected exposure to HBV should receive the first dose of a course of
vaccination unless the patient is known to be Hepatitis B immune.

• All cases should receive the first vaccination or booster of Hepatitis B vaccine.
• Baseline Bloods:
  
  • Patient immunised - HBsAb – check titre
  • Patient not immunised - HBcAb – check if already infected
• Vaccination can be beneficial up to 6 weeks after exposure.
• Hepatitis B immunoglobulin is indicated if the source is known to be an infectious hepatitis B carrier (defined as HBsAg positive).

There is no PEPSE available for Hepatitis C.

• Drug interactions: www.hiv-druginteractions.org
• 2015 BASHH guidelines:
  https://www.bashhguidelines.org/media/1027/pepse-2015.pdf
• Patient information leaflet:
  https://www.bhiva.org/file/ieJHUmCnjsWIM/PEP-HIVPA-leaflet_Oct_2014.docx