UK guideline for the use of HIV Post-Exposure Prophylaxis Following Sexual Exposure, 2015

Abstract

We present the updated British Association for Sexual Health and HIV guidelines for HIV post-exposure prophylaxis following sexual exposure (PEPSE). This document includes a review of the current data to support the use of PEPSE, considers how to calculate the risks of infection after a potential exposure, and provides recommendations on when PEPSE should and should not be considered. We also review which medications to use for PEPSE, provide a checklist for initial assessment, and make recommendations for monitoring individuals receiving PEPSE. Special scenarios, cost-effectiveness of PEPSE, and issues relating to service provision are also discussed. Throughout the document, the place of PEPSE within the broader context of other HIV prevention strategies is considered.

What are the characteristics of, and clinical outcomes in men who have sex with men prescribed HIV postexposure prophylaxis following sexual exposure (PEPSE) at sexual health clinics in England?

“…In our analysis, 15% of MSM were prescribed PEPSE more than once at the same clinic and exhibited a fivefold increased risk of acquiring HIV infection despite receiving counselling and advice on risk reduction strategies. MSM prescribed PEPSE, and especially those returning for repeat PEPSE would benefit from more intensive risk reduction interventions 1. Furthermore, national trends show a steadily increasing number of HIV diagnoses in MSM, and evidence from community-based surveys of sexual behaviour in MSM suggest that there is a need to enhance the existing HIV prevention package.…”

“…Current UK guidelines recommend that PEPSE, consisting of a 28-day course of antiretroviral therapy (Truvada (emtricitabine/tenofovir) and raltegravir) is offered to individuals who present within 72 hours of a defined risk exposure such as receptive unprotected anal intercourse (UAI) with a partner of unknown HIV status and from a known risk-group 1. An HIV test is performed at baseline to rule out undiagnosed HIV infection, and a follow-up HIV test is performed 8–12 weeks postexposure 1…”

“…Prospective randomised controlled trials (RCTs) to measure the efficacy of PEPSE are not ethically justifiable 1. Consequently, there is a lack of evidence on the clinical effectiveness of PEPSE, and current UK guidelines draw on observational studies, animal studies and an understanding of the biology of HIV transmission 1.…”

“…Consequently, there is a lack of evidence on the clinical effectiveness of PEPSE, and current UK guidelines draw on observational studies, animal studies and an understanding of the biology of HIV transmission 1. The guidelines also state that other HIV prevention strategies should be prioritised, such that PEPSE is considered only where these have failed 1…”

HIV post-exposure prophylaxis (PEP)

“…PEP is typically initiated when the exposure risk is moderate to high4 (table 1) and when the source has a non-negligible risk of HIV,1256 such as with condomless anal insertive or receptive intercourse or sharing of drug injecting paraphernalia 3456. When adherence or recent viral load data are unknown, PEP is frequently offered and subsequently discontinued during follow-up if additional data reveal the source to be non-infectious.…”