392 American Family Physician www.aafp.org/afp Volume 94, Number 5 ◆ September 1, 2016
CDC Releases Updated Guidelines for Postexposure
Prophylaxis After Sexual, Injection Drug, or Other
Nonoccupational Exposures to HIV
Coverage of guidelines
from other organizations
does not imply endorsement by AFP or the AAFP.
This series is coordinated
by Sumi Sexton, MD,
Associate Deputy Editor.
A collection of Practice
Guidelines published in
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Postexposure prophylaxis (PEP) with antiretroviral drugs to prevent transmission of
human immunodeficiency virus (HIV) following sexual or injection drug use exposures
(nonoccupational PEP or nPEP) is an essential intervention requiring a timely response.
Updated guidelines from the Centers for Disease Control and Prevention (CDC) provide
clinicians with guidance on assessing and
managing exposures, new nPEP regimens,
schedules for baseline and follow-up testing for HIV and associated infections, and
longer-term prevention measures including
preexposure prophylaxis (PrEP).
Indications for nPEP
Indications for nPEP remain unchanged. The
patient must be exposed to a potentially infec-
tious fluid, including semen, vaginal or rectal
secretions, and blood or any body fluid con-
taminated with blood. Non-bloody saliva,
urine, feces, vomitus, sputum, nasal secre-
tions, sweat, and tears are not infectious for
HIV. There should be knowledge or rea-
sonable suspicion that the source person is
infected with HIV. With sex partners and
injection drug use, it might not be possible
to obtain accurate information on the source
person’s HIV status. The patient needs to
come into contact with a mucous mem-
brane (e.g., vagina, rectum, mouth) for sexual
exposures or through the skin for injection
drug exposures. And finally, exposure needs
to have occurred within the previous 72 hours.
Exposed persons should have HIV testing,
preferably using a rapid antibody or rapid
antigen-antibody test, to rule out infection
from a previous exposure. Exposed persons
with HIV infection are not candidates for
nPEP and need further evaluation for treatment. If HIV test results will not be available during the initial evaluation, a decision
whether nPEP is indicated should be made
without delay, based on the assumption that
the exposed person is not infected with HIV.
nPEP can be discontinued if the patient is
later determined to have HIV infection.
Source person testing should also be
obtained, if possible. A fourth-generation
HIV antigen-antibody test is recommended
because it can detect recent infection a few
weeks earlier than standard antibody tests.
If this test is negative, the source person is
presumed to be uninfected, and nPEP is not
indicated. If there are signs or symptoms of
acute HIV infection, additional evaluation
is required. For many exposures, the source
person’s HIV status will not be known, so
risk will be estimated based on known or
suspected risk factors.
The guideline provides schedules for baseline laboratory testing, including hepatitis B
and C and sexually transmitted infections,
for source and exposed persons initiating
nPEP. Pregnancy testing is recommended
Initiating nPEP as Soon as Possible
Postexposure prophylaxis is a time-sensitive
intervention because effectiveness appears to
Key Points for Practice
• Evaluate exposures promptly and initiate nPEP as soon as possible after
• Do not delay nPEP pending HIV test results or source person risk factor
• Prescribe three-drug nPEP regimens.
• Test for other sexually transmitted infections.
• Offer PrEP to those who continue to be at risk.
From the AFP Editors