In February 2006 the guidelines from the British Association for Sexual Health and HIV (BASHH) were issued.1
The guidelines cover, among other things:
- The scientific basis for recommending PEP
- A guide to calculating the risk of a given exposure
- The pros and cons of PEP as a prevention measure
- Situations in which PEP is recommended
- Recommended drug regimens
- Pathways for access
PEP is recommended after sexual exposure, as follows:
Situations in which PEP would be considered
|
Partner status HIV+ |
Partner status unknown, but from a group or area of high prevalence (>10%) |
Partner status unknown, not from a group or area of high prevalence |
Receptive anal intercourse |
Recommended |
Recommended |
Considered |
Insertive anal intercourse |
Recommended |
Considered |
Not recommended |
Receptive vaginal intercourse |
Recommended |
Considered |
Not recommended |
Insertive vaginal intercourse |
Recommended |
Considered |
Not recommended |
Fellatio with ejaculation |
Considered |
Considered |
Not recommended |
Splash of semen into eye |
Considered |
Not recommended |
Not recommended |
Fellatio without ejaculation |
Not recommended |
Not recommended |
Not recommended |
Cunnilingus |
Not recommended |
Not recommended |
Not recommended |
Source: Adapted from BASHH 2006
When the source partner’s HIV status is not known, attempt should be made, where possible, to establish it as soon as possible, whilst following appropriate guidance on HIV testing and consent.
High prevalence groups notably include men who have sex with men and people who have immigrated to the UK from areas of high HIV prevalence, including sub-Saharan Africa.
Other factors to consider include whether either partner has a concurrent STI, the viral load in the HIV-positive partner, and whether there was sexual assault/trauma.
PEP “is only recommended where the individual presents within 72 hours of exposure,” the guidelines say, though they add that PEP “may be considered after this time if the exposure is ‘high risk’”.
Recommendations for PEP regimens are:
Recommended PEP combinations
One of the NRTI/NtRTI options: |
Plus one of the protease inhibitor options: |
AZT (zidovudine) and 3TC (lamivudine) in combined pill Combivir or D4T (stavudine, Zerit) and 3TC (lamivudine, Epivir) or tenofovir and FTC (emtricitabine) in combined pill Truvada or tenofovir (Viread) and 3TC (lamivudine, Epivir) |
either an unboosted protease inhibitor: Nelfinavir (Viracept) or one of the protease inhibitors boosted with ritonavir: lopinavir/ritonavir in the combined pill Kaletra or fosamprenavir (Telzir) and ritonavir (Norvir) or saquinavir (Invirase) and ritonavir (Norvir) |
Source: Adapted from BASHH 2006
The nucleoside ddI is excluded for possible liver or pancreatic toxicity; abacavir (Ziagen) and nevirapine are excluded because of the well-known risk of acute hypersensitivity reactions to these drugs; and efavirenz (Sustiva) is excluded because it also causes rash and because it “causes short-term psychostimulation, which is possibly less well tolerated in anxious patients receiving PEP than in patients with established HIV infection”.
It is recommended that PEP should be provided on a 24-hour basis at casualty departments. Other recommendations on service provision include:
- A mandatory baseline HIV test
- Rapid GUM/HIV clinic referral
- Weekly follow-up during PEP period
- Three- and six-month HIV antibody test
The guidelines say that people who present repeatedly for PEP should not be penalised but should be “considered for repeat courses…according to the risk of HIV acquisition at the time of presentation”, particularly if their life situation means they are exposed to a degree of regular risk (such as the negative partner of a positive person, a sex worker, or someone unable to get their partner to use condoms). However, all repeat presenters should be encouraged to see a health adviser or psychologist. This recommendation contrasts with Australia’s ‘three strikes and you’re out’ policy. France and Spain allow a maximum of four and five repeats respectively.
The guidelines end by setting targets for PEP: at least 90% of prescriptions should be filled within 72 hours and should fall within the ‘recommended’ criteria; at least 75% of individuals should complete their four-week course; and at least 60% should get HIV tests done three and six months after presenting themselves.
PEP will never replace other HIV prevention strategies, the authors emphasise. They say: “It is crucial to consider PEP…as only one strategy in preventing HIV infection and, as such, it should be considered as a last measure where conventional, and proven, methods of HIV prevention have failed.”
When people are seeking PEP at A&E departments, it can be helpful to have a print-out of the guidelines in case of difficulties. When the GUM clinic is open, patients should tell reception they need to be seen immediately as an emergency appointment for PEP because of exposure to HIV. If the GUM clinic is not open, patients should go as soon as possible to the hospital's A&E department with the guidelines or take a piece of paper with the web address of the guidance.
The Terrence Higgins Trust national helpline, THT Direct, can advise patients who have problems getting PEP while they are still at the A&E or GUM. Patients can also ask the hospital worker to speak to THT Direct if this would help – 0845 12 21 200 (open Monday to Friday 10am to 10pm, Saturday and Sunday 12 noon to 6pm).
The 2006 UK Guidelines for PEP after sexual exposure can be read at http://www.bashh.org/documents/58/58.pdf.