UK non-occupational exposure guidelines for PEP

In December 2011, guidelines¹ were issued by the British Association for Sexual Health and HIV (BASHH) and the British HIV Association (BHIVA), to replace the previous document, which was issued in 2006.

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 and pathways for access.

When considering whether PEP should be provided, the document recommends that clinicians consider:

• The risk of transmission during a particular sexual act or other type of exposure.
• The risk of the source partner being HIV positive – if his or her HIV status is unknown, this will depend on the prevalence of HIV in different local communities.
• The viral load of the source partner, if this is known.

The recommendations concerning undetectable viral load were new in the 2011 guidelines. After sexual contact with a person with diagnosed HIV and an undetectable viral load, PEP is not recommended if the sexual activity was unprotected vaginal intercourse, unprotected insertive anal intercourse or oral sex. But PEP is recommended following unprotected receptive anal intercourse.

Moreover, the guidelines do not recommend PEP in any situation in which the source partner is thought not to belong to a social group in which HIV prevalence is high. In other words, if a person’s sexual partner was not thought to be either a gay man or a migrant from a high prevalence country (such as in sub-Saharan Africa), PEP would not normally be given following sexual exposure.

The guidelines also clarify that, due to the very low risk of infection, PEP is unnecessary following human bites or contact with a discarded needle.

The table below summarises this part of the guidelines.

*When the guidelines say that PEP should be ‘considered’, it should only be given if there is an additional factor which increases the likelihood of transmission, such as particularly high local HIV prevalence, a sexually transmitted infection, acute HIV infection in the source partner, sexual assault or trauma, bleeding (including menstruation) or – in the case of vaginal sex – the HIV-negative male partner not being circumcised.

The guidelines note that 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.

PEP should only be provided when the patient presents within 72 hours (three days) after exposure.

The recommended combination of drugs is Truvada (tenofovir and FTC) and Kaletra (lopinavir and ritonavir). This combination could be modified if the ‘source’ partner was known to be HIV-positive and to have resistance to certain anti-HIV drugs. Another reason to modify the drugs given is if the patient is already taking other medication which may interact with the ARVs (e.g. statins or emergency contraceptives).

Targets suggested by the guidelines include:

• 90% of prescriptions are in accordance with the BASHH guidelines
• 90% of PEP patients take their first dose within 72 hours of exposure
• 75% of patients complete four weeks’ PEP
• 60% of patients return for an HIV test three months after starting PEP.

The guidelines say that people presenting 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.

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 for them to have a print-out of the guidelines in case of difficulties. When a 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 printed out, or take a piece of paper with the web address of the guidance.

The Terrence Higgins Trust helpline, THT Direct, can advise patients who have problems getting PEP while they are still at the A&E department or GUM clinic. Patients can also ask the hospital worker to speak to THT Direct if this would help - 0808 802 1221 (open Monday to Friday 10am-10pm, Saturday and Sunday 12noon to 6pm).

The 2011 UK guidelines for PEP after sexual exposure can be read at www.bhiva.org/PEPSE.aspx