PEP after sexual exposure for HIV

Patient information – PEP after sexual exposure to HIV.

‘Post-exposure prophylaxis’ (PEP) is a course of antiviral medication taken for 4 weeks. The aim is to prevent infection with HIV. It is used in situations where there has been "high risk" for exposure to HIV in the preceding 72 hours. The risk situation discussed in this leaflet is unprotected sex with untreated HIV, or has a high risk for untreated HIV infection. Unprotected sex means sex without a condom, or sex with a condom which breaks or comes off during sex.

Although PEP can be very useful in emergency situations, using condoms during sex and PrEP are more effective way of preventing HIV infection. If you have taken PEP more than once in the past year, you should ask your doctor/health care worker at your local sexual health clinic about PrEP.

What is HIV?
HIV stands for ‘human immunodeficiency virus.’ It is a virus which damages a person’s immune system and puts them at risk of a range of serious illnesses. AIDS (acquired immunodeficiency syndrome) is a term used to describe advanced HIV with complications. Nowadays people diagnosed with HIV start treatment early, therefore very few develop AIDS conditions. Thanks to HIV treatment/antiretroviral treatment (ART) people living with HIV enjoy good health and have a normal life expectancy. Unfortunately, ART cannot get rid of HIV from the body and it has to be taken for life.

Do I need to take PEP?
You should seek advice if, in the last 72 hours if you believe you may have had unprotected sex with someone who has untreated HIV

Even if the person you have had contact with (the source) is known to be HIV positive, it does not automatically mean that you will be infected. The chances of becoming infected depend on several factors including;

 The type of exposure e.g. receptive anal sex ("bottom" or "passive anal sex" carries a higher risk of infection than insertive anal sex ("top" or active anal sex") or vaginal sex.

 The presence of other sexually transmitted infections (STIs), ulcers, and ejaculation all increase the risk of transmission.

 If the source is known to have HIV, the risk of transmission depends on the amount of virus present (viral load), and whether they are taking HIV medicine (ART)

 People living with HIV on ART with an undetectable viral load in their blood have a negligible risk of sexual transmission of HIV. (Undetectable=Uninfectious)

If you think you need PEP ask for help immediately. Do not delay, as every hour counts. The tablets work best if taken ideally within 4 hours of exposure. There is no strong evidence for its use beyond 72 hours after exposure. It is important for you to know that PEP is not always needed after unprotected sex. Health professionals can help determine your recent risk and whether you will benefit from PEP. PEP reduces the risk of being infected but it is NOT A GUARANTEE that you will not be infected.

What does PEP treatment involve?
The most common PEP prescribed in a combination of 3 different HIV medicines-tenofovir, emtricitabine and isentress which you take every day for a month. You will receive a "start dose" from the doctor at the clinic and then an electronic prescription (e-resept) which you can pick up from the pharmacy. Bring your photo identification. You will receive a one month supply of medication. It is free of charge.

All hospital pharmacies should have PEP in stock. Some local pharmacies, may not have PEP in stock. DO NOT WAIT to order it in. In Oslo the following community pharmacies should always have the medication in stock.

 Apotek 1, Storgata 8, 0155 Oslo

 Vitus Apotek, Jernbanetorget 4B, 0154 Oslo (open 24 hours a day, 7 days a week)

 Apotek 1 Legevakten, Storgata 40, 0182 (open 24 hours a day, 7 days a week)

PEP is usually taken for 30 days and then stopped. Most side effects are mild. Tests (blood and STI testing) will be taken the day you start PEP, as well as during and after the treatment. The final HIV test is taken 12 weeks AFTER you started PEP. Part of the assessment and follow up care is to offer vaccination against Hepatitis B, advice regarding Hepatitis C, and other STI (sexually transmitted infections) e.g syphilis, chlamydia, gonorrhea.

Where can I get PEP?
You can get PEP from every legevakt (accident and emergency) in Norway. Oslo Legevakt, Storgata 40 is open 24 hours a day, 7 days a week. It is important that you tell the clinical staff that you think you need PEP. They will make sure that you are seen as soon as possible. PEP medicine is free of charge

How soon should I start PEP?
As soon as possible, because the sooner the treatment is taken, the better it works. PEP can offer protection if it is started up to 72 hours after a risk has happened.

How long do I take PEP?
PEP needs to be taken for a month. It is important to take the full course of treatment to get the full benefit from it.

What medicines are in PEP?
PEP is usually a combination of two yellow tablets containing raltegravir 600mg (marketed as Isentress®) TOGETHER WITH one blue tablet that contains two medicines: tenofovir and emtricitabine, once daily. Some countries use different ART as PEP (e.g. raltegravir 400mg, one pink tablet taken morning and evening with emtricitabine/tenofovir). In certain situations, your doctor may give you treatment other than raltegravir and emtricitabine/tenofovir.

How do I take PEP?
It will be written on the prescription, however it is usually two raltegravir tablets (yellow) and one emtricitabine/tenofovir tablet (blue) every day. After the first dose, you should take the medicines as follows:

Raltegravir (Isentress®) two yellow tablets taken together, every day for 4 weeks

Emtricitabine/tenofovir: one blue tablet taken every day for 4 weeks

NB: All 3 tablets should be taken together, at around the same time every day, for 4 weeks.

Does PEP have any side effects?
PEP is safe and most people who take it will have no side effects. However, like all medicines, raltegravir and emtricitabine/tenofovir can sometimes cause unwanted symptoms. Commonly reported problems (up to 1 in 10 patients) include feeling sick/ nauseated, bloated, tired, dizzy, having diarrhoea (loose or watery bowel motions), loss of appetite, trouble sleeping, headache and stomach ache. They are usually mild and don’t last very long. However, if the side effects are problematic or making it difficult for you to continue taking PEP you should contact your provider / the department where you started PEP.

If you get a skin rash or flu-like illness while taking PEP this may be an allergic reaction to the medication. However, the same symptoms can occur in HIV infection. So if you develop a skin rash or a flu-like illness while taking PEP or in the weeks after you stop taking PEP, you should contact your doctor as soon as possible.

What tests do I need?
 Blood tests: It is important to have an HIV test before you start taking PEP to make sure you are not already infected. Tests to check your liver and kidneys are taken because PEP can cause liver or kidney damage, although this is extremely rare.

 STI tests for chlamydia, gonorrhea, syphilis, hepatitis B and C

 Hepatitis B vaccination: If you are not already vaccinated against hepatitis B, a course should be commenced (because hepatitis B virus can also be caught during sex). Some risk groups have a higher risk for hepatitis B infection. Vaccination for these groups is provided free of charge. You can read more about this here: https://www.fhi.no/sv/smittsomme-sykdommer/hepatitt/hepatitt-b/

Does PEP work?
The risk of catching HIV from a single sex act is very small. However, research shows that becoming infected with HIV is less likely if you take PEP properly and within a defined period. However PEP does not work every time and some people may be infected with HIV despite taking it. PEP is less likely to work if you miss tablets or if you don’t complete the full course (1 month)

What do I do if I forget to take PEP?
Less than 24 hours late: take the missed dose immediately and then take the next dose at the normal time.

24–48 hours late: don’t take the dose(s) you have missed. Wait until your next dose would have been due and then start to take your PEP again as normal.

More than 48 hours late: stop taking PEP and contact your provider for follow up testing

Can I take PEP if I am pregnant?
Yes. ART like raltegravir and tenofovir/ emtricitabine are taken by HIV positive women in their pregnancies. If you are pregnant or breastfeeding, please tell the doctor. They will discuss the benefits and risks of PEP with you.

What should I do if I am taking other medication?
It is very important to tell the doctor about any other medication you are taking. This includes over-the-counter medicines and herbal preparations. The doctor can check that these won’t stop PEP from working. Some indigestion treatments (like antacids e.g, Link, Gaviscon) and vitamin tablets can interfere with PEP. So check with the doctor before taking any other kind of medicine, tablet or herbal preparation when taking PEP

Can I have sex while taking PEP?
We advise you to have protected sex (with a condom) until you have your final HIV test. The final HIV test is 12 weeks after you started PEP. Free condoms are available at your local sexual health clinic or can be ordered online https://www.gratiskondomer.no/bestill/en/.

Who can support me through this time?
Doctors and nurses in the sexual health clinic are there to support you. They can also put you in touch with voluntary agencies and charities in the community. If you feel able to talk to friends or family during this time you may find it very helpful.

What happens after I finish PEP?
The clinic will advise you to have repeated testing for HIV, syphilis and hepatitis C. You should also consider if you are a candidate for PrEP.

Resources: 

https://www.bashh.org/guidelines

https://www.legeforeningen.no/foreningsledd/fagmed/norsk-forening-for-infeksjonsmedisin/aktuelt/2020/hiv-retningslinje-2020/

Authors:

Åse Haugstvedt, overlege, Nasjonal kompetansetjeneste for seksuelt overførbare infeksjoner og Olafiaklinikken.

Michelle Hanlon, overlege, Olafiaklinikken

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