PEP Quick Guide for Occupational Exposures

 

PEP Quick Guide
Updated: June 26, 2017.

These CCC post-exposure prophylaxis (PEP) recommendations will help you with urgent decision-making for occupational exposures to HIV and hepatitis B and C. Consultation can be obtained from Occupational Health or Employee Health Services, local experts, or the CCC’s PEPline. The PEPline (888-448-4911) is available daily from 9 a.m. – 9 p.m. EST (6 a.m. – 6 p.m. PST). Note: Our hours have changed.

Commonly Asked Questions

Initial Evaluation: Assessing Exposures and Testing

What is considered to be a potential exposure to HIV, HBV or HCV?
For transmission of blood borne pathogens (HIV, HBV and HCV) to occur, an exposure must include both of the following:
• Infectious body fluid
o Blood, semen, vaginal fluid, amniotic fluid, breast milk, cerebrospinal fluid, pericardial fluid, peritoneal fluid, pleural fluid and synovial fluid can transmit HIV, HBV and HCV.

• Note that saliva, vomitus, urine, feces, sweat, tears and respiratory secretions do not transmit HIV (unless visibly bloody). The risk of HBV and HCV transmission from non-bloody saliva is negligible.

• A portal of entry (percutaneous, mucous membrane, cutaneous with non-intact skin).

If both of these factors are not present, there is no risk of transmission and further evaluation is not required.

What baseline testing should be performed after an exposure?
Source Person (SP):
• HIV Ag/Ab or HIV Ab (rapid HIV testing preferred if accessible)*
• HCV Ab or HCV RNA (HCV viral load). CDC prefers HCV RNA
• HBV surface Ag
*If SP’s rapid HIV test is positive, assume this is a true positive and send confirmatory/supplemental testing. See below*.
Exposed Person (EP):
(If no exposure occurred or SP is confirmed negative on baseline testing, no baseline testing is clinically indicated for the EP. Testing may be considered for other purposes including medicolegal concerns or as per institutional protocols. For bites, see “How should a human bite be managed?”)
• HIV Ag/Ab or HIV Ab
• HCV Ab
• HBV testing: Depends on immunization status.
Note that most healthcare and public safety personnel have been vaccinated against hepatitis B. If previously vaccinated and they know they responded to the vaccination series (a positive titer is ≥10mIU/mL), they are considered to have lifelong immunity and require no further testing or treatment. Similarly, if employee health records indicate they responded to the vaccination series, they can be considered immune. For all others, see the “Exposures to HBV” section of this guide.

*Is a rapid HIV test accurate enough to decide on whether to give PEP?
Yes, rapid HIV tests are generally very sensitive and specific, and can be used to determine whether to offer PEP. A positive rapid HIV test should be preliminarily considered a true positive for the purposes of PEP decision-making. A negative rapid test should be considered a true negative. Investigation of whether a source might be in the “window period” is unnecessary for determining whether HIV PEP is indicated unless acute HIV (acute retroviral syndrome) is clinically suspected.
(See What if the source might be in the “window period” for HIV? below).

Deciding Whether to Give HIV PEP

What is the time frame for using PEP?
Efficacy is time sensitive: first dose should be given as soon as possible. Optimal time to start PEP is within hours of exposure, rather than days. Do not wait for SP test results (unless results will be available within an hour or two) to proceed with a PEP decision and initiation, when indicated. The PEPline considers 72 hours post-exposure as the outer limit of opportunity to initiate PEP; however, a delay of that scale is believed to compromise PEP efficacy. The 72-hour outside limit recommendation is based on animal studies; no human data are available.
Note: PEP should be initiated as soon as possible; if additional information indicates PEP might not be needed (e.g., source person is confirmed to be HIV negative), PEP can always be discontinued.

What is the risk of HIV transmission?

Route of exposure Risk of exposure when source person is HIV positive Factors increasing risk
Percutaneous ~ 1/435 episodes (0.23%) hollow bore needles, visibly bloody devices, deep injury, and device used in an artery/vein
Mucous membrane ~ 1/1000 episodes (0.09%) large volume
Cutaneous < 1/1000 episodes (0.09%) must involve non-intact skin integrity

Note: These estimates are from exposures to blood; risk for transmission from infectious fluids other than HIV-infected blood is probably considerably lower than for blood exposures.

Is PEP always recommended if the source person is HIV infected?
PEP is generally recommended when an exposure to an HIV positive person has occurred.
(See What is considered to be a potential exposure to HIV, HBV or HCV?)
• Additional source person information (e.g., the SP’s current or most recent viral load, HIV treatment, history of resistance to HIV medications) can be helpful in PEP decision-making including regimen selection. Initiation of PEP should not be delayed if this information or consultation is not available. Additionally, for an HIV positive SP who has been durably suppressed on HIV medications, transmission risk to the exposed person is significantly lowered.

Is PEP recommended if the source person has an unknown HIV status?
PEP is generally not warranted in cases of unknown status. However, consider PEP for exposures from a source with HIV risk factors. If questions exist, seek expert consultation.

Is PEP recommended if the source person is unknown (e.g. sharps box injury)?
PEP is generally not warranted in cases of an unknown source person. However, consider PEP in settings where exposure to HIV-infected persons is likely.

Should PEP be given if it is uncertain whether the exposure constitutes a significant risk?
If consultation is not available within a few hours, PEP can be started and then consultation may be obtained at a later time, although timely and comprehensive assessment is key.

What if the source person might be in the “window period” for HIV?
If the source person’s HIV test is negative at the time of the exposure, they are generally considered uninfected and HIV PEP is not recommended.
• The “window period” for HIV Ab seroconversion (the period between initial HIV acquisition/infection and development of detectable HIV antibodies) can cause patient and provider anxiety. The Guidelines state, “To date, no transmission to health care workers from an exposure source during the window period has been detected in the United States.”
• Therefore, investigation of whether a source person might be in the “window period” is unnecessary for determining whether HIV PEP is indicated unless acute HIV is clinically suspected, or recent (within the previous 1-2 months) high-risk exposure has occurred. If acute HIV is highly suspected, PEP should be started while an HIV RNA PCR (“viral load”) is sent from the source person.

Is PEP recommended for a person who was stuck with a sharp device (e.g. needle, razor) from an unknown source outside of a healthcare setting?
This common occurrence falls into the classification of exposure to blood/body fluid from an unknown SP. A “found needle” is the classic occurrence. No documented cases of HIV transmission from a “found needle” outside of a healthcare setting in the US have occurred. Therefore, the PEPline generally discourages PEP in these cases. Even within health care settings, “found needles” have only been implicated in two cases of transmission over the past two decades.

How should a human bite be managed?
• Human bites can result in exposures to both the biter and the bitten person. The bitten sustains a cutaneous exposure to HIV if blood was present in the mouth of the biter before the bite. The biter sustains a mucous membrane exposure to HIV if blood from the bitten person enters the oral cavity of the biter.
• If the saliva is non-bloody, there is no HIV transmission risk to the bitten. The risk of HBV and HCV transmission from non-bloody saliva is negligible.

HIV PEP: What to Give

How to choose a PEP regimen?
Three-drug PEP regimens are now the recommended regimens for all exposures. The most recent Guidelines no longer require assessing the degree of risk for the purpose of choosing a “basic” two-drug regimen vs. an “expanded” three-drug regimen, which was confusing for many treating clinicians. There are some special circumstances, however, in which a two-drug regimen can be considered/used, especially when recommended antiretroviral medications are unavailable or there is concern about potential toxicity or adherence difficulties. In addition, the Guidelines state, “PEP is not justified for exposures that pose a negligible risk for transmission.” Consultation with an expert can help determine if the exposure poses a “negligible risk” to explore whether alternative approaches, including a modified regimen, are appropriate.

PREFERRED HIV 3-DRUG OCCUPATIONAL PEP REGIMEN:

Truvada™ 1 tablet by mouth once daily
[co-formulated Tenofovir DF (Viread®; TDF) 300mg + emtricitabine (Emtriva™; FTC) 200mg]

PLUS

raltegravir (Isentress®; RAL) 400mg by mouth twice daily
or
dolutegravir (Tivicay™) 50mg PO once daily

Duration: 28 days

ALTERNATIVE REGIMENS*
May combine one drug or drug pair from the left column with one pair of nucleoside/nucleotide reverse transcriptase inhibitors from the right column.

Raltegravir (Isentress® ; RAL) Tenofovir DF (Viread® ; TDF) + emtricitabine
(Emtriva™ ; FTC); available co-formulated as Truvada™
Dolutegravir (Tivicay™; DTG) Tenofovir DF (Viread® ; TDF) + lamivudine
(Epivir® ; 3TC)
Darunavir (Prezista® ; DRV) + ritonavir (Norvir® ; RTV) Zidovudine (Retrovir™ ; ZDV; AZT) + lamivudine (Epivir® ; 3TC); available co-formulated as Combivir®
Atazanavir (Reyataz® ; ATV) + ritonavir (Norvir® ; RTV) Zidovudine (Retrovir™ ; ZDV ; AZT) + emtrictabine (Emtriva™ ; FTC)
Lopinavir/ritonavir (Kaletra® ; LPV/RTV)
Etravirine (Intelence® ; ETR)
Rilpivirine (Edurant™ ; RPV)

*Note: For additional information on dosing, drug-drug interactions and toxicities, and toxicity monitoring, see the antiretroviral drug tables in the Pharmacy section of the CCC website.

ARV Drug Dosing and Toxicity Monitoring*

HIV meds Adult Dosing Combination Form Toxicity monitoring
Tenofovir DF 300 mg by mouth once daily Truvada™ BUN, Creatinine, LFTs
Emtricitabine 200 mg by mouth once daily Rash
Raltegravir 400 mg by mouth twice daily Nausea, headache
Dolutegravir 50 mg by mouth once daily Headache, insomnia
Zidovudine 300 mg by mouth twice daily Combivir® CBC, LFTs
Lamivudine 150 mg by mouth twice daily Rash
Lopinavir/ritonavir
(200/50 mg)
2 tabs by mouth twice daily Kaletra® GI toxicity, especially diarrhea. LFTs
*Note: Lopinavir/ritonavir has many drug-drug interactions with common medications; use with caution (see below).

*Note: For additional information on dosing, drug-drug interactions and toxicities, and toxicity monitoring, see the antiretroviral drug tables in the Pharmacy section of the CCC website.

How long is PEP taken?
PEP is taken for 28 days. If source person testing is negative for HIV, PEP can be stopped before 28 days.

How to monitor and manage side effects of PEP?
Side effects can be a limiting factor in PEP adherence. Side effects are generally self-limited but sometimes can last the duration of the 28-day PEP course. Gastrointestinal side effects (nausea, vomiting, GI upset, diarrhea) are most common. Headache, fatigue, and insomnia are other side effects. Antiemetic and antidiarrheal medications can be prescribed to help with adherence. If side effects are severe, consider changing to a different regimen. Toxicities are rare with the current preferred regimens, are generally not life-threatening and are reversible once PEP medications are stopped.
The most important side effect of the preferred regimen, tenofovir DF + emtricitabine (Truvada™) plus raltegravir, is renal toxicity from tenofovir. This regimen should be used with caution in those with impaired renal function or at high risk for impaired renal function.
Lab monitoring for drug toxicity: Test CBC, renal and hepatic function tests at baseline and two weeks after starting PEP.

What are common drug-drug interactions between PEP and the exposed person’s medications?
• There are few significant drug interactions with medications used in first-line PEP regimens. When taking raltegravir and dolutegravir patients should avoid antacids that contain aluminum, magnesium, or calcium as well as iron supplements. Other common medications may have interactions with PEP medications and require dosing adjustments. Consultation with the PEPline or a PEP-experienced clinical pharmacist/clinician is advised for specific questions on drug-drug interactions.

See the antiretroviral drug tables in the Pharmacy section of the CCC website.

Pregnancy and Breastfeeding

How should HIV exposures in pregnant women be managed?
• Starting PEP in pregnant exposed persons should be based on considerations similar to those of non-pregnant exposed persons.
• When deciding to start PEP, a pregnant exposed person should discuss with the treating clinician the potential risks of exposing her fetus to antiretroviral (ARV) medications.
• All pregnant women starting ARVs should be entered in the Antiretroviral Pregnancy Registry, a database designed to collect information on the outcomes of ARV-exposed pregnancies regardless of HIV status: http://www.apregistry.com.

Special considerations
• The pregnant exposed person and her fetus are at risk for HIV acquisition.
• Acute HIV in pregnancy incurs a high risk of vertical transmission.
• The use of most PEP medications can be justified when the benefits outweigh the risk of infant (and maternal) exposure to ARVs.
• Based on limited data, use of ARVs in pregnancy, including in the first trimester, does not appear to increase the risk of birth defects compared to the general population.
• Toxicities from currently recommended PEP medications are not thought to be increased in pregnancy.

PEP options in pregnancy
If PEP is to be started in a pregnant exposed person, reasonable options include:

Tenofovir DF/emtricitabine (Truvada™, TDF/FTC) 1 tab daily + raltegravir (Isentress, RAL) 400 mg twice daily
Pros
• Well-tolerated
• TDF/FTC and RAL are both preferred agents in treating HIV+ pregnant women per current DHHS Perinatal Guidelines
• Very low potential for drug-drug interactions
Cons
• Need for twice daily dosing with RAL

or

Zidovudine/lamivudine (Combivir®, also available as generic, AZT/3TC) 1 tab twice daily +

Darunavir (Prezista®, DRV) 800 mg once daily + ritonavir (Norvir®, RTV) 100 mg daily#

OR

Atazanavir (Reyataz®, ATV) 300 mg# daily + ritonavir (Norvir®, RTV) 100 mg daily

#PK data in pregnant women suggest increasing to DRV 600 mg twice daily + RTV 100 mg twice daily in the 2nd and 3rd trimesters. Similarly, atazanavir should be increased to 400 mg daily in the 2nd and 3rd trimesters.

Pros
• Extensive experience with use of AZT/3TC in pregnancy
• Darunavir/ritonavir as well as atazanavir/ritonavir are preferred agents in treating HIV+ pregnant women per DHHS Perinatal Guidelines
Cons
• More side effects: nausea, vomiting, diarrhea, headache, fatigue
• AZT associated with hematologic toxicity
• High drug-drug interaction potential with darunavir/ritonavir, atazanavir/ritonavir (and other PIs)

Other PEP options may be considered in the event of intolerance, source persons with resistant virus, medication access challenges, or EP preference. In these instances, providers should seek expert consultation.

How should HIV exposures in lactating exposed persons be managed?
• Breastfeeding is not a contraindication for PEP.
• When deciding to start PEP, lactating exposed persons should discuss with the treating clinician the potential risks and benefits of infant exposure to antiretroviral (ARV) medications through breastmilk. The decision to take PEP and/or continue breastfeeding is complex and individualized, and expert consultation is recommended.

Special considerations:
• The lactating exposed person and her infant are at risk for HIV acquisition.
• Acute HIV in a breastfeeding mother greatly increases the risk of HIV transmission to her infant.
• There are somewhat limited data on PEP medications in breastmilk:
o Tenofovir DF and emtricitabine (TDF and FTC, components of Truvada™) and protease inhibitors can be detected in breastmilk only in very limited amounts
o Lamivudine (3TC, Epivir®) can penetrate the breastmilk in significant amounts
o Raltegravir (RAL, Isentress®)—unknown extent of breastmilk penetration
• For women who choose to take PEP, pumping and discarding is an option to allow continuation of lactation while preventing infant ARV and (possible) HIV exposure.
• For women who choose not to take PEP, pumping and storing breastmilk while waiting for the source person’s HIV testing results is an option. This allows continuation of lactation while not exposing infants to PEP medications or potentially to HIV.

Exposures to HBV

How are exposures to HBV managed?
We strongly encourage source person testing for Hepatitis B surface antigen.
• If source person is known to be hepatitis B uninfected, no hepatitis B testing or post-exposure treatment of the exposed person is needed.
• If exposed person is known to be immune (e.g., they were told they had a positive response to a complete HBV vaccine series, indicated by post-vaccination HBsAb titer ≥10 mIU/mL), they are considered to have lifelong immunity and need no hepatitis B testing or post-exposure treatment.


If source person is known to have hepatitis B or the source person’s hepatitis B status is unknown, manage blood exposures as follows:

Recommendations for Post-Exposure Prophylaxis After HBV Exposure

EXPOSED PERSON VACCINATION STATUS TEST RECOMMENDED FOR EXPOSED PERSON TREATMENT
Previously Vaccinated (see below *)
Responder after complete series (HBsAb ≥10 mIU/mL) None No action needed
Response unknown after 3 doses HBsAb If ≥10 mIU/mL: No action needed

If <10 mIU/mL§: check HBcAb (total) as well, administer HBIG** x 1 and revaccinate

Non-responder
(HBsAb <10 mIU/mL after two series of 3 doses)
 HBcAb (total) HBIG** x 2 (one month apart)
Unvaccinated or Incompletely Vaccinated
Unvaccinated or incompletely vaccinated HBcAb (total)
Follow-up at 6 months: HBcAb (total) and HBsAg
HBIG** x 1 and vaccinate/revaccinate
* HBV (vaccine): The series is usually given at baseline, 1 month, and 6 months, followed by HBsAb to confirm immunity (HBsAb ≥10 mIU/mL). For persons previously immunized with the series of 3 immunizations but have negative HBsAb titer when tested at the time of exposure and source patient is negative for HBsAg, a 4th vaccine dose (booster) can be followed with a HBsAb at 4-6 weeks; if this is positive (≥10 mIU/mL) the person is considered immune and no further treatment is needed.

** HBIG: 0.06mL/kg ASAP (max dose: 5mL). HBIG is considered effective up to a week after occupational exposures. Per CDC Guidelines, healthcare personnel (HCP) with anti-HBs <10mIU/mL after complete vaccination series (or who are unvaccinated/incompletely vaccinated), and sustain an exposure to a source person who is HBsAg-positive or has unknown HBsAg status, should undergo baseline testing for HBV infection as soon as possible after exposure, and follow-up testing approximately 6 months later. Initial baseline tests consist of total anti-HBc; follow-up testing consists of HBsAg and total anti-HBc.

§ Healthcare personnel (HCP) with HBsAb < 10 mIU/mL after complete vaccination series or who are unvaccinated/incompletely vaccinated who sustain an exposure to a source person who is HBsAg-positive or has unknown HBsAg status should undergo baseline HBV testing with a HBcAb (total) as soon as possible after exposure, and follow-up testing approximately 6 months later with HBsAg and HBcAb (total) to determine whether HBV transmission occurred.

Note: Testing the exposed HCP for prior HBV infection is not required before vaccinating unless the exposed is at independent risk of HBV infection (e.g., from HBV endemic area). Adapted from: CDC guidance for evaluating health-care personnel for hepatitis B virus protection and for administering postexposure management. MMWR: December 20, 2013

How soon do hepatitis B vaccine and HBIG need to be given?
In general, if hepatitis B vaccine and/or HBIG are required, the sooner they are administered the better. The effectiveness of HBIG when given after 7 days for occupational exposures is unknown.

Exposures to HCV

How are exposures to HCV managed?
• The risk of HCV transmission after percutaneous exposure is about 1 in 56 (1.8%) when the source person is HCV-infected. There is no post-exposure prophylaxis currently available/approved for HCV prevention.
• After review of available studies, guidelines and summary documents, the CCC PEPline recommends the following approach:

Testing Recommendations for the Exposed Person

Recommendations Baseline testing Initial follow-up Final follow-up
PEPline 2017 HCV+ SP [1]
or
SP has potential HCV risk factors [1]
HCV Ab [2] 6 weeks [3]
HCV RNA (HCV viral load)
≥6 months [4][5]
HCV Ab [2]
SP HCV status unknown [1]
or
SP is known and has no known HCV risk factors [1]
Optional:
6 week HCV RNA
CDC 2016 [6] All source persons [1] HCV Ab [2] ≥3 weeks HCV RNA Optional: ≥6 month HCV Ab [2]
CDC 2001 [7] HCV Ab and ALT If earlier diagnosis desired: HCV RNA at 4-6 weeks 4-6 months
HCV Ab and ALT
Abbreviations: HCV+ = hepatitis C positive; SP = source person; Ab = antibody; ALT = aminotransferase
[1] For purposes of initial post-exposure management, a source person is considered HCV-positive if either HCV RNA (HCV viral load) or HCV antibody is positive. HCV RNA, when performed on the SP within a few days of the exposure, is the more accurate indicator of infectivity. For the purpose of deciding whether the source can potentially transmit HCV, HCV antibody can be obtained. Positive HCV antibody, however does not always indicate infectivity because: some patients eradicate HCV naturally but retain HCV antibody; and those with active HCV infection can have fluctuating HCV RNA (viral load) as well as undetectable viral load (and are presumably un-infectious at that time when viral load was undetectable).
[2] If HCV antibody is positive at any point, follow-up HCV RNA testing is required. Persons with confirmed positive HCV RNA results should be referred for further evaluation and care.
[3] The PEPline recommends initial HCV follow-up test at 6 weeks, to coincide with the first HIV follow-up test. There are no data that establish a clinical advantage to testing at 3 weeks vs. 6 weeks [Glynn, et al, Busch, et al, Hajarizadeh, et al]. HCV RNA becomes detectable beginning at 3 weeks. Testing earlier than 6 weeks can be performed at the discretion of the managing clinician, especially if preliminary assessment is needed. Positive HCV RNA indicates likely infection. However, approximately 25% of new infections will clear spontaneously [Naggie, et al]. Refer to an experienced provider for additional counseling, testing, and follow-up if positive.
[4] In HCV infection, HCV RNA can be transiently undetectable [Mosley, et al]. Additionally, HCV antibodies develop slowly. Therefore, even though an early initial negative HCV RNA can be preliminarily reassuring, the PEPline recommends further HCV antibody testing at 6 months (24 weeks) post-exposure to confirm transmission did not occur.
[5] An interval (i.e. 12-16 week) HCV antibody test may provide some reassurance for exposed persons in many instances (and align with HIV surveillance). However: (a) testing at this time point may not impact overall exposure management significantly, and (b) it is not sufficiently sensitive to completely exclude HCV transmission. Even at 15 weeks, only about 80% of HCV-infected persons will have positive HCV Ab [MMWR rr5005a1]. Therefore, the 6 month (24-week) HCV antibody test is considered to be conclusive in excluding HCV acquisition: ≥97% will be positive at 6 months post exposure [MMWR rr5005a1].
[6] Updated Information for Healthcare Personnel Potentially Exposed to Hepatitis C Virus (HCV): Recommended Testing and Follow-up (CDC). Nov 2016. Available at http://www.cdc.gov/hepatitis/pdfs/testing-followup-exposed-hc-personnel-3d.pdf.
[7] Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis. MMWR 2001; 50 (RR11): 1-42.
Note regarding exposed persons with symptoms: Symptoms of a viral illness compatible with acute HCV at any point up to 6 months post-exposure should prompt immediate evaluation.
Note regarding availability and feasibility of HCV RNA testing: HCV RNA testing might not be available or feasible at all institutions.  If it is not possible to obtain the recommended HCV RNA testing, surveillance using antibody testing is essential in assessing HCV transmission.
Note regarding hepatic enzyme testing: The PEPline does not recommend routine liver enzyme testing for follow-up because of the possibility of abnormal results from causes other than HCV.
References cited:
Busch MP, Shafer KAP. Acute-phase hepatitis C virus infection: implications for research, diagnosis, and treatment. Clin Infect Dis. (2005) 40 (7):959-961.
Glynn SA, Wright DJ, Kleinman SH, et al. Dynamics of viremia in early hepatitis C virus infection. Transfusion. 2005 June; 45(6):994–1002.
Hajarizadeh B, Grebely J, Applegate T, et al. Dynamics of HCV RNA levels during acute hepatitis C virus infection. J Med Virol. 2014 Oct; 86(10): 1722–1729.
Mosley JW, Operskalski EA, Tobler LH, et al. The course of hepatitis C viraemia in transfusion recipients prior to availability of antiviral therapy. J Viral Hepat. 2008 Feb;15(2):120-8.
Naggie S, Holland DP, Sulkowski MS, et al. Hepatitis C virus postexposure prophylaxis in the healthcare worker: why direct-acting antivirals don’t change a thing. Clin Infect Dis. 2017 Jan 1;64(1):92-99. Epub 2016 Sep 28.
Recommendations for preventing transmission of infections among chronic hemodialysis patients. MMWR. April 27, 2001;50(RR05):1-43. Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5005a1.htm.

Follow-Up Testing of the Exposed Person

HIV
• If SP is HIV negative, no follow-up testing is clinically indicated for the EP.
• If SP is HIV positive, re-test EP for HIV at 6 weeks and at 3-4 months.

Note: Follow-up testing (as opposed to baseline testing) can be with either a 3rd or 4th generation HIV test. Both reliably identify if HIV infection has occurred, although the 4th generation HIV Ag/Ab test is preferred for diagnosing acute HIV.  A 4th generation test would not necessarily provide important advantages in post-exposure follow-up beyond the first month (or so) after an exposure. Follow-up HIV testing is not needed out to 6 months, as final testing at 3-4 months is sufficient to identify whether transmission has occurred. These PEPline recommendations are slightly different from the USPHS occupational PEP Guidelines, and consistent with the more recent USPHS non-occupational PEP Guidelines.

• Extended HIV testing to 12 months is indicated only for HCP who actually acquire HCV infection after exposure to an HCV-HIV co-infected source person.
• If SP cannot be tested for HIV or SP is unknown, testing should be as above.
• Symptoms of acute HIV should prompt immediate evaluation.

HBV (See Exposures to HBV)
• If SP is HBV negative, no follow-up testing is clinically indicated for the EP.
• Follow-up testing is only necessary for exposed persons who do not have hepatitis B immunity (i.e., do not have baseline positive HBsAb after complete vaccine series or do not have knowledge that they responded to the vaccine series).
• For those who do not have HBV immunity, see section on HBV.
• Symptoms of acute hepatitis should prompt immediate evaluation.

HCV (See Exposures to HCV)
• If SP is HCV negative, no follow-up testing is clinically indicated for the EP.
• See section on HCV for testing protocols.
• Symptoms of acute hepatitis should prompt immediate evaluation.

Guidance for Exposed Persons

What do I do if I am the exposed individual?
Exposure to HIV, HBV, and HCV requires immediate evaluation by a medical professional (e.g., emergency room, urgent care, Occupational/Employee Health service, primary care provider). Report your exposure to your supervisor immediately.

For a comprehensive description of HIV post-exposure management, see the 2013 CDC occupational post-exposure prophylaxis guidelines:

  • Updated US Public Health Service Guidelines for the Management of Occupational Exposures to Human Immunodeficiency Virus and Recommendations for Postexposure Prophylaxis, 2013
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