University of California, San Francisco |
Updated: October 2025
Provisional Guidance Notice:
Updated HIV post-exposure management guidance from the NCCC is being shared to reflect recent changes to clinical practice recommendations. The HRSA review and clearance process is currently experiencing delays; final NCCC content will be posted once the review and approval process is complete.
NCCC’s post-exposure prophylaxis (PEP) guide aims to provide useful information to assist with urgent decision-making for occupational and non-occupational exposures to HIV, hepatitis B, and hepatitis C. Individualized consultation can be obtained from the PEPline, as well as Occupational Health/Employee Health Services groups and/or local experts. The CDC’s post-exposure guidelines and other relevant resources can be accessed on our PEP Guidelines page. Please visit the PEPline webpage for current service hours and availability.
Commonly Asked Questions
Initial Evaluation: Assessing Exposures and Baseline Testing
- Lightly wash needlestick/cut exposed area with soap and water
- Flush splashes to the nose, mouth, or skin with water
- Irrigate eyes with clean water, saline, or sterile irrigants
What is considered to be a potential exposure to HIV, HBV or HCV?
For transmission of bloodborne pathogens to occur, an exposure must include BOTH of the following:
- Infectious body fluid: Blood, semen, cervicovaginal fluid, amniotic fluid, breast milk, cerebrospinal fluid, pericardial fluid, peritoneal fluid, pleural fluid and synovial fluid can potentially transmit HIV, HBV and HCV;
AND…
- 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 bloodborne pathogen (HIV, HBV, HCV) transmission and further clinical evaluation for PEP initiation is not required.
Note that saliva, vomitus, urine, feces, sweat, tears and respiratory secretions do not transmit HIV (unless visibly bloody). The risks of HBV and HCV transmission from non-bloody saliva are considered negligible. Therefore, the PEPline does not recommend routine HIV, HBV or HCV surveillance testing following exposure or possible exposure to non-bloody saliva.*
* Note: Federal guidelines consistently emphasize that non-bloody saliva does not carry risk for transmitting HIV, as it is not considered infectious for HIV. Federal guidelines on hepatitis B and hepatitis C are less clear: they emphasize that certain non-bloody fluids, including saliva, are unlikely to transmit those viruses but do not make specific recommendations about follow-up testing. In the absence of standardized guidelines regarding this concern, the PEPline recommendation above regarding surveillance testing has taken various factors into consideration. Given the negligible risk (if any) of transmission from non-bloody saliva, the potential advantages of follow-up testing are likely outweighed by various disadvantages. Local regulations (e.g., state, hospital, or practice protocols/guidelines) may differ.
What baseline testing should be performed after an exposure?
Source Person (SP):
- HIV Ag/Ab or HIV Ab (expedited testing is strongly preferred if accessible, so that results are available within hours of the exposure)*. For source persons known to be living with HIV, obtain information on recent HIV RNA (“HIV viral load”) testing and results. For source persons who have been on long-acting injectable medications as HIV pre-exposure prophylaxis (PrEP), additional testing may be considered – consider seeking expert guidance.
- Testing for HBsAg (HBV surface antigen) alone is generally sufficient to inform management of exposed persons. If possible, consider comprehensive, triple HBV screening of source persons (i.e., HBsAg, total HBcAb, and HBsAb) to facilitate universal HBV screening.
- HCV Ab or HCV RNA (“HCV viral load”)
*Note: If the SP’s HIV screening test is positive/reactive, assume this is a true positive for purposes of initial PEP decision-making and send additional, supplemental testing (e.g., differentiation immunoassay and/or nucleic acid testing) to confirm SP status. If a point-of-care (“rapid”) assay was used for initial screening and results are positive/reactive, repeat testing as soon as possible using a laboratory-based (instrumented) test.
Exposed Person (EP):
If no bloodborne pathogen exposure occurred, or the SP is confirmed negative on baseline testing, then no baseline testing is clinically indicated for the EP. Testing can be considered for other purposes, including medicolegal concerns or as per institutional protocols (for occupational scenarios) and to facilitate increased HIV/viral hepatitis and STI screening in general (for non-occupational scenarios). For bites, see “How should human bites be managed?”
- HIV Ag/Ab or HIV Ab. For exposed persons who have been on long-acting injectable medications as HIV pre-exposure prophylaxis (PrEP), additional testing may be considered – consider seeking expert guidance.
- HBV testing: Based on immunization status.
- HCV Ab (if positive, follow-up with HCV RNA testing)
Note that most healthcare and public safety personnel have been vaccinated against hepatitis B. Additionally, the hepatitis B vaccine was incorporated into routine childhood immunizations in the United States beginning in 1991. Immunocompetent persons who previously received a complete vaccine series and have subsequent documentation of sufficient antibody response are considered to have lifelong immunity and require no further post-exposure testing or treatment. [Specifically, immunocompetent persons with vaccine-induced anti-HBs levels of ≥ 10 mIU/mL 1-2 months after series completion are considered seroprotected and deemed “vaccine responders”.] If employee health records indicate they responded to the vaccine series, they are typically considered immune. For all others, see the “Exposures to HBV” section of this guide.
For SP testing, is a “rapid” HIV test accurate enough to decide whether to initiate PEP?
Rapid (or “point of care”) HIV tests provide preliminary results within 20-30 minutes at the testing location; by contrast, laboratory-based tests involve specimen processing at a designated laboratory, typically using specific instruments/machines. Overall, FDA-approved rapid HIV tests are very sensitive and specific, and can be used to determine whether to start PEP. A positive (reactive) rapid HIV test should be preliminarily considered a true positive for purposes of initial PEP decision-making. A negative (non-reactive) rapid test should be considered a true negative. Investigation of whether a source might be in the “window period” is usually unnecessary for determining whether HIV PEP is indicated, unless acute HIV infection (e.g. acute retroviral syndrome) is clinically suspected or the SP has had recent/ongoing exposures of concern.
Deciding Whether to Give HIV PEP
Efficacy is time sensitive: the first dose should be given as soon as possible*. The optimal time frame to start PEP is believed to be within hours of exposure, rather than days. Managing providers should not wait for SP results (unless they will be available within 1-2 hours) to decide on medication initiation when PEP is indicated. The PEPline generally considers 72 hours post-exposure as the outer limit of opportunity to initiate PEP: this is largely based on animal studies, and no clinical data are available that definitively establish an outer limit of PEP effectiveness. Consultation with the PEPline or an expert is recommended if considering PEP initiation beyond 72 hours.
* Note: Exposures to HIV are considered medically urgent/emergent and therefore PEP should typically be initiated as soon as possible. If additional information subsequently becomes available that the source person does not have HIV, PEP can be discontinued.
What is the likelihood of HIV acquisition, by type of exposure, if the source is a person with HIV who is NOT virologically suppressed on treatment?
| Type of exposure | Estimated risk of HIV acquisition (per 10,000 exposures) ** |
|---|---|
| Mucous membrane | |
| Receptive anal intercourse | 138 |
| Insertive anal intercourse | 11 |
| Receptive vaginal-penile intercourse | 8 |
| Insertive penile-vaginal intercourse | 4 |
| Oral intercourse | < 1 in 10,000 |
| Other (e.g., splash during occupational exposure) | ~ 1/1000 (large volume splash may confer increased risk) |
| Parenteral | |
| Blood transfusion | 9,250 |
| Sharing injecting equipment/needles | 63 |
| Percutaneous (e.g., occupational needlestick) | 23 (hollow bore needle, visibly bloody device, deep injury, and/or device used in artery/vein are factors that may confer increased risk) |
| Cutaneous | < 1/1000 (must involve non-intact skin) |
Is PEP always recommended if the source person is living with HIV?
PEP is typically recommended for recent exposures which present substantial risk for HIV acquisition: this may include exposures involving a source person with HIV where the source does not have sustained virologic suppression or viral suppression information is unknown. (See “What is considered to be a potential exposure to HIV, HBV or HCV?” above)
- Data are clear that, when the source person has sustained virologic suppression on ART, sexual transmission does not occur (“U=U”). Although there is no direct evidence for applying “U=U” to occupational scenarios, the per-act transmission risk for occupational exposures is overall lower than that for many sexual exposure scenarios. Therefore, it can reasonably be inferred that occupational transmissions should also not occur for exposures where the source has an undetectable viral load on ART. A case-by-case determination with shared decision-making should be made for exposures (non-occupational and occupational) involving a source person with HIV, guided by the nature of the incident. Potential side effects of PEP, monitoring, and other relevant considerations should be taken into account.
- Importantly, for exposed persons interested in starting PEP, medication initiation should not be delayed or withheld if the source person’s HIV viral load and/or treatment information or consultation are not immediately available. PEP can be discontinued once additional information becomes available confirming no substantial risk for HIV acquisition. Further, for exposed persons who anticipate potential future exposures, PEP can be initiated and the exposed person can be linked to a PrEP service provider to share information on HIV pre-exposure prophylaxis (PrEP) options (see“What if the exposed person is interested in PrEP for future exposures?” below or visit our PrEP Quick Guide).
Is PEP recommended if the source person has an unknown HIV status, or if the source person identity is unknown (e.g., sharps box injury in healthcare setting)?
PEP may be considered in cases of unknown source person status, and the decision to initiate PEP should involve individualized, shared decision-making based on accurate exposure assessment and a discussion of the potential side effects of PEP, monitoring, and other relevant considerations. For scenarios where the source person’s identity is known, every effort should be made to determine their HIV status. However, PEP initiation should not be delayed while coordinating source person testing (e.g., medications can be started and then later discontinued if the source is determined not to have HIV infection). For scenarios where the source cannot be identified and/or tested, PEP should be considered on a case-by-case basis to determine if there is a substantial risk for HIV acquisition—if questions exist, seek expert guidance. For exposed persons who anticipate potential future exposures, PEP can be initiated and the exposed person can be linked to a PrEP service provider to share information on HIV pre-exposure prophylaxis (PrEP) options (see “What if the exposed person is interested in PrEP for future exposures?” below).
Should PEP be initiated if it is uncertain whether the exposure constitutes a significant risk?
If consultation is not available within a few hours, PEP can be started pending consultation. Timely and accurate assessment is key, and PEP can be discontinued later if the final decision is that PEP is not indicated.
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 PEP is not recommended.
- Although concerns about the “window period” for HIV seroconversion (the period between initial HIV acquisition and development of detectable HIV antibodies) have been identified, no instances of occupational transmission during the window period have been reported in the United States to date. For non-occupational exposures, additional evaluation may be helpful to guide initial management of the exposed person.
- Investigation of whether a source person might be in the “window period” is typically unnecessary for determining whether HIV PEP is indicated unless acute HIV is clinically suspected, or the source has had recent (within the previous 1-2 months) exposure to HIV. If acute HIV is suspected, PEP should be started while HIV testing (including an HIV RNA) is completed for the source person.
Note that only ~50-60% of persons with acute HIV develop symptoms, typically presenting as a non-specific viral syndrome 2-10 weeks after infection.
Is PEP recommended for persons who were stuck with a sharp device (e.g. needle, razor, other instrument) from an unknown source outside of a healthcare setting?
This common occurrence falls into the classification of possible exposure to blood/body fluid from an unknown community source. No cases of HIV transmission from a “found needle” outside of a healthcare setting in the United States have been documented to date. Therefore, the PEPline generally discourages PEP in these scenarios and advises careful shared decision-making with exposed persons, considering various factors such as: nature/severity of the exposure, route of injury, amount of potentially infectious material involved, and epidemiologic likelihood of HIV exposure. Even within healthcare settings, “found needles” have only been implicated in two cases of transmission over the past two decades.
What if the exposed person has been on PrEP?
If the exposed person has been on PrEP and adherent with doses as prescribed, PEP is generally not necessary. Given varying guidelines and data on “levels of protection” conferred by different PrEP options/exposure scenarios, expert guidance may be helpful for determining whether PEP should be considered.
How should human bites be managed?
- Human bites can result in exposures to both the biter and the bitten person. The bitten sustains a cutaneous exposure if blood was present in the mouth of the biter before the incident involving broken skin. The biter sustains a mucous membrane exposure 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 PEPline does not recommend routine HIV, HBV or HCV surveillance testing following exposures or possible exposures to non-bloody saliva (see above).
HIV PEP: What to Give
Three-drug PEP regimens are now considered the standard approach for all exposures. There are some special circumstances in which a two-drug regimen can be considered, e.g., recommended agents are unavailable or concern for potential toxicity or adherence challenges. Consultation is recommended if a two-drug regimen is considered.
PREFERRED 3-DRUG HIV PEP REGIMENS (WITH DOSING INFORMATION) FOR MOST ADULTS AND ADOLESCENTS WITHOUT RELEVANT CONTRAINDICATIONS*:
| Co-formulated bictegravir (BIC)/emtricitabine (FTC)/tenofovir alafenamide (TAF) [Biktarvy®] 50/200/25mg, 1 tablet by mouth once daily
OR Dolutegravir (DTG) [Tivicay®] 50mg, 1 tablet by mouth once daily
Duration: 28 days Side effects and drug-drug interactions are described below *For people with renal/hepatic impairment, please see other section for medication selection and dosing recommendations. |
How long is PEP taken?
PEP is taken for 28 days. If source person testing is negative for HIV, PEP should be discontinued.
How to monitor and manage side effects of PEP?
Side effects are typically self-limited but can occasionally affect medication adherence. Gastrointestinal side effects (upset stomach, nausea, vomiting, diarrhea) are most common and can be relieved with antiemetic and/or antidiarrheal agents as needed. Headache, fatigue, and insomnia can also occur. If side effects are severe, consider regimen modification or PEP discontinuation. Toxicities are rare with currently preferred regimens, generally not life-threatening, and reversible once PEP medications are stopped.
The most important concern with currently preferred agents is potential renal toxicity associated with tenofovir disoproxil fumarate (TDF) and, to a lesser extent, tenofovir alafenamide (TAF). Given the limited duration of PEP use, clinically significant changes in renal function and other adverse events are rare with tenofovir when it is taken as part of a PEP combination. However, exposed persons with impaired renal function at baseline or who are at elevated risk for developing renal disease may require dose adjustments and/or additional monitoring. Consultation may be helpful if a tenofovir-sparing PEP regimen is desired.
Additionally, liver disease with decompensated cirrhosis may limit use or require dose adjustment for some PEP agents. For exposed persons with hepatitis B, consultation may be helpful to guide monitoring after PEP completion.
Lab monitoring for drug toxicity: check renal and hepatic function tests (serum creatinine, aspartate transaminase, alanine transaminase) at baseline. Follow-up laboratory monitoring with repeat testing of kidney and liver function while on PEP is no longer considered necessary unless baseline results are abnormal or there are clinical indications for additional monitoring.
What are key drug-drug interactions between PEP and commonly used medications?
There are important drug interactions between polyvalent cations (e.g., calcium, aluminum, magnesium, iron) and both bictegravir and dolutegravir. Bictegravir (and dolutegravir) should be taken two hours before or six hours after medications or supplements containing polyvalent cations. Alternatively, bictegravir (and dolutegravir) can be co-administered with calcium- or iron-containing products but only if taken with food. Consult the PEPline or a PEP-experienced clinical pharmacist/clinician for additional questions on specific drug-drug interactions.
What if the exposed person is interested in PrEP for future exposures?
For individuals who initiate PEP and are interested in transitioning to PrEP once PEP has been completed, timely referral/linkage to a PrEP service provider is recommended to provide more information about available PrEP options and formulate an individualized care plan, including plans for repeat HIV testing. Additional expert guidance may be helpful.
For more information, please refer to our PrEP Quick Guide.
PREFERRED AND ALTERNATIVE REGIMENS FOR PATIENTS WITH RENAL DYSFUNCTION OR HEPATIC IMPAIRMENT:
| Moderate renal dysfunction (creatinine clearance (CrCl) 30-49 mL/min)*
Preferred combinations include co-formulated bictegravir (BIC)/emtricitabine (FTC)/tenofovir alafenamide (TAF) [Biktarvy®] 50/200/25mg, 1 tablet by mouth once daily OR Dolutegravir (DTG) [Tivicay®] 50mg, 1 tablet by mouth once daily plus co-formulated tenofovir alafenamide (TAF)/emtricitabine (FTC) [Descovy®] 25/200mg, 1 tablet by mouth once daily. Alternative combinations are available but may introduce challenges such as additional pill burden, side effects, and drug interaction concerns. Options identified by the CDC include: dolutegravir PLUS dose-reduced tenofovir disoproxil fumarate PLUS either emtricitabine or lamivudine; co-formulated darunavir/cobicistat/tenofovir alafenamide/emtricitabine; and ritonavir-boosted darunavir PLUS either tenofovir alafenamide or dose-reduced tenofovir disoproxil fumarate PLUS either emtricitabine or lamivudine. Please consult NCCC or a local expert for further information including dosing considerations. Severe renal dysfunction (CrCl under 30 mL/min) and on hemodialysis* Preferred combinations include co-formulated bictegravir (BIC)/emtricitabine (FTC)/tenofovir alafenamide (TAF) [Biktarvy®] 50/200/25mg, 1 tablet by mouth once daily OR Dolutegravir (DTG) [Tivicay®] 50mg, 1 tablet by mouth once daily plus co-formulated tenofovir alafenamide (TAF)/emtricitabine (FTC) [Descovy®] 25/200mg, 1 tablet by mouth once daily. Alternative combinations are available but may introduce challenges such as additional pill burden, side effects, and drug interaction concerns. Options identified by the CDC include: dolutegravir PLUS dose-reduced tenofovir disoproxil fumarate PLUS either emtricitabine or dose-reduced lamivudine; co-formulated darunavir/cobicistat/tenofovir alafenamide/ emtricitabine; and ritonavir-boosted darunavir PLUS either tenofovir alafenamide or dose-reduced tenofovir disoproxil fumarate PLUS either emtricitabine or dose-reduced lamivudine. Please consult NCCC or a local expert for further information including dosing considerations. Hepatic impairment (Child-Pugh class A/B)* OR Dolutegravir (DTG) [Tivicay®] 50mg, 1 tablet by mouth once daily PLUS Any of the following co-formulations:
Alternative combinations are available but may introduce challenges such as additional pill burden, side effects, and drug interaction concerns. Options identified by the CDC include: boosted darunavir PLUS either tenofovir alafenamide or tenofovir disoproxil fumarate PLUS either emtricitabine or lamivudine. Please consult NCCC or a local expert for further information including dosing considerations. Expert consultation is recommended for people with severe hepatic impairment (Child-Pugh class C) or severe renal dysfunction (CrCl < 30 mL/min) and not on dialysis*. |
*Note: For additional detailed information on dosing, side effects, and drug-drug interactions, please see antiretroviral drug tables on our website’s Pharmacy section.
Pregnancy and Breastfeeding
How should HIV exposures in pregnant people be managed?
- Starting PEP in pregnant exposed persons should be based on considerations similar to those of non-pregnant exposed persons, and involve shared decision-making.
- Additionally, the treating clinician and exposed person should discuss any potential concerns regarding maternal and fetal exposure to antiretroviral (ARV) medications.
- All cases of ARV exposure in pregnancy should be submitted to the Antiretroviral Pregnancy Registry, which collects information on outcomes of ARV-exposed pregnancies regardless of HIV status (http://apregistry.com).
Special considerations:
- The pregnant exposed person and fetus are at risk for HIV acquisition, as acute HIV infection during pregnancy incurs a high risk of perinatal transmission.
- 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. Detailed information is available in the DHHS Perinatal HIV Clinical Guidelines, in Appendix B: Safety and Toxicity of Individual Antiretroviral Agents in Pregnancy.
- Safety events associated with currently recommended PEP medications are not thought to be increased in pregnancy.
The PEP regimens that are currently preferred for most adults and adolescents are also preferred for use in exposed persons who are pregnant or breastfeeding:
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Co-formulated bictegravir (BIC)/emtricitabine (FTC)/tenofovir alafenamide (TAF) [Biktarvy®] 50/200/25mg, 1 tablet by mouth once daily OR Dolutegravir (DTG) [Tivicay®] 50mg, 1 tablet by mouth once daily PLUS Any of the following co-formulations:
Duration: 28 days See above for common side effects and drug-drug interactions; additional considerations for use in pregnancy are described below Other PEP options can be considered in the event of intolerance, source persons with HIV drug resistant virus, medication access/adherence challenges, or EP preference. In these instances, providers should seek expert consultation, as pharmacokinetics in pregnancy may affect drug levels of some agents in the second and third trimesters. |
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Advantages
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Potential Challenges
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How should HIV exposures in lactating exposed persons be managed?
- Breastfeeding is not a contraindication for PEP: starting PEP in lactating exposed persons should be based on considerations similar to those of non-pregnant/lactating exposed persons and involve shared decision-making.
- Additionally, the treating clinician and exposed person should discuss any potential concerns regarding infant exposure to ARV medications through breast milk. The decision to take PEP and/or continue breastfeeding is complex and individualized, requiring an exploration of various options (see below). Expert consultation is available.
Special considerations:
- The lactating exposed person and breastfeeding infant are at risk for HIV acquisition.
- Acute HIV in a breastfeeding person greatly increases the risk of HIV transmission to the breastfed infant.
- There are limited data on PEP medications in breast milk (details are available in LactMed®, a database which contains information on drugs and other chemicals to which breastfeeding mothers may be exposed).
– Bictegravir (BIC, a component of Biktarvy®) and dolutegravir (DTG, Tivicay®) – Low levels have been detected in breast milk and breastfed infants.
– Tenofovir disoproxil fumarate (TDF, Viread®, component of Truvada® and Cimduo®) and tenofovir alafenamide (TAF, Vemlidy®, component of Descovy® and Biktarvy®) can occasionally be detected in breast milk and breastfed infants in very limited amounts.
– Lamivudine (3TC, Epivir®, component of Cimduo®) and emtricitabine (FTC, component of Truvada® and Descovy® and Biktarvy®) can be detected in breast milk and breastfed infants at levels which are a small fraction of the therapeutic doses used to treat HIV. - For breastfeeding people who choose to take PEP, pumping and discarding is an option that allows continuation of lactation while preventing infant ARV and (possible) HIV exposure.
- For breastfeeding people who do not take PEP, pumping and storing breast milk while waiting for the source person’s HIV testing results is an option. This allows continuation of lactation while not exposing infants (and breastfeeding people) to ARVs or potentially to HIV.
How are occupational exposures to HBV managed? Recommendations for post-exposure testing and prophylaxis after OCCUPATIONAL HBV exposures (source with known chronic HBV or unknown status) If HBsAb ≥10mIU/mL: No action needed If HBsAb <10mIU/mL2: Check HBcAb (total) and administer HBIG x 1 dose3 and revaccinate as soon as possible. HBV vaccine may be administered at the same time as HBIG but they should be given in different anatomical locations. 1 For the 3-dose HBV vaccine series, doses are usually given at baseline, 1 month, and 6 months. Alternatively, the newer 2-dose recombinant adjuvanted vaccine series involves 2 doses administered at least 4 weeks apart. Immunity is confirmed if follow-up testing performed 1-2 months after vaccine series completion indicates HBsAb ≥10mIU/mL. For exposed healthcare personnel (HCP) who previously completed an immunization series but were found to have a negative/insufficient (<10mIU/mL) HBsAb titer when tested at the time of an exposure, if the source person is negative for HBsAg the employee should be offered an additional (“booster” or “challenge”) dose followed by repeat HBsAb testing 1-2 months after vaccination to confirm an appropriate titer and immune response (≥10mIU/mL). 2 Healthcare personnel with HBsAb <10mIU/mL after a complete 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 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 transmission occurred. Additionally, because HBIG administration will result in circulating antibodies for up to 6 months, HBsAb testing for confirmation of vaccine-induced immunity should be performed after HBIG-related antibodies are no longer detectable – therefore, it may be necessary to defer HBsAb testing in these situations for a period longer than 1-2 months after the last vaccine dose has been given. 3 HBIG: 0.06 mL/kg IM (up to maximum 5mL for adults), give as soon as possible (preferably within 24 hours). Studies are limited regarding the maximum post-exposure interval during which HBIG prophylaxis is effective, but the interval is unlikely to exceed 7 days for percutaneous exposures and 14 days for sexual exposures. Similarly, when HBV vaccine is administered after exposure, studies are limited on the maximum interval during which prophylaxis is effective. Note: Testing the exposed HCP for prior HBV infection is not generally required before vaccinating unless the exposed is at independent risk of HBV infection (e.g., from an HBV endemic area). However, universal HBV screening with HBsAg, HBcAb (total), and HBsAb is widely recommended by several professional and public health organizations. Sources: (1) Schillie S, Murphy TV, Sawyer M, et al. CDC guidance for evaluating health-care personnel for hepatitis B virus protection and for administering postexposure management. MMWR: December 20, 2013.; (2) Schillie S, Vellozzi C, Reingold A, et al. Prevention of Hepatitis B Virus Infection in the United States: Recommendations of the Advisory Committee on Immunization Practices. MMWR Recomm Rep 2018; 67 (1): 1-31.; (3) Tanner MR, O’Shea JG, Byrd KM, et al. Antiretroviral Postexposure Prophylaxis After Sexual, Injection Drug Use, or Other Nonoccupational Exposure to HIV – CDC Recommendations, United States, 2025. MMWR Recomm Rep 2025; 74 (NO. RR-1): 1-56.; (4) Division of Viral Hepatitis, CDC, Table 1: Treatment for HBV Exposures in Health Care Settings (posted May 13, 2024), available at: https://www.cdc.gov/hepatitis-b/hcp/infection-control/table-1.html; (5) Recommendation of the Immunization Practices Advisory Committee (ACIP) Postexposure Prophylaxis of Hepatitis B. MMWR: June 1, 1984. Available at: https://www.cdc.gov/mmwr/preview/mmwrhtml/00022736.htm How should non-occupational exposures to HBV be managed? Recommendations for post-exposure management after NON-OCCUPATIONAL HBV exposures (source with known chronic HBV or unknown status) 2 HBIG: 0.06 mL/kg IM (up to maximum 5mL for adults), give as soon as possible (preferably within 24 hours). Studies are limited regarding the maximum post-exposure interval during which HBIG prophylaxis is effective, but the interval is unlikely to exceed 7 days for percutaneous exposures and 14 days for sexual exposures. Similarly, when HBV vaccine is administered after exposure, studies are limited on the maximum interval during which prophylaxis is effective. Sources: (1) Schillie S, Vellozzi C, Reingold A, et al. Prevention of Hepatitis B Virus Infection in the United States: Recommendations of the Advisory Committee on Immunization Practices. MMWR Recomm Rep 2018; 67 (1): 1-31.; (2) Tanner MR, O’Shea JG, Byrd KM, et al. Antiretroviral Postexposure Prophylaxis After Sexual, Injection Drug Use, or Other Nonoccupational Exposure to HIV – CDC Recommendations, United States, 2025. MMWR Recomm Rep 2025; 74 (NO. RR-1): 1-56.; (3) Recommendation of the Immunization Practices Advisory Committee (ACIP) Postexposure Prophylaxis of Hepatitis B. MMWR: June 1, 1984. Available at: https://www.cdc.gov/mmwr/preview/mmwrhtml/00022736.htm How soon do hepatitis B vaccine and HBIG need to be given?Exposures to HBV
EXPOSED PERSON VACCINATION STATUS
EXPOSED PERSON BASELINE TESTING
INTERVENTION
Previously Vaccinated
Known responder after complete series1 (post-vaccination HBsAb ≥10 mIU/mL)
None
No action needed
Response unknown after complete series1
HBsAb
HBsAb <10mIU/mL after complete series1-2
HBcAb (total)
HBIG3 x 1 dose and revaccinate as soon as possible. HBV vaccine may be administered at the same time as HBIG but they should be given in different anatomical locations.
Known non-responder
(HBsAb <10mIU/mL after two complete series)2HBcAb (total) if not previously done
HBIG3 x 2 doses, given one month apart. Some experts would also offer the 2-dose recombinant adjuvanted series given enhanced seroconversion rates observed with newer vaccine.
Unvaccinated or Incompletely Vaccinated
Unvaccinated or incompletely vaccinated2
HBcAb (total)
HBIG3 x 1 dose and initiate or complete vaccination as soon as possible. HBV vaccine may be administered at the same time as HBIG but they should be given in different anatomical locations.
SOURCE PERSON STATUS
UNVACCINATED AND INCOMPLETELY VACCINATED PERSONS
PERSONS WHO RECEIVED COMPLETE VACCINE SERIES
HBsAg-positive
Initiate/complete vaccine series and administer HBIG1-2. Unvaccinated persons should receive both HBIG and the first dose of HBV vaccine as soon as possible, preferably within 24 hours of the exposure. HBV vaccine may be administered at the same time as HBIG but they should be given in different anatomical locations.
Administer dose of HBV vaccine
Unknown HBsAg status
Initiate/complete vaccine series1. Unvaccinated persons should receive the first dose of HBV vaccine as soon as possible, preferably within 24 hours of the exposure.
No action needed
1 For the 3-dose HBV vaccine series, doses are usually given at baseline, 1 month, and 6 months. Alternatively, the newer 2-dose recombinant adjuvanted vaccine series involves 2 doses administered at least 4 weeks apart.
In general, if hepatitis B vaccination and/or HBIG are required, the sooner they are administered the better (ideally within 24 hours). Studies are limited regarding the maximum post-exposure interval during which HBIG prophylaxis is effective, but the interval is unlikely to exceed 7 days for percutaneous exposures and 14 days for sexual exposures. Similarly, when HBV vaccine is administered after exposure, studies are limited on the maximum interval during which prophylaxis is effective.
How are exposures to HCV managed? The following is a PEP Quick Guide summary of those recommendations: Recommendations for post-exposure assessment and management after HCV exposure, occupational or non-occupational If HCV RNA positive/detected, refer source person to care and test exposed person (see table below) Option B If HCV antibody positive/reactive, confirm with HCV RNA. If RNA negative/not detected, no post-exposure testing needed for exposed person. If RNA positive/detected, refer source person to care and test exposed person (see table below) Exposed Person Testing 1 Check HCV RNA if source is HCV RNA positive or positive HCV antibody with unknown RNA, or if source HCV status unknown: If early RNA is negative/not detected, follow-up with additional testing at 4-6 months If early RNA is positive/ detected, refer to care Check Anti-HCV (HCV Ab): If positive/reactive, refer to care (and consider testing for HCV RNA)Exposures to HCV
Source Person Status
Management
Known HCV-positive1 (with viremia)
Refer source person to care and test exposed person (see table below)
Known HCV-negative
No post-exposure testing needed for exposed person (may rescreen source in future as clinically indicated)
Unknown status
Option A (preferred)
Check HCV RNA on source:
If HCV RNA negative/non-reactive, no post-exposure testing needed for exposed person
Check anti-HCV (HCV Ab) on source:
If HCV antibody negative/non-reactive, no post-exposure testing needed for exposed person
1 A source person is considered HCV-positive if either HCV antibody or HCV RNA (“HCV viral load”) is positive. A positive HCV antibody result, however, does not always indicate infectivity because: (a) some people eradicate HCV naturally but retain HCV antibody (“spontaneous clearance”); and (b) some people have been successfully treated and cured but retain HCV antibody. Additionally, persons with untreated HCV infection can have fluctuating HCV RNA levels as well as short periods of undetectable viral load (especially in very early infection), and presumably are not infectious when the viral load is undetectable.
Baseline testing
Early testing (3-6 weeks) 2
Final testing (4-6 months) 3
Anti-HCV (HCV Ab): if positive/reactive, confirm with HCV RNA
If negative/non-reactive, transmission reasonably excluded
For details, see: Moorman AC, de Perio MA, Goldschmidt R, et al. Testing and Clinical Management of Health Care Personnel Potentially Exposed to Hepatitis C Virus — CDC Guidance, United States, 2020. MMWR Recomm Rep 2020;69(No. RR-6):1–8. Available at: https://www.cdc.gov/mmwr/volumes/69/rr/rr6906a1.htm; and/or: Tanner MR, O’Shea JG, Byrd KM, et al. Antiretroviral Postexposure Prophylaxis After Sexual, Injection Drug Use, or Other Nonoccupational Exposure to HIV – CDC Recommendations, United States, 2025. MMWR Recomm Rep 2025;74(NO. RR-1):1-56.
1 Exposed persons with symptoms of a viral illness compatible with acute HCV at any point up to 6 months post-exposure should be evaluated for acute HCV (anti-HCV, HCV RNA and liver function testing).
2 6 weeks coincides with early HIV follow-up testing, when indicated.
3 6 months coincides with HBV follow-up testing, when indicated.
Follow-Up Testing of the Exposed Person
HIV
- If SP tests negative for HIV, no follow-up HIV testing for that exposure is clinically indicated for the EP.
- If SP is person with HIV (or SP cannot be tested/identity is unknown), re-test EP for HIV at 4-6 weeks and 3-4 months.
- Symptoms of acute HIV should prompt immediate evaluation.
Note: Although prior CDC/USPHS Guidelines (and many institutional protocols) recommended final HIV Ab testing be performed at 6 months (or 4 months if using a “4th generation” Ag/Ab test), waiting until 6 months to conclude testing is no longer typically necessary given the performance characteristics of contemporary, standard HIV screening/testing assays. Additionally, updated CDC/USPHS Guidelines suggest that interim testing (4-6 weeks post-exposure) may be deferred for exposed persons who initiated PEP within 24 hours of exposure and did not miss any PEP doses. Persons who took PEP and then subsequently initiated PrEP should develop an individualized laboratory testing and clinical monitoring plan with their PrEP provider, and many experts would recommend HIV testing specifically at the PEP to PrEP transition point.
HBV (See Exposures to HBV)
- If SP tests negative for HBV, no follow-up HBV testing for that exposure is clinically indicated for the EP.
- See tables in “Exposures to HBV” section for follow-up testing recommendations, which vary based on the exposed person’s vaccine and testing history. In general, follow-up HBV testing is only necessary after occupational exposures involving exposed persons who are not known to have hepatitis B immunity at the time of exposure.
- Symptoms of acute hepatitis should prompt immediate evaluation.
HCV (See Exposures to HCV)
- If SP tests negative for HCV, no follow-up HCV testing for that exposure is clinically indicated for the EP.
- See tables in “Exposures to HCV” section for follow-up testing recommendations.
- 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/or HCV requires evaluation by a medical professional as soon as possible (e.g., via urgent care, emergency room, primary care, or Occupational/Employee Health service). Occupational exposures should immediately be reported to a supervisor.
