HIV Prophylaxis in Sexual Assault Medication

Updated: Jul 08, 2021
  • Author: Derek T Larson, DO; Chief Editor: Michael Stuart Bronze, MD  more...
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Medication

Medication Summary

HIV PEP Regimens

Although the exact drug regimens for HIV PEP have changed in recent years, consensus remains that the preferred regimen is a 3-drug regimen given over a 28-day course. [1] Anyone prescribed PEP should be given the full 28-day course. On occasion, a 30-day supply will be dispensed due to the cost of adjusting manufacterer-supplied bottles, but no added benefits have been shown for continuation of the treatment course beyond 28 days.

The FDA announced in May 2018 that it was investigating correlations between dolutegravir use in early pregnancy and neural tube defects. Although such a correlation had not been shown definitively, guidance was issued at that time that women who were pregnant or of childebearing potential avoid dolutegravir and bictegravir while further evaluation was performed. Studies indicated that the increased rate of neural tube deficits seen in a cohort of HIV-infected individuals in Botswana [34] was not seen in the United States. [35]  Further, Raltegravir has a well-established safety profile for this use and remains a primary treatment option. [36]  In February of 2021, the Panel on Treatment of Pregnant Women with HIV Infection and Prevention of Perinatal Transmission recommended the use of dolutegravir as a prefered agent both for women who are pregnant, and those attempting to get pregnant. This was based on the lack of neural tube defect in later cohorts, as well as the known benefits of dolutegrvir which include therapeutic efficacy, tolerance, and ease of administration with once daily dosing. [37]

Adults and adolescents

Patients older than 13 years with normal renal function (CrCl ≥60 mL/min), including pregnant individuals

The preferred 3-drug regimen is as follows:

OR

Caution: Coadministration of raltegravir or dolutegravir with antacids or cations (iron, calcium, or magnesium) can reduce drug absorption and therefore efficacy of PEP.

An alternative regimen is as follows:

  • Tenofovir disoproxil fumarate 300 mg/emtricitabine 200 mg (Truvada) daily AND
  • Darunavir 800 mg daily AND
  • Ritonavir 100 mg daily OR cobicistat 150 mg daily (as pharmacokinetic booster)

Patients older than 13 years with chronic kidney disease (CrCl < 60 mL/min)

The preferred 3-drug regimen is as follows:

  • Renally dose-adjusted zidovudine and lamivudine daily AND
  • Raltegravir 400 mg twice daily OR dolutegravir 50 mg once daily

Caution: Coadministration of raltegravir or dolutegravir with antacids or cations (iron, calcium, or magnesium) can reduce drug absorption and therefore efficacy of PEP.

An alternative regimen is as follows:

  • Renally adjusted zidovudine and lamivudine daily AND
  • Darunavir 800 mg daily AND
  • Ritonavir 100 mg daily OR cobicistat 150 mg daily (as pharmacokinetic booster)

PEP is especially important in pregnant women and should not be avoided because of known or possible pregnancy.

Note that tenofovir alafenamide (TAF), a newer formulation of tenofovir, has not been specifically studied for HIV PEP and is not currently recommended for this indication. A TAF-containing co-formulation with emtricitabine (Descovy) is FDA-approved for the treatment of HIV infection in combination with other active agents, but its ultimate role in HIV PEP remains undefined at the time of this writing.

Infants and children

Children aged 2-12 years

Each drug dosed to age and weight

Preferred 3-drug regimen: Tenofovir DF AND  emtricitabine AND raltegravir

Alternative regimens are as follows:

  • Zidovudine AND lamivudine with raltegravir
  • Lopinavir/ritonavir with raltegravir
  • Tenofovir DF AND  emtricitabine AND lopinavir/ritonavir

Children aged 3-12 years: Tenofovir DF AND  emtricitabine AND darunavir/ritonavir (darunavir is approved in children aged 3 years or older)

Children aged 4 week to < 2 years

Preferred 3-drug regimen: Zidovudine AND lamivudine with raltegravir or lopinavir/ritonavir

Alternative regimen: Zidovudine AND emtricitabine with raltegravir or lopinavir/ritonavir

Children aged birth to 27 days

Consult a pediatric HIV specialist.