A 29-year-old male with high-risk HIV exposure (receptive anal intercourse with HIV-positive partner with unknown viral load) presents 52 hours after exposure. He has no prior HIV test. What is the most appropriate management?

• A Start post-exposure prophylaxis (PEP) with tenofovir DF/emtricitabine + raltegravir or dolutegravir for 28 days, as PEP is effective up to 72 hours ✓
• B PEP is only effective within 24 hours; offer pre-exposure prophylaxis (PrEP) going forward
• C Perform HIV RNA PCR first; start PEP only if negative to avoid treating established infection
• D Start PEP with zidovudine/lamivudine alone as a 2-drug regimen is adequate for sexual exposure

Explanation

HIV PEP is effective when started within 72 hours of potential exposure (not 24 hours); earlier initiation is more effective. The recommended PEP regimen per CDC 2016 and WHO guidelines is a 3-drug combination: tenofovir disoproxil fumarate (TDF)/emtricitabine (FTC) [Truvada] as the NRTI backbone plus a third agent — currently preferred is dolutegravir (50 mg/day) or raltegravir (400 mg BID) as the integrase inhibitor. PEP must be taken for the full 28-day course. HIV testing before starting PEP is recommended but should not delay initiation if the test cannot be performed promptly. 2-drug regimens are no longer recommended. Follow-up HIV testing at 4–6 weeks and 3 months post-exposure is required.

Reference: Harrison's Principles of Internal Medicine, 21st ed.

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Written and medically reviewed by the StethoPrep medical team.