Postexposure prophylaxis (PEP) of HIV among adults

Abstract

In the last several decades, postexposure prophylaxis (PEP) with antiretroviral therapy (ART) has become an effective tool for the prevention of HIV transmission. The continuous evolution of antiretrovirals and the associated update of clinical practice guidelines create a challenge for NPs caring for patients exposed to HIV. Understanding the life cycle of HIV is of paramount importance in streamlining treatment regimens in exposed individuals. ART is a complex combination of drugs targeting different stages of the virus's life cycle within the host. NPs play an essential role in managing treatment for people exposed to HIV and following up on these patients' response and adherence to the treatment protocol. This article provides a comprehensive overview of HIV and step-by-step guidance for NPs treating patients who have been exposed.

In Brief

In the last several decades, postexposure prophylaxis (PEP) with antiretroviral therapy (ART) has become an effective tool for the prevention of HIV transmission. The continuous evolution of antiretrovirals and the associated update of clinical practice guidelines create a challenge for NPs caring for patients exposed to HIV. This article provides a comprehensive overview of HIV and step-by-step guidance for NPs treating patients who have been exposed.

Figure

There are approximately 38 million people worldwide who live with HIV.¹ The HIV epidemic continues to be one of the most serious challenges for public health today. In 2021, the United Nations General Assembly announced and adopted its 95-95-95 testing, treatment, and viral suppression targets in the organization's Political Declaration on HIV and AIDS.² According to the announcement, the organization aims to meet the following benchmarks by the year 2025: 95% of people infected with HIV will know their status, 95% of people diagnosed with HIV will have access to and receive treatment, and 95% of people receiving treatment for HIV will be virally suppressed.² In 2021, these measures were reported at 85-88-92: that is, 85% of people infected with HIV knew their status, 88% of those who knew about their HIV-positive status were receiving treatment, and 92% of those receiving treatment for HIV were virally suppressed.³

Postexposure prophylaxis (PEP) is an underutilized tool for preventing HIV transmission in people who experience both occupational and nonoccupational exposure, and it may represent an opportunity to achieve the UN's 95-95-95 testing, treatment, and viral suppression targets. Although PEP can decrease the risk of HIV transmission by more than 80% when taken as prescribed, one study found that only 40% of providers felt they could confidently prescribe an appropriate regimen and provide care for those exposed to HIV.^4,5 Exposure to HIV is a medical emergency, and patients should be treated accordingly.^4,6 Given the knowledge gap in practice and the need for reduction in HIV transmission according to the UN's targets, a comprehensive overview of HIV pathophysiology and step-by-step guide for NPs in managing its exposure is critical and timely.

HIV pathophysiology

HIV is a bloodborne infectious disease that attacks the immune system, specifically CD4 T lymphocytes (also known as CD4 cells or helper T cells). HIV may cause significant complications if not treated and may lead to AIDS.⁷ To be diagnosed with AIDS, a person with HIV must have an AIDS-defining condition or have a CD4 count of fewer than 200 cells/mm^3.3,8 AIDS is the terminal stage of HIV, and affected patients usually have an abysmal prognosis due to their severely compromised immune function. Preventing patients from acquiring HIV and then risking the development of AIDS if not treated is the main goal of HIV PEP.

HIV life cycle

Knowledge about the HIV life cycle is an essential theoretical foundation for NPs (see HIV replication cycle). It allows providers in turn to understand how antiretroviral therapy (ART) works at the cellular and molecular levels as well as its use in managing HIV and preventing its progression. The seven main steps in the virus life cycle are outlined below.

• (1) Binding: In attacking CD4 cells, HIV attaches its envelope spikes (consisting of surface envelope glycoprotein [gp120] and transmembrane envelope glycoprotein [gp41] subunits) to receptors on the cells' surfaces. In addition, the virus attaches to one of two types of chemokine coreceptors, CXCR4 or CCR5.^8-10
• (2) Fusion: After binding, HIV fuses with the CD4 cell membrane. Fusion allows HIV to enter the CD4 cell. Once inside the CD4 cell, the virus releases HIV RNA and HIV enzymes (reverse transcriptase and integrase).^8-10
• (3) Reverse transcription: Reverse transcriptase converts HIV genetic material (HIV RNA) into HIV DNA. This conversion allows HIV to enter the CD4 cell nucleus.^8-10
• (4) Integration: Once inside the host CD4 cell nucleus, integrase works to insert (integrate) viral DNA into the DNA of the CD4 cell.^8-10
• (5) Replication: Once HIV is integrated into the host CD4 cell DNA, the new “infected” DNA undergoes the routine process of replication, creating building blocks for more HIV.^8-10
• (6) Assembly: New HIV RNA and HIV proteins made by the host CD4 cell move to the surface of the cell and assemble into immature (noninfectious) HIV.^8-10
• (7) Budding: Immature HIV pushes itself out of the host CD4 cell. Once outside the CD4 cell, the new HIV releases protease, another HIV enzyme. Protease acts to break up the long protein chains that form the immature virus. The smaller HIV proteins combine to form mature, infectious HIV.^8-10

Approach to PEP for HIV exposure

Exposure and risk evaluation. NPs need to obtain information from patients about the type of exposure they have experienced and then evaluate their risk for HIV infection accordingly.¹¹ Learning more about exposure incidents helps NPs to determine eligibility and need for HIV PEP treatment. Because PEP use carries risks in certain cases, NPs should adopt a patient-centered approach to its prescription while following best practices and set guidelines based on exposure details and risk factors.

According to a systematic review, the estimated per-act HIV transmission risk is greatest for blood transfusion, followed (in descending order) by mother-to-child transmission, receptive anal intercourse, needle-sharing injection drug use, and percutaneous needle-stick injuries.¹² In addition, lower, but still significant, risk exists for other sexual exposures such as insertive or receptive penile-vaginal intercourse and insertive anal intercourse.^11,12 Across PEP guidelines, patients who seek medical help following these exposure events should be prescribed PEP immediately.^6,11,13-15 Risk for receptive and insertive oral sex is considered low, and according to the Canadian guideline, PEP is not required for these exposures.^11,12

The HIV status of the source also plays an important role in determining eligibility for PEP.¹³ According to the New York State Department of Health AIDS Institute (NYSDOH AI) PEP guideline, if the source is available, the NP should obtain a history from them regarding their HIV status. For a source with unknown HIV status who provides consent, the NP should order HIV testing with a 4th generation HIV antigen/antibody assay and assess for risk of HIV acquisition within the past 4 weeks.¹³ An HIV RNA nucleic acid test (NAT), if available, or repeat 4th generation assay 7 to 14 days later, should be ordered, if the source has signs and symptoms of acute HIV infection.¹¹ For a source with confirmed HIV who provides consent, the NP should obtain a history of current and previous ART regimens and order HIV RNA (viral load) and HIV drug resistance testing.⁶ HIV RNA (viral load) testing is done to assess HIV presence in the blood and its amount.¹⁴ Viral load is a vital metric for healthcare professionals that should be assessed regularly to monitor the effectiveness of ART in patients who are HIV positive and to modify or change treatment courses as needed.¹⁴ If ART is successful, there is significant evidence that viral load will be undetectable (defined in some guidelines as HIV RNA <200 copies/mL) and therefore untransmittable (otherwise known as the Undetectable=Untransmittable, or “U=U,” concept) from one person to another.^6,15 Therefore, if the source person has HIV but has an undetectable viral load, then this constitutes a negligible risk for the exposed person and does not require PEP prescription. PEP treatment, however, should not be delayed while ascertaining this information about the source.⁶ The NYSDOH AI PEP guideline emphasizes the importance of understanding this concept for both the source and the patient.⁶ However, the same guideline highlights that the U=U concept pertains only to consensual sexual exposure, and it does not apply to exposure through needle sharing, breastfeeding, or needle-stick injury.⁶

Figure: HIV replication cycle

In many cases, however, the source is not available for assessment. Because it can be challenging for patients and NPs to know with certainty the HIV status of the source person, the World Health Organization recommends that NPs assume that all unknown sources are positive for HIV to guide the decision-making process regarding PEP initiation; treatment for the patient is therefore usually advised.¹⁶

Exposure through sexual assault. NPs must determine whether exposure occurred as a result of sexual assault in evaluating risk for HIV transmission. Canadian guidelines on HIV preexposure prophylaxis (PrEP) and nonoccupational PEP (nPEP) stipulate that “health care providers who undertake initial assessment for nPEP should distinguish between consensual and nonconsensual exposures and should provide or refer to sexual assault services accordingly.”¹¹

Lack of awareness of and access to PEP, as well as failure to initiate the PEP regimen promptly and to adhere to it as prescribed, are major challenges in this population. For example, a study from Africa found that only 54% of survivors of sexual assault started and only 34% completed the PEP regimen.¹⁷ In view of the results, the study's authors recommended that survivors of sexual assault be encouraged to seek PEP early in areas of high HIV prevalence.¹⁷

In a qualitative interpretive study, 11 participants who were sexually assaulted were interviewed to explore their understanding of HIV PEP and to uncover the barriers and facilitators of HIV PEP acceptance and adherence in this population. Decision-making was affected by elements of losing and reclaiming control.¹⁸ Adherence to PEP regimens has been found to be markedly lower among sexual assault victims.^13,18 NPs are pivotal in improving adherence to PEP through education and follow up. Patients are more likely to adhere when they understand the indications and mechanism of the medications they are prescribed.

Raising awareness about PEP among the public and clinicians is a key factor in facilitating access to PEP for all patients, though particularly for survivors of sexual assault. Phone numbers for helplines should be easily accessible so that survivors of sexual assault can seek guidance and support through them. Access to specialized clinics and referral to sexual assault centers where HIV screening and PEP are part of the services provided could also play a role in initiating PEP in a timely manner. Finally, individuals who experience sexual assault may present to the ED, so developing an algorithm for or approach to their care may help to ensure that patients are offered the opportunity to receive PEP.

Exposure through occupational needle-stick injury. In Guidance for the Use of Post-Exposure Prophylaxis (PEP) for the Prevention of HIV in British Columbia, the British Columbia Centre for Excellence in HIV/AIDS recommends using the Risk Assessment Stratification Protocol (RASP) screening tool to determine the need for PEP after occupational needle-stick injury.¹⁹ RASP is a freely available online questionnaire that includes four questions about the exposure. The tool makes a recommendation regarding initiation of PEP based on the risk level of the exposure.²⁰

Lab work. Another priority for NPs when initiating PEP for adults is to order comprehensive baseline and follow-up lab work. According to the Canadian guideline for PEP, baseline evaluation should include testing for HIV, certain other sexually transmitted infections (STIs), and pregnancy, as well as a complete blood cell (CBC) count and renal and hepatic function testing.

The CDC identifies three main HIV diagnostic tests: antigen/antibody assays, antibody tests, and NATs.¹⁴ An HIV antigen/antibody test aims to detect the HIV p24 antigen and HIV antibodies.²¹ There are antigen/antibody tests using venous blood which are run in labs and which are the most common initial diagnostic tools to confirm a positive HIV status, and there are also rapid antigen/antibody tests using blood from a finger stick.²² Antibody testing often utilizes a self-testing kit or point-of-care testing to detect virus antibodies in body fluid (blood, saliva).¹⁹ A NAT can identify the virus in the blood, but it is not routinely used because of its high cost.

Most guidelines, including the British Columbia Centre for Excellence in HIV/AIDS, recommend that individuals undergo both an HIV point-of-care test, if available, as well as the preferred diagnostic test for patients potentially exposed to the virus: 4th generation HIV antigen/antibody assay.^11,13,19 The Canadian guideline points out that while point-of-care tests can be used, they should not replace the standard serology test.¹¹ A NAT may be recommended as a baseline HIV test in select situations, such as if the patient has had signs and symptoms of an acute HIV infection within the previous 2 weeks, as it can detect infection sooner than other tests.¹⁹

- Determining whether exposures require HIV PEP^13,16,19,24

Exposures potentially requiring HIV PEP

Exposures not requiring HIV PEP

Occurs when potentially infectious body fluid (including blood; semen; vaginal secretions; rectal secretions; breast milk; cerebrospinal, synovial, pleural, peritoneal, pericardial, or amniotic fluids; or any body fluid that is visibly contaminated with blood) comes into contact with any of the following: - mucous membranes (vagina, anorectum, eye, mouth, nose) - nonintact skin - subcutaneous tissue (percutaneous contact, such as a needlestick)

Negligible risk events that do not require HIV PEP include: - Exposure to: tears nonbloody saliva nonbloody urine sweat nonbloody feces - Human bites not involving blood

If the result of the initial rapid HIV test is negative, the PEP protocol should be activated as soon as possible.¹⁹ However, if the result is positive, PEP might be contraindicated, and confirmation of a positive result is needed. The CDC advises that PEP not be started for individuals with a positive baseline rapid test.¹³ If PEP therapy is otherwise indicated but a rapid HIV test is not available, initiation of PEP therapy should not be delayed to await results of the HIV antigen/antibody assay or the NAT.^13,19 The reason for testing for HIV at the outset of the PEP process is to determine whether the patient is already HIV positive without being aware. If the patient has HIV, then PEP would be contraindicated, as initiating PEP in patients who are HIV positive may lead to ART drug resistance, complicating future HIV treatment.^6,16 If a patient is later found to be HIV positive, care should quickly be transferred to an HIV treatment specialist, and PEP should be continued until then.¹³ The challenge with all the test types is the time gap between exposure to HIV and the time at which the tests become positive. For example, after exposure to HIV, an antibody test will not be positive until seroconversion, or the transition from infection with HIV to the presence of HIV antibodies in the blood.²¹

Other baseline lab tests should include those for syphilis; hepatitis A, B, and C; gonorrhea; and chlamydia.^11,13 If confirmed, these diseases should be treated according to current best-practice guidelines. For appropriate individuals, a pregnancy test should be completed.¹¹ A CBC count and renal and hepatic function testing at baseline are also vital.^11,19 These tests provide NPs with insight into the patient's overall health status and the ability of the patient to tolerate ART. However, PEP initiation should not be delayed while awaiting lab results.¹⁹

Follow-up lab testing of hepatic and renal function should be completed at week 2 if it was abnormal at baseline or if the patient is symptomatic.¹¹ Follow-up lab testing to be completed at week 12 after exposure (8 weeks after completion of PEP) includes repeat testing for HIV, syphilis, hepatitis C, gonorrhea, and chlamydia.¹¹

ART medications. Timely assessment and initiation of appropriate ART decreases the incidence of HIV infections in adults exposed to the virus. NPs are in an ideal position to prescribe ART and follow up with patients exposed to HIV to ensure desirable clinical outcomes. There are eight drug classes for HIV treatment. Each drug class is specific to a particular stage of the virus life cycle. These classes are nucleoside reverse transcriptase inhibitors (NRTIs), integrase strand transfer inhibitors (INSTIs), protease inhibitors (PIs), nonnucleoside reverse transcriptase inhibitors (NNRTIs), fusion inhibitors, CCR5 antagonists, postattachment inhibitors, and attachment inhibitors.¹⁴

Because HIV exposure is a medical emergency, time is critical for PEP initiation and duration. The sooner PEP is taken, the more likely it is to prevent HIV infection (see Determining whether exposures require HIV PEP). The CDC and Canadian guidelines for HIV nPEP recommend a 28-day course of a 3-drug antiretroviral regimen beginning within 72 hours of exposure for otherwise healthy, nonpregnant adults.^11,13 These preferred regimens consist of certain combinations of two NRTIs plus an INSTI or two PIs (see Preferred and alternative antiretroviral medication 28-day regimens for nPEP).^11,13 The guidelines also provide regimen recommendations for individuals with renal insufficiency or who are pregnant as well as for children. ART medications may have adverse reactions, and regimen selection should be done carefully, considering the patient's health history (see Antiretroviral medications used in PEP formulations). Providers should refer to the guidelines for further information on preferred regimens in cases in which the source is known or suspected to have drug-resistant virus.¹¹ Additionally, consultation with an HIV specialist is recommended in such cases, although initiation of PEP should not be delayed pending consultation. Of note is that all PEP use is off-label in Canada and the US.

- Preferred and alternative antiretroviral medication 28-day regimens for nPEP^a,^b

Age group	Preferred/alternative	Medication
Adults and adolescents age ≥13 years, including pregnant women, with normal renal function (creatinine clearance ≥60 mL/min)	Preferred	A 3-drug regimen consisting of tenofovir DF 300 mg and fixed-dose combination emtricitabine 200 mg (Truvadac) once daily with raltegravir 400 mg twice daily or dolutegravir 50 mg once daily
	Alternative	A 3-drug regimen consisting of tenofovir DF 300 mg and fixed-dose combination emtricitabine 200 mg (Truvada) once daily with darunavir 800 mg (as two 400-mg tablets) once daily and ritonavirb 100 mg once daily
Adults and adolescents age ≥13 years with renal dysfunction (creatinine clearance ≤59 mL/min)	Preferred	A 3-drug regimen consisting of zidovudine and lamivudine, with both doses adjusted to the degree of renal function with raltegravir 400 mg twice daily or dolutegravir 50 mg once daily
	Alternative	A 3-drug regimen consisting of zidovudine and lamivudine, with both doses adjusted to the degree of renal function with darunavir 800 mg (as two 400-mg tablets) once daily and ritonavirb 100 mg once daily

Abbreviations: nonoccupational postexposure prophylaxis, nPEP; tenofovir DF, tenofovir disoproxil fumarate.

^aThese recommendations do not reflect current FDA-approved labeling for antiretroviral medications listed in this table.

^bRitonavir is used in clinical practice as a pharmacokinetic enhancer to increase the trough concentration and prolong the half-life of darunavir, lopinavir, and other protease inhibitors. Ritonavir is not counted as a drug directly active against HIV in the above “3-drug” regimens.

^cGilead Sciences, Inc., Foster City, Calif.

Notes:

Information about PEP for children is outside the scope of this article. Information about recommended regimens for children can be found in the CDC's latest guidelines for antiretroviral PEP.¹³

Providers are encouraged to review appropriate guidelines for further considerations regarding PEP use in individuals who are pregnant or breastfeeding.

Source: Adapted from “Updated guidelines for antiretroviral postexposure prophylaxis after sexual, injection drug use, or other nonoccupational exposure to HIV—United States, 2016.”¹³

Reproduction of this material in the journal does not constitute the journal or publisher's endorsement or recommendation by the US Government, Department of Health and Human Services, or CDC.

- Antiretroviral medications used in PEP formulations6,11,13,14,25-31

Medication	Drug class	Notes
Tenofovir disoproxil fumarate (TDF) / emtricitabine (FTC) (Truvada)	NRTIs	- Adverse reactions are generally mild and include fatigue, headache, N/V/D. - Risk of rash. - Carries risk for severe acute hepatitis B exacerbation in individuals with HBV infection when medication is discontinued. Although the medication can be used for PEP in these individuals, hepatic function tests should be monitored upon regimen discontinuation. - Risk for nephrotoxicity; should not be used in those with acute or chronic renal impairment or eCrCl <60mL/min. Those with history of or risk factors for kidney disease (such as diabetes) and those taking nephrotoxic medications should be closely monitored.
Raltegravir (RAL)	INSTI	- Adverse reactions are generally mild and include headache, insomnia, fatigue, dizziness, myalgia, abdominal pain, N/V/D. - Carries risk for severe skin and hypersensitivity reactions (such as SJS and TEN). - Coadministration with drugs that inhibit UGT1A1 may increase RAL levels; coadministration with drugs that induce UGT1A1 (such as rifampin) may decrease RAL levels. - Coadministration of magnesium- or aluminum-containing antacids is contraindicated.
Dolutegravir (DTG)	INSTI	- Adverse reactions may include insomnia and headache. - DTG is contraindicated in patients receiving dofetilide. - DTG may increase drug concentration of metformin, thus necessitating metformin dose adjustment when concurrently taking DTG. - Certain medications, such as carbamazepine, rifampin, and St. John's wort, may decrease dolutegravir plasma concentration. - Medications containing polyvalent cations (such as magnesium- or aluminum-containing antacids and sucralfate) can reduce DTG absorption. DTG should be administered at least 2 hours before or 6 hours after their administration. - Iron and calcium supplements and some multivitamins can also reduce DTG absorption. These can be coadministered with DTG if taken with food; otherwise, DTG should be administered at least 2 hours before or 6 hours after their administration.
Darunavir (DRV)/ ritonavir (RTV) (DRV/r)	PIs	- RTV is used as a pharmacokinetic enhancer to increase the trough concentration and prolong the half-life of DRV. - Significant risk of multiple drug interactions through effects at cytochrome P450. Some drug interactions may cause life-threatening adverse reactions. - Risk of skin reactions and rash (severe or mild-to-moderate); hepatotoxicity; pancreatitis; hyperglycemia. - Risk of PR and QT interval prolongation. Use with caution in patients with cardiac disease; who have or are at risk for cardiac conduction abnormalities; or who are taking other drugs with similar effects. - Other adverse reactions include fatigue; dizziness, headache, and paresthesia; peripheral neuropathy; dysgeusia; abdominal pain; GI symptoms such as N/V/D. - Should be used with caution in patients with sulfonamide allergy. - Must be administered with food.
Zidovudine (ZDV; AZT)	NRTI	- Risk of anemia and neutropenia. - Risk of lactic acidosis and hepatotoxicity. - Other adverse reactions include fatigue, headache, insomnia, anorexia, nausea, vomiting.
Lamivudine (3TC)	NRTI	- Generally well tolerated in short-term therapy. - Risk of decreased absolute neutrophil count. - Other adverse reactions include fatigue, headache, neuropathy, insomnia, nasal signs and symptoms, cough, N/V/D. - Carries risk for severe acute hepatitis B exacerbation in individuals with HBV infection when medication is discontinued. Although the medication can be used for PEP in these individuals, hepatic function tests should be monitored upon regimen discontinuation.

Abbreviations: eCrCl, estimated creatinine clearance; GI, gastrointestinal; HBV, hepatitis B virus; INSTI, integrase strand transfer inhibitor; NRTI, nucleoside reverse transcriptase inhibitor; N/V/D, nausea, vomiting, diarrhea; PI, protease inhibitor; SJS, Stevens-Johnson syndrome; TEN, toxic epidermal necrolysis.

Note: This is not a complete list of all prescribing considerations. Providers should refer to appropriate guidelines and drug package inserts for more information.

Source: Adapted from “Updated guidelines for antiretroviral postexposure prophylaxis after sexual, injection drug use, or other nonoccupational exposure to HIV—United States, 2016.”¹³

Reproduction of this material in the journal does not constitute the journal or publisher's endorsement or recommendation by the US Government, Department of Health and Human Services, or CDC.

Another critical aspect of PEP that NPs should discuss with patients is adherence to the protocol. The main challenges associated with PEP regimens are pill burden, treatment cost, and adverse reactions. Throughout this period, the patient must follow a strict medication schedule, which presents a challenge in terms of its rigidity and the significant amount of time required. According to a major North American cohort study, adherence to the regimen and patient collaboration are crucial for the success of PEP.²³ The same study also revealed that the toxicity of a specific PEP regimen is associated with worse adherence due to lower tolerability.²³

Discontinuation of PEP. NPs should be aware of PEP's possible adverse reactions and toxicity as well as situations that require PEP discontinuation. HIV PEP should be discontinued in three possible scenarios. First, PEP should be discontinued if the source person tests negative for HIV using a 4th generation antigen/antibody test (unless the source person had an exposure associated with risk of HIV acquisition within the past 4 weeks).^6,11 Second, PEP may be discontinued early if the source is HIV positive but has had an undetectable viral load for at least 6 months with no evidence of concurrent STI at the time of the exposure, for cases of consensual sexual exposure.^6,11 Finally, if the patient misses taking prescribed PEP for more than 72 consecutive hours, PEP will no longer be effective and may therefore be discontinued.¹¹

Counseling and patient education. Providing counseling sessions with support and education for patients who may have been exposed to HIV and need to take PEP medication is a vital aspect of the care that NPs are expected to deliver. Several North American guidelines suggest counseling for patients to address psychological support needs and services, deficits in knowledge about HIV and treatment, possible adverse reactions of PEP, and risk reduction strategies.^6,11,13,19 The Canadian PEP guideline emphasizes provision of interventions to support PEP adherence, such as education, medication reminders, peer support, follow-up calls or text messages, and assistance with minimizing PEP cost.¹¹ Furthermore, the NYSDOH AI PEP guideline offers a patient education checklist with prompts that NPs should cover during their meetings with patients who are about to start PEP.⁶

In addition to the NYSDOH AI PEP guideline, the Alberta PEP guideline emphasizes the use of risk reduction teachings (on, for example, safer sex practices, use of clean needles, and prevention of occupational exposures) to minimize or prevent the transmission of HIV.²⁴ Referral to harm reduction, addiction, and mental health services and/or to infection prevention education and services should be conducted as appropriate.²⁴ Another risk reduction strategy that NPs should consider for eligible patients is PrEP for HIV. PrEP should be discussed with and offered to patients who remain at risk for HIV exposure to prevent infection.⁶

Conclusion

This article offers a summary of standards of care for individuals exposed to HIV who might require initiation of PEP protocol. It provides NPs with a simplified approach to HIV PEP to expedite delivery of care in accordance with current, major guideline recommendations from the US and Canada. Because exposure to HIV is an emergency, NPs should act quickly to prevent infection by interrupting the HIV life cycle. Ultimately, the goal is to mitigate the worldwide health crisis that HIV and, subsequently, AIDS continue to present.