HIV PEP — three protocols side-by-side

Preferred regimen

Tenofovir disoproxil 245 mg + Emtricitabine 200 mg + Dolutegravir 50 mg

1 tablet every 24 h × 28 days

Alternatives

• ▸ Tenofovir alafenamide (TAF) 25 mg + Emtricitabine 200 mg + Dolutegravir 50 mg (if TDF contraindicated)
• ▸ Bictegravir/Emtricitabine/Tenofovir alafenamide (single-tablet) — increasingly used in clinical practice

Scope

Occupational + non-occupational exposure (sexual, IDU). HCW shared decision with Infectious Diseases.

HBV approach

Anti-HBs ≥10 mUI/mL: no action. Anti-HBs 1–9 or unknown in prior responder: HBV vaccine booster. Non-responder: HBIG 0.06 mL/kg IM <72 h + repeat vaccine. Unvaccinated: HBIG + accelerated vaccine schedule 0-1-2-12 months.

HCV follow-up

Anti-HCV + HCV RNA baseline, week 6, week 12 and month 6. No effective PEP exists for HCV; if seroconversion → direct-acting antivirals (DAAs) achieve >95% cure.

Preferred regimen

Tenofovir disoproxil 245 mg / Emtricitabine 200 mg + Raltegravir 1200 mg

Once daily × minimum 28 days

Alternatives

• ▸ Tenofovir disoproxil / Emtricitabine + Raltegravir 400 mg twice daily (legacy dosing)
• ▸ Tenofovir disoproxil / Emtricitabine + Dolutegravir 50 mg once daily

Scope

Occupational + sexual exposure (PEPSE). NHS PEP available via emergency departments and GUM clinics.

HBV approach

Risk-based per Green Book Chapter 18. Booster vaccine for adequate-responder HCW exposed; HBIG + accelerated vaccine for non-responders or unvaccinated exposed to known HBsAg-positive source.

HCV follow-up

HCV RNA + anti-HCV baseline, then HCV RNA at week 6 and 12. Anti-HCV at week 24. Refer to hepatology if positive.

Preferred regimen

Option A: Bictegravir / Emtricitabine / Tenofovir alafenamide (single tablet) — OR — Option B: Dolutegravir 50 mg + (Tenofovir alafenamide or Tenofovir disoproxil) + (Emtricitabine or Lamivudine)

Once daily × 28 days

Alternatives

• ▸ Darunavir + cobicistat OR Darunavir + ritonavir + (Tenofovir alafenamide or Tenofovir disoproxil) + (Emtricitabine or Lamivudine) — for INSTI contraindications

Scope

Adults + adolescents — both occupational PEP (OPEP, 2025 US PHS Guidelines) and non-occupational PEP (nPEP, CDC MMWR 2025;74(RR-1)). Children ≥2 y per separate INSTI-based combinations.

HBV approach

Test HBsAg + anti-HBs + anti-HBc at baseline. Tenofovir and FTC/3TC are active against HBV — abrupt withdrawal after PEP may cause HBV flare in chronic HBV carriers. CDC ACIP guidance for vaccination + HBIG separately.

HCV follow-up

HIV Ag/Ab 4th-gen baseline; final week 12. Interim weeks 4–6 only if PEP started >24 h after exposure or doses missed. HCV monitoring per CDC HCV guidance (anti-HCV + RNA baseline, follow-up per source status).