A 29-year-old woman comes to the physician 24 hours after unprotected intercourse with an individual who just learned that he is HIV-positive. She is frightened and wants to "do something." The patient's past medical history is insignificant. She has had 2 sexual partners in the past year and used condoms for every sexual encounter before this episode. She has never been tested for HIV or other sexually transmitted diseases. The patient has no known allergies. Physical examination findings are normal. Immediate HIV and pregnancy tests are negative. Which of the following is the best next step in management of this patient?

Question

A 29-year-old woman comes to the physician 24 hours after unprotected intercourse with an individual who just learned that he is HIV-positive.  She is frightened and wants to "do something."  The patient's past medical history is insignificant.  She has had 2 sexual partners in the past year and used condoms for every sexual encounter before this episode.  She has never been tested for HIV or other sexually transmitted diseases.  The patient has no known allergies.  Physical examination findings are normal.  Immediate HIV and pregnancy tests are negative.  Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

Explanation: Post-exposure prophylaxis (PEP) is successful in preventing HIV transmission in health care workers and infants (ie, perinatal transmission). Although there is no direct evidence for non-occupational PEP after unprotected sexual intercourse with an individual who is HIV-positive, it is currently recommended if it can be initiated within 72 hours after high-risk sexual encounters. In cases of low-risk exposure (eg, exposure to urine or saliva without visible blood) or presentation >72 hours after exposure, the risks of PEP likely outweigh the potential benefits and it is not recommended. Standard PEP consists of triple drug therapy for 4 weeks (Table). Tenofovir-emtricitabine with raltegravir is preferred due to a low side effect profile and few drug-to-drug interactions. Based on evidence of benefit for highly active antiretroviral therapy in the treatment of HIV, triple drug therapy is recommended. However, 2-drug regimens may be considered for individual cases when better tolerability or compliance is needed (Choice C). (Choices A and B) This patient is a good candidate for prophylaxis due to high-risk exposure. She needs repeat HIV testing in 4-6 weeks, but prophylaxis should be started now. (Choice E) If drug resistance of the source strain is known, this may be helpful for PEP drug selection. However, PEP is most effective when started as soon as possible (within 72 hours at most) and should not be delayed for resistance testing. Educational objective: Postexposure HIV prophylaxis with highly active antiretroviral therapy for 28 days is recommended following high-risk exposure to an HIV-infected individual. Triple drug therapy is preferred and should be started within 72 hours of exposure. References: Postexposure prophylaxis against human immunodeficiency virus. (http://www.ncbi.nlm.nih.gov/pubmed/20642270)

A 29-Year-Old Woman Comes to the Physician 24 Hours After