Appendix A: Known or Possible HIV Exposure Scenarios and Associated Nonoccupational Postexposure Prophylaxis Considerations

Recommendations and Reports / May 8, 2025 / 74(1);44–47

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Exposure nPEP considerations Rationale and references
All known or possible exposures The NCCC PEPline is available for clinical consultation on nPEP questions, including questions about HIV exposure and nPEP indications, at 888-448-4911 or https://nccc.ucsf.edu/clinician-consultation/pep-post-exposure-prophylaxis Persons with a recent HIV exposure might be concerned about disclosing all details of the behaviors that might have exposed them to HIV. Multiple factors might contribute to this reluctance, including trauma from sexual assault, concerns about stigma, and medical mistrust, among others (1–4). Health care professionals can prescribe nPEP to persons who request it, even if they are unable to elicit all details necessary to assess HIV acquisition risk.
Sexual exposure
Sexual exposure with an intact condom nPEP not recommended When used as recommended, condoms are highly effective at preventing HIV transmission (5–7). If the condom was not used consistently or correctly throughout the sexual encounter to prevent body fluid exposure, consider the situation as though the sexual exposure was without a condom.
Sexual exposure in which the exposed person is taking HIV PrEP as recommended nPEP not recommended PrEP taken as directed is highly effective at preventing HIV acquisition, and nPEP is not generally recommended for persons who are consistently taking PrEP (8–11). However, nPEP may be considered in certain scenarios, including 1) persons who have recently started PrEP and might not have yet reached maximum protection (12), 2) persons who have missed PrEP doses, 3) persons using an intermittent regimen outside of current ob体育 PrEP guideline recommendations (12), and 4) persons with exposure to a source without sustained viral suppression and resistance to PrEP components.
Sexual exposure in which the source has sustained HIV viral suppression defined for the purposes of nPEP as HIV treatment >6 mos, consistent high level of ARV adherence, and HIV RNA <200 copies/mL or undetectable on all laboratory assessments in the last year, with the most recent HIV RNA test result within 1–2 mos of exposure nPEP not routinely recommended For sources with sustained HIV viral suppression, the available data indicate that they will not transmit HIV sexually (13–16). It is important that health care professionals establish that the source has continued to have a high level of ARV adherence in the time since the last HIV RNA test. Individual situations for persons seeking nPEP might differ from the exposure scenarios in the studies informing this recommendation. Consultation with nPEP experts (e.g., NCCC) might be useful when individual questions arise.
Anal or vaginal intercourse without a condom when the source has HIV with detectable viremia or unknown viral suppression status nPEP recommended The recommendation to routinely offer nPEP in this scenario is based on the potential for HIV acquisition (Table 2) and the overall safety and tolerability of current nPEP regimens (17).
Anal or vaginal intercourse without a condom when it is not known whether the source has HIV Case-by-case determination Quantifying the likelihood of HIV acquisition in this scenario is not possible. The decision to initiate nPEP must be based on individual risk assessment and shared decision-making. Health care professionals can use available resources to consider how sexual behaviors (Table 2) and other factors (e.g., population HIV prevalence) influence the overall likelihood of HIV acquisition (18). Other factors that might influence the likelihood of HIV transmission, including trauma and concurrent STIs, should also be considered (17,19,20,21). The high level of safety and tolerability of newer nPEP regimens also might factor into discussions when the risk for HIV acquisition is unknown (17). HIV nPEP should be offered to survivors of sexual assault as part of comprehensive post-assault services when the assault included any contact associated with substantial risk for HIV transmission and the source’s HIV status is unknown (21).
Oral-genital sexual contact without a condom, regardless of source’s HIV status nPEP not routinely recommended The likelihood of HIV transmission with oral-genital sexual contact is low (22). On the basis of the individual risk assessment, health care professionals might choose to offer nPEP in the presence of other factors that might increase the risk for HIV transmission (e.g., trauma with blood exposure, non-intact mucus membranes, or high-level viremia) (23).
Injection drug exposure
Sharing needles or other drug injection equipment that resulted in exposure to the source’s blood when the source has sustained HIV viral suppression (HIV treatment >6 mos, consistent high level of ARV adherence, and HIV RNA <200 copies/mL or undetectable on all laboratory assessments in the last year, with the most recent HIV RNA test result within 1–2 mos of exposure) Case-by-case determination Extrapolation from studies examining HIV transmission risk from sexual exposure or accidental percutaneous exposure to persons with viral suppression suggests that HIV transmission is not expected in this setting (14–16,24,25). However, data directly addressing this exposure scenario are lacking, and individual situations for persons seeking nPEP services might differ from available studies. Health care professionals should establish that the source has continued to have a high level of ARV adherence in the time since the last HIV RNA test before deciding that the source meets criteria for sustained viral suppression. nPEP decisions must be based on an individual risk assessment and shared decision-making.
Sharing needles or other drug injection equipment that resulted in exposure to the source’s blood, when the source has HIV with detectable viremia or unknown viral suppression status nPEP recommended The scenario represents a substantial risk for HIV acquisition and nPEP is recommended (26).
Sharing needles or other drug injection equipment that resulted in exposure to the source’s blood, when it is not known whether the source has HIV Case-by-case determination Quantifying the risk for HIV acquisition is not possible when the HIV status of injection partners is unknown. Sharing needles and other drug injection equipment that results in blood exposure is associated with increased risk for HIV transmission compared with injection drug use without sharing (26,27). The high level of safety and tolerability of newer nPEP regimens also might factor into discussions when the risk for HIV acquisition is unknown (17).
Other exposures
Human bites nPEP not routinely recommended HIV transmission through human bites is rare but has been reported (28–30). Human bites with no blood exposure are not an indication for nPEP. Exposure to visibly bloody saliva presents some risk for HIV acquisition, especially if the source is known or suspected to have detectable HIV viremia; in such cases nPEP should be considered (31). Clinical evaluation of human bites should include the possibility that both the bitten person and the person biting might have been exposed to HIV and other bloodborne pathogens such as HCV.
Oral-oral exposure (kissing), mutual masturbation, any exposure to body fluids not associated with HIV transmission (e.g., tears, sweat, urine, nasal secretions, and saliva) nPEP not routinely recommended Other than exceptional circumstances where blood contamination is visible and the exposed person’s mucus membranes or non-intact skin were affected, these exposures represent negligible risk for HIV transmission, and nPEP is not indicated (23).
Blood or other infectious body fluid splash to non-intact skin or mucous membranes Case-by-case determination Rare cases of HIV acquisition from mucocutaneous exposure to splashed infectious body fluids have been described (32,33). Mucus membrane or non-intact skin exposure to blood or infectious body fluid (e.g., semen, cervicovaginal secretions, breast milk, or any visibly bloody secretions) from a source with known detectable HIV viremia is an indication for nPEP, similar to oPEP recommendations (34). Splashes from body fluids not associated with HIV transmission (e.g., tears, sweat, urine, nasal secretions, and saliva) when not visibly bloody are not an indication for nPEP.
Injury from a discarded needle in the community nPEP not recommended unless exceptional circumstances nPEP is not typically indicated for accidental injuries from discarded needles in community settings (35). No confirmed reports are available of HIV acquisition from this route of exposure. Viral characteristics, including rapid decline in HIV infectivity outside of the human body, likely contribute to the reduced risk for transmission via discarded needles compared with percutaneous injury in health care settings (36,37). Individual risk assessments are required. In exceptional circumstances, certain experts would offer nPEP (e.g., penetrating injury from a freshly bloody discarded needle used by a person who injects drugs).

Abbreviations: ARV = antiretroviral; HCV = hepatitis C virus; NCCC = National Clinician Consultation Center; nPEP = nonoccupational postexposure prophylaxis; oPEP = occupational postexposure prophylaxis; PrEP = pre-exposure prophylaxis; STI = sexually transmitted infection.

References

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