Occupational Exposure Risk

The risk of HIV transmission in a healthcare setting has been reported as 0.3% through percutaneous exposure to the blood of a source with HIV [Cardo, et al. 1997] and 0.09% after a mucous membrane exposure [Kuhar, et al. 2013]. In the Centers for Disease Control and Prevention (CDC) Needlestick Surveillance Group study, use of zidovudine as PEP by healthcare workers reduced the risk of HIV acquisition by 81% overall for percutaneous exposures [Cardo, et al. 1997]. With the use of potent antiretroviral medications that have increased bioavailability, it is presumed the use of a 3-drug PEP regimen would further reduce this risk.

In the current era of increasing viral suppression in patients with HIV, early and appropriate PEP initiation, and improved infection control protocols, these rates may be lower. In a cohort of 266 healthcare workers who had percutaneous or mucocutaneous injuries and exposure to HIV-contaminated body fluids, there were no seroconversions over a 13-year period (seroconversion rate 0%). In addition to their internal findings, the investigators compared their results to a calculated overall HIV seroconversion rate of 0.13% after a literature review conducted in October 2016 yielded 17 articles documenting 10 seroconversions among 7,652 healthcare-related exposures [Nwaiwu, et al. 2017].

The mean risk may be significantly higher in cases of percutaneous exposure in which more than 1 risk factor is present (e.g., in individuals who incur a deep injury with a hollow-bore needle from a source with HIV and a high viral load). Although the effect of viral load level has not been studied in patients with occupational exposures, there is evidence that the probability of sexually transmitting HIV is correlated with the source’s HIV viral load [Attia, et al. 2009; Modjarrad, et al. 2008; Quinn, et al. 2000].

Prevention of occupational exposure: As part of the employer’s plan to prevent transmission of bloodborne pathogens, the following measures can be taken to avoid injuries:

• Eliminate unnecessary use of needles and other sharps.
• Ensure use of and compliance with devices with safety features.
• Eliminate needle recapping.
• Ensure safe handling and prompt disposal of needles in containers for sharps disposal.
• Provide ongoing education about and promote safe work practices for handling needles and other sharps.

Even when effective prevention measures are implemented, exposures to blood and bodily fluid still occur. Employers of personnel covered by OSHA Bloodborne Pathogens and Needlestick Prevention are obligated to provide post-exposure care, including prophylaxis, at no cost to the employee. The employer may subsequently attempt to obtain reimbursement from Workers’ Compensation. For more information, see Employer Responsibilities in PEP Management to Prevent HIV Infection Following an Occupational Exposure.

Non-Occupational Exposure Risk

Sexual exposures (consensual): Exposures that may prompt a request for non-occupational PEP include condom slippage or breakage; lapse in condom use by serodiscordant or unknown status partners; or other episodic exposure to blood or other potentially infectious body fluids, including semen, vaginal secretions, or body fluids with visible blood contamination. In addition to the viral load of a source with HIV, other factors that influence transmission and acquisition risk include [Sultan, et al. 2014]:

• Genitorectal trauma
• Type of sexual exposure (receptive anal, receptive vaginal, insertive anal, insertive vaginal, receptive oral)
• Presence of STIs and genital/anal ulcers
• Circumcision status

Condomless receptive anal sex with and without ejaculation carries a risk of 1.43% and 0.65%, respectively. Condomless insertive anal intercourse carries a risk of 0.62% in uncircumcised men and 0.11% in circumcised men [Jin, et al. 2010]. In a European study, the risk associated with condomless receptive and insertive vaginal intercourse was 0.08% and 0.04%, respectively [Mastro and de Vincenzi 1996]. Information for patients is available about correct use of male (insertive) and female (receptive) condoms. The CDC HIV Risk Reduction Tool can help identify an individual’s risk of acquiring HIV.

Needle sharing and needlestick injuries: Needle sharing among injection drug users is a common reason to request PEP, as the associated risk has been estimated to be as high as 63 per 10,000 exposures based on a study among injection drug users in Thailand [Hudgens, et al. 2002; Hudgens, et al. 2001]. For this reason, PEP should always be considered in this scenario provided the potential exposure was within 72 hours.

Another route of exposure that prompts requests for PEP is needlestick injury in the community. Factors associated with risk from needlestick injuries include the potential source of the needle, type of needle, presence of blood, and skin penetration. Individuals who incur needlestick injuries from discarded needles are often concerned about potential HIV exposure. Consideration of potential risk from discarded needles should include the prevalence of HIV in the community or facility where the exposure occurred and the prevalence of injection drug use in the surrounding area. However, the risk of HIV transmission through exposure to dried blood found on syringes is extremely low [Zamora, et al. 1998]. Discarded needles should not be tested for HIV because of low yield and the risk of injury to personnel involved in the testing.

Vaccination to prevent tetanus and administration of hepatitis B vaccine are indicated for needlestick injures resulting in puncture wounds, based on immunization history and hepatitis B virus status of the source [Medscape 2021; Bader and McKinsey 2013]. Hepatitis B immunoglobulin may also be necessary (see guideline sections Management of Potential Exposure to Hepatitis B Virus and Management of Potential Exposure to Hepatitis C Virus).

Bite wounds: An estimated 250,000 human bites occur annually in the United States in a variety of settings [American Academy of Pediatrics 1997]. Although possible, HIV transmission through bites is thought to be extremely rare. Though many reported instances of bites have occurred, few cases of associated HIV infection have been established. Cases of possible HIV transmission have been documented following bites in adults exposed to blood-tinged saliva [Pretty, et al. 1999; Vidmar, et al. 1996]. A systematic review found no cases of HIV transmission through spitting and 9 possible cases of HIV transmission through a bite (6 occurred between family members, and 2 involved untrained first responders who placed their fingers in the mouth of an individual experiencing a seizure); only 4 of the 9 cases were confirmed or classified as highly plausible [Cresswell, et al. 2018].

A bite wound resulting in blood exposure should prompt consideration of PEP. When a human bite occurs, it is possible for both the individual who was bitten and the biter to incur blood exposure (see scenarios listed below). Use of PEP in such a case may be indicated if there is significant exposure to deep, bloody wounds. A bite is not considered a risk exposure to either party when the integrity of the skin is not disrupted.

Scenarios in which bites may result in blood exposure:

• Blood exposure to the biter: When the biter inflicts a wound that breaks the skin and blood from the bitten individual enters the biter’s mouth
• Blood exposure to the bitten individual: When the biter has blood in his or her mouth (e.g., from bleeding gums or lesions) and inflicts a wound that breaks the skin of the individual bitten
• Blood exposure to both parties: A break in the skin of the individual who was bitten and the biter has blood in their mouth (e.g., from bleeding gums or lesions)

Prevention of non-occupational exposure: HIV transmission can be prevented through use of condoms and safer drug injection techniques. HIV infection can be prevented with use of antiretroviral medications as PrEP to protect an individual who engages in behaviors that may result in exposure to HIV. “Treatment as prevention (TasP)” and “undetectable equals untransmittable (U=U)” are evidence-based strategies for greatly reducing the risk of HIV transmission through sexual exposure.

Sexual Assault Exposure Risk

Statistics on sexual assault in the United States show high rates of attempted or completed rape among several populations, including cisgender women, men, children, and transgender individuals:

• 26.8% of women reported attempted or completed rape* in their lifetime, with the first assault occurring [CDC 2022]:

  • Before age 18 years in 49.0% (~16.4 million)
  • Between the ages of 11 and 17 years in 34.9% (~11.7 million)
  • At age 10 years or younger in 14.0% (~4.7 million)
• 3.8% of men reported attempted or completed rape in their lifetime, with the first assault occurring [CDC 2022]:

  • Before age 18 years in 56.6% (~2.5 million)
  • Between the ages of 11 and 17 years in 29.8% (~1.3 million)
  • At age 10 years or younger in 26.8% (~1.2 million)
• About 16 million women and 11 million men who were victims of sexual violence, physical violence, or stalking by an intimate partner in their lifetime first experienced these or other forms of violence by that partner before age 18 years [CDC(a) 2024].
• 10% of 27,715 respondents to the 2015 U.S. Transgender Survey reported that they had been sexually assaulted in the 12 months prior to survey completion; 47% reported that they had experienced sexual assault during the course of their lives [James, et al. 2016].

*See How NISVS Measured Sexual Violence for definitions.

Risk of HIV infection: Increased risk of infection in cases of sexual assault has been associated with trauma at the site of exposure and absence of barrier protection:

• Genitorectal trauma has been documented in 50% to 85% of sexual assault patients [Sommers, et al. 2012; Jones, et al. 2009; Sachs and Chu 2002], and anogenital trauma has been observed in 20% to 85% [Larsen, et al. 2015; Laitinen, et al. 2013; Sugar, et al. 2004; Grossin, et al. 2003; Jones, et al. 2003; Riggs, et al. 2000].
• High rates of unprotected receptive anal intercourse (88%) and vaginal penetration (>60%) have been reported [Draughon Moret, et al. 2016]. Perpetrators of intimate partner violence are unlikely to use condoms (or they use condoms inconsistently), and are likely to force sexual intercourse without a condom and to have sexual intercourse with other partners [Stephenson and Finneran 2017; Casey, et al. 2016; Raj, et al. 2006].

PEP is the only proven method of reducing HIV acquisition after exposure, and it should be offered in cases of sexual assault. There are published reports of HIV seroconversion following sexual assault [Myles, et al. 2000; Albert, et al. 1994; Claydon, et al. 1991; Murphy, et al. 1989].

Exposure Risk in Children

Although there is evidence to support HIV prophylaxis for perinatal exposure, there are no randomized clinical trials of PEP in children beyond the perinatal period. Types of exposures that may be reported in children include sexual assault, needlesticks, or bite from a child who has HIV, but as noted below, this last type of exposure is no longer likely to occur.

Biting: Biting is a common occurrence among young children and in daycare settings. The levels of HIV detected in saliva alone are very low. The few documented cases of possible HIV transmission following bites occurred in adults exposed to blood-tinged saliva [Andreo, et al. 2004; Pretty, et al. 1999; Vidmar, et al. 1996]. As mentioned previously, a recent systematic review found no cases of HIV transmission through spitting and 9 possible cases of transmission through biting [Cresswell, et al. 2018]. A bite is not considered a risk exposure to either party when the integrity of the skin is not disrupted. Because there are so few children with HIV now, it is unlikely that a child would be the source of an HIV exposure.

Sexual abuse: HIV transmission has been described in children who have been sexually abused, and this abuse was identified as the only risk factor for infection [Lindegren, et al. 1998; Gellert, et al. 1993]. Children might be at increased risk of becoming infected with HIV because of the cervical ectopy in adolescent girls and the thinness of the vaginal epithelium in prepubertal girls [Kleppa, et al. 2015]. Additionally, children who experience abuse multiple times over an extended period by the same perpetrator are at increased risk because of mucosal trauma with bleeding [CDC 2016; Smith, et al. 2005; Dominguez 2000].

Discarded needles: Risk of transmission from discarded needles is thought to be low. In 2 cohorts of children (1 with 59 children and the other with 249) exposed to needlesticks from discarded needles, there was no HIV transmission [American Academy of Pediatrics 1999]. HIV could not be isolated from the washings of 28 discarded needles from public places and 10 needles collected from a needle exchange program [American Academy of Pediatrics 1999]. In a Canadian study evaluating 274 pediatric community-acquired needlestick injuries, only 30% of those exposed received PEP, but there were no seroconversions in 189 children tested for HIV after 6 months [Papenburg, et al. 2008]. These studies, as well as the intolerance of HIV to environmental conditions through exposure to air over time, provide reassuring data regarding the low risk of transmission from this type of exposure. See Table 1: Baseline Testing of Exposed Individuals and Table 6: Recommended Laboratory Monitoring After PEP Initiation for recommendations regarding laboratory testing, including for hepatitis C virus, based on type of exposure.

Exposure to HIV Is An Emergency

An HIV exposure is a medical emergency and rapid initiation of PEP—ideally within 2 hours of and no later than 72 hours after exposure—is essential to prevent infection. Therefore, this committee encourages emergency departments, outpatient clinics, and urgent care centers to train triage staff to assign high priority to patients who report a potential exposure. Given the urgency of PEP initiation, prescribing PEP by telehealth is reasonable when cooperative agreements are in place for PEP recipients to pursue recommended testing and follow-up. In deciding whether to continue PEP beyond the first emergency dose, care providers must balance the benefits and risks. PEP can be discontinued later in the evaluation process if indicated.

Because the efficacy of PEP in preventing an established HIV infection diminishes rapidly, initiation as soon as possible after exposure is best [CDC 2016; Kuhar, et al. 2013]. Animal models have consistently demonstrated improved outcomes at 12 to 36 hours after exposure compared with 72 hours [Otten, et al. 2000; Smith, et al. 2000; Van Rompay, et al. 2000; Tsai, et al. 1998; Van Rompay, et al. 1998; Black 1997]. Consistent with these findings, the virus can be detected in the regional lymph nodes of SIV-infected rhesus macaques within 2 days of intravaginal exposure [Spira, et al. 1996].

PEP-in-pocket (PIP): Studies of PIP, which entails giving individuals with an anticipated low frequency of high-risk HIV exposures a prescription for PEP to be used in the event of an HIV exposure, demonstrated that participants could initiate PEP appropriately on their own, often within a much shorter period between exposure and first PEP dose [Billick, et al. 2023; Alghamdi, et al. 2020; Tumarkin, et al. 2018]. Advise patients who receive PIP to store the medication so it remains clean and dry.

PEP for an individual who is taking PrEP: Occasionally, an HIV-exposed individual who has been taking PrEP insists on receiving a third ARV medication as PEP despite a clinician’s reassurance that it is unnecessary. A clinician may reassure a patient who is taking PrEP with daily adherence that no current evidence supports adding an additional ARV after a potential exposure. However, if the exposed individual has only recently started taking PrEP, has been taking PrEP inconsistently, or has been taking the medications “on-demand,” it may be reasonable to consider a 28-day course of 3-drug PEP after a high-risk exposure. Similarly, if the source has virus with known underlying resistance to the components of a PrEP regimen (FTC or tenofovir), offering 3-drug PEP to the exposed individual should be considered, particularly if the source’s viral load is unsuppressed (HIV RNA >200 copies/mL). Lastly, there may be instances in which the clinician may have to balance an exposed individual’s level of anxiety with maintaining the therapeutic alliance between the patient and care provider: offering 3-drug PEP in these scenarios may be appropriate to daily PrEP users in rare circumstances, such as high-risk needle sharing exposures or on a case-by-case basis. A request for PEP from a patient who is consistently using PrEP should not be accommodated following an exposure that is evaluated to be low or zero risk.

Request for PEP later than 72 hours after exposure: Because evidence indicates that PEP is ineffective when initiated more than 72 hours after exposure, clinicians should not initiate PEP after this time point [Beymer, et al. 2017; Otten, et al. 2000; Smith, et al. 2000; Van Rompay, et al. 2000; Tsai, et al. 1998; Van Rompay, et al. 1998; Black 1997].

By 72 hours after exposure, HIV infection may have been established. If PEP is prescribed after 72 hours and then discontinued after 28 days, the risk of viral rebound with that inadvertent interruption in ART is significant, as is the associated risk of developing resistance to ART; therefore, this committee stresses that PEP should not be initiated later than 72 hours after exposure.

In response to an exposure reported 72 hours after exposure, follow-up appropriate to the type of exposure should be arranged as detailed in Table 1: Baseline Testing of Exposed Individuals.

Managing the Exposure Site

Care of the exposure site should prioritize appropriate cleansing and infection prevention measures and minimize further trauma and irritation to the exposed wound site. The site of a wound or needlestick injury should be cleaned with soap and water only. It is best to avoid use of alcohol, hydrogen peroxide, povidone-iodine, or other chemical cleansers. Squeezing the wound may promote hyperemia and inflammation at the wound site, potentially increasing systemic exposure to HIV if present in the contaminating fluid. The use of surgical scrub brushes or other abrasive tools should be avoided, as they can cause further irritation and injury to the wound site. Eyes and other exposed mucous membranes should be flushed immediately with water or isotonic saline.

When to Consult an Expert Regarding the First Dose of PEP

Examples of clinical scenarios that warrant consultation with an experienced HIV care provider include a source with ARV-resistant HIV, an exposed individual with limited options for PEP medications because of potential drug-drug interactions or comorbidities, or an exposed individual who is pregnant or unconscious. In such circumstances, New York State clinicians are advised to call the Clinical Education Initiative (CEI Line) to speak with an experienced HIV care provider. Call 866-637-2342 and press “1” for HIV PEP. The CEI Line is available 24/7.

The National Clinical Consultation Center (NCCC) for PEP (part of the AIDS Education and Training Centers and located at the University of California, San Francisco/Zuckerberg San Francisco General Hospital) may be reached by calling 888-448-4911. The NCCC is funded by the Health Resources and Services Administration and the Centers for Disease Control and Prevention.

Evaluating Occupational Exposure Risk

PEP is indicated whenever an occupational exposure to blood, visibly bloody fluids, or other potentially infectious material occurs through percutaneous or mucocutaneous routes or through nonintact skin. Figure 2, below, illustrates the steps in determining whether ongoing PEP is indicated after the first emergency dose.

Occupational exposures for which PEP is indicated include the following:

• Break in the skin by a sharp object (including hollow-bore, solid-bore, and cutting needles or broken glassware) that has been in the source’s blood vessel or is contaminated with blood, visibly bloody fluid, or other potentially infectious material
• Bite from a patient with visible bleeding in the mouth that causes bleeding in the exposed individual
• Splash of blood, visibly bloody fluid, or other potentially infectious material to the mouth, nose, or eyes
• A nonintact skin (e.g., dermatitis, chapped skin, abrasion, or open wound) exposure to blood, visibly bloody fluid, or other potentially infectious material

PEP is not indicated for an exposure to saliva, including from being spat on, in the absence of visible blood.

Evaluation for other bloodborne pathogens: See guideline sections Management of Potential Exposure to Hepatitis B Virus and Management of Potential Exposure to Hepatitis C Virus.

Figure 2

Occupational HIV Exposure. Abbreviations: Ag/Ab, antigen/antibody; BIC/TAF/FTC, bictegravir/tenofovir alafenamide/emtricitabine (brand name Biktarvy); CrCl, creatinine clearance; DTG, dolutegravir (brand name Tivicay); HBV, hepatitis B virus; HBsAg, hepatitis (more...)

Evaluating Non-Occupational Exposure Risk

In many cases of non-occupational exposure, the source is not available for testing. The HIV status of the source should not be the focus of the initial evaluation; determining whether the exposure warrants PEP and, when indicated, prompt initiation of PEP, should be the focus. Figure 3, below, illustrates the steps in determining whether ongoing PEP is indicated after the first emergency dose.

Risk of transmission: Box 1: Risk per 10,000 Exposures of Acquiring HIV From an Infected Source and Factors That Increase Risk outlines the risk of HIV infection following various types of non-occupational exposure to an individual known to have HIV and factors that may increase risk. HIV transmission occurs most frequently during sexual or drug use exposures; however, many factors can influence risk.

Exposure to a source with acute HIV: Because of the presence of high HIV viral load levels, the probability of transmission when the source is in the acute and early stage of HIV infection (first 6 months) is 8- to almost 12-fold higher than it is once a source’s viral set point has been established, typically about 6 months after infection [Wawer, et al. 2005; Pilcher, et al. 2004]. The presence of STIs in either the source or the exposed individual also increases risk of HIV transmission [CDC(b) 2024; Johnson and Lewis 2008; Advisory Committee for HIV and STD Prevention 1998]. Conversely, transmission risk with sexual exposure is significantly decreased when a source is taking effective antiretroviral therapy (ART) and has an undetectable viral load [Cohen, et al. 2011].

Box 3, below, lists non-occupational exposures that should prompt consideration of PEP and those that do not warrant PEP.

A frank discussion between the clinician and an exposed individual regarding sexual activities, needle sharing, and other drug-using activities that have the potential for exposure to blood and other body fluids can help determine a patient’s need for PEP (see Box 1: Risk per 10,000 Exposures of Acquiring HIV From an Infected Source and Factors That Increase Risk and Box 3, above). The behaviors that confer the highest risk are needle sharing and receptive unprotected anal intercourse with an individual who has HIV [Varghese, et al. 2002; CDC 1997; DeGruttola, et al. 1989].

Clinicians should also assess factors that have been associated with increased risk of HIV infection, including:

• Trauma at the site of exposure, especially if there was contact with blood, semen, or vaginal fluids
• Presence of genital ulcer disease or other STIs [CDC(b) 2024; LeGoff, et al. 2007]
• High plasma viral load in a source with HIV [Patterson, et al. 2002; Tovanabutra, et al. 2002]
• Exposure in an uncircumcised male [Bailey, et al. 2007; Gray, et al. 2007; Patterson, et al. 2002]

Factors that may significantly decrease transmission of HIV include exposure to a source who is taking effective ART, use of daily PrEP, and use of condoms during sexual exposures [Weller and Davis 2002]. After consensual sexual exposures that meet NYSDOH U=U guidance criteria in the source, there is no evidence to support the use of PEP by the exposed individual. Furthermore, there is no evidence that a 3-drug PEP regimen provides any additional benefit to an exposed individual who adheres to a daily PrEP regimen; consistent use of PrEP has been shown to be 99% effective when taken appropriately. Correct condom use is highly effective in preventing transmission of HIV; however, during the post-exposure evaluation, it often is not possible to reliably ascertain whether condoms were used correctly or whether breakage, slippage, or spillage occurred.

Exposure to STIs other than HIV: Risk behaviors leading to HIV infection also confer risk of exposure to other STIs. Patients who present for PEP after a consensual sexual exposure should be evaluated for other STIs.

Baseline testing generally cannot detect STIs that were acquired as a result of the exposure, but may detect infections present before the exposure that prompted the evaluation for PEP. Presentation for PEP is an opportunity to screen individuals at risk of STIs and treat infections as indicated. High rates of concomitant STIs at the time of presentation for PEP have been found in men who have sex with men [Jamani, et al. 2013; Hamlyn, et al. 2006].

Routine empiric treatment for STIs is not recommended for consensual sexual exposures. Education about STI symptoms should be provided, and patients should be instructed to call their healthcare provider if symptoms occur. Follow-up STI screening should be considered at 2 weeks after exposure to definitively exclude STIs [Mayer, et al. 2017; McAllister, et al. 2017; Mulka, et al. 2016; Oldenburg, et al. 2015; Mayer, et al. 2012; Tosini, et al. 2010; Mayer, et al. 2008].

Exposure to other bloodborne pathogens: See guideline sections Management of Potential Exposure to Hepatitis B Virus and Management of Potential Exposure to Hepatitis C Virus.

Emergency contraception: For individuals who can but do not wish to become pregnant, and who consent, emergency contraception should be initiated immediately. There are a range of methods (copper intrauterine device, levonorgestrel, and ulipristal acetate) that can be taken within 5 days of a sexual exposure. Of note, emergency contraception is not an abortifacient and will generally not disrupt an ongoing healthy pregnancy. For more information, see Bedsider: Emergency Contraception.

Figure 3

Non-Occupational HIV Exposure. Abbreviations: 3TC, lamivudine (brand name Epivir); Ag/Ab, antigen/antibody; BIC/TAF/FTC, bictegravir/tenofovir alafenamide/emtricitabine (brand name Biktarvy); CrCl, creatinine clearance; CT/GC NAAT, chlamydia/gonorrhea (more...)

Evaluating Sexual Assault Exposure Risk

The decision to recommend PEP to an individual who may have been exposed to HIV through sexual assault should not be based on the geographic location of the assault but rather on the nature of the exposure during the assault and the HIV status of the defendant, if known. Although the seroprevalence of HIV in different New York State communities may vary, the HIV status of an individual accused of sexual assault remains unknown until that individual has been tested.

Risk of HIV transmission: The risk of HIV transmission in sexual assault is greater with the presence of genitorectal trauma, which may be present in as many as 50% to 85% of sexual assault patients [Sommers, et al. 2012; Jones, et al. 2009; Sachs and Chu 2002]. Studies on sexual assault document high rates of unprotected receptive anal intercourse (10% to 15%) and unprotected vaginal penetration (55% to 80%) [Draughon Moret, et al. 2016]. Studies also demonstrate a wide range (20% to 85%) of incidence of anogenital trauma [Larsen, et al. 2015; Laitinen, et al. 2013; Sugar, et al. 2004; Grossin, et al. 2003; Jones, et al. 2003; Riggs, et al. 2000]. In one study, 1% of men convicted of sexual assault in Rhode Island had HIV when entering prison [Di Giovanni, et al. 1991], higher than the general male population (0.3%).

The absence of visible trauma does not rule out sexual assault; microabrasions and bruising are common, and the appearance of these manifestations following sexual assault may be delayed. Oral trauma may also occur during sexual assault, with potential exposure to blood, semen, or vaginal fluids from the defendant, which carries a risk of HIV exposure. Bites or trauma may be inflicted during an assault and are indications for prophylaxis if there is the possibility of contact with blood, semen, or vaginal fluids from the defendant. A bite from a source with visible bleeding in the mouth that causes bleeding in the exposed individual is an indication for PEP.

HIV testing of the sexual assault patient should be performed in the emergency department setting. HIV testing may be performed on excess blood specimens obtained in the emergency department for other reasons, but only if informed consent has been obtained. In the absence of a baseline HIV test result, it may not be possible to establish that the assault resulted in HIV infection if the patient is later confirmed to have HIV.

If PEP is initiated, monitoring and follow-up should be coordinated by the treating clinician. If the baseline screening HIV test is reactive, the assault patient should continue the PEP regimen until the result is confirmed with an HIV-1/HIV-2 antibody differentiation immunoassay or HIV RNA test and linkage to care with an experienced HIV care provider has been made. If the patient is not under the care of a primary care clinician, the emergency department clinician who has obtained the HIV test is responsible for ensuring that the patient is promptly informed of the result. If HIV infection has been diagnosed, the PEP regimen may be altered by the HIV care provider or continued as ART.

Every hospital that provides emergency treatment to a sexual assault patient must adhere to and fully document services provided, consistent with the following standards of professional practice and Public Health Law 2805-P:

• Counsel sexual assault patients about options for emergency contraception to prevent pregnancy. Prompt access improves efficacy.
• Provide sexual assault patients with written information about emergency contraception that has been prepared or approved by the NYSDOH.
• Consider a urine pregnancy test to diagnose unplanned pregnancy, similar to STI screening in individuals who may be at risk. Inform the individual that a pregnancy test is being performed.

More information about the use of emergency contraception is available at Bedsider: Emergency Contraception and Emergency Contraception: What You Need to Know.

STI prophylaxis: Clinicians should offer all sexual assault patients prophylactic medication to prevent gonorrhea, chlamydia, and trichomoniasis.  STI rates have increased in all populations in the United States through a combination of increased incidence of infection and changes in diagnostic, screening, and reporting practices. Surveillance data for the United States indicate that between 2014 and 2018, rates increased for chlamydia (by 19%), gonorrhea (by 64%), primary and secondary syphilis (by 71%), and congenital syphilis(by 185%) [CDC(b) 2019; CDC 2018]. Trichomoniasis can be diagnosed or excluded in the emergency department if microscopy is available; otherwise, empiric treatment should be administered.

In cases of sexual assault, routine testing for gonorrhea, chlamydia, trichomoniasis, and syphilis is not recommended because test results would only determine whether the patient had an STI prior to the assault, and this information can be used to bias a jury against a survivor of sexual assault in court [NYSDOH 2024].

Evaluation for exposure to other bloodborne pathogens: See guideline sections Management of Potential Exposure to Hepatitis B Virus and Management of Potential Exposure to Hepatitis C Virus.

Figure 4, below, illustrates the steps in determining whether ongoing PEP is indicated after the first emergency dose.

Figure 4

Sexual Assault HIV Exposure. Abbreviations: 3TC, lamivudine (brand name Epivir); Ag/Ab, antigen/antibody; ART, antiretroviral therapy; BIC/TAF/FTC, bictegravir/tenofovir alafenamide/emtricitabine (brand name Biktarvy); CrCl, creatinine clearance; DTG, (more...)

Considerations for Sexual Assault in Children

Care providers with experience managing childhood sexual assault should assist in evaluating children who have been sexually assaulted to best assess the comprehensive needs of the child. Clinicians should assess children who have been sexually assaulted for possible exposure to other STIs, including gonorrhea, syphilis, chlamydia, hepatitis B, hepatitis C, and trichomoniasis. Indications for laboratory evaluation and antimicrobial prophylaxis depend on the nature of the assault.

Once the initial emergency dose of PEP has been administered, care for children exposed to HIV through sexual assault should be managed by a multidisciplinary team that includes the following:

• Clinicians with expertise in providing care for children who have been sexually assaulted
• Child protective services, which are mandated by law to conduct an initial assessment and investigation of reported assault or abuse
• Law enforcement officials to gather and evaluate evidence
• Rape crisis counselors or advocates to provide support to the child and family
• Mental health workers to provide immediate services as needed and who can provide long-term follow-up of the child and family, if appropriate

For more information, see the New York State Child Abuse Medical Provider Program > Education for Child Abuse Medical Providers.

Children who are sexually assaulted should be treated in an emergency department or other setting where appropriate resources are available to address the resulting medical, psychological, and legal issues. Children who present for care following sexual assault may have been victims of multiple exposures over time. PEP is indicated only for a sexual exposure that occurred within the 72 hours before the reported sexual assault. However, HIV testing may be indicated if a high-risk exposure occurred after the 72-hour cut-off for PEP efficacy.

For children who may have been exposed to HIV through sexual assault, the decision to continue PEP beyond the first emergency dose should be made based on the exposure evaluation; all sources of sexual exposure in children should be assumed to have HIV unless and until negative status can be confirmed. Clinicians should not delay initiating PEP in an exposed child pending results of the source’s HIV test.

Exposed Workers

In cases of occupational exposure, exposed workers should be counseled that it is in their best interest to receive a baseline HIV test to document their HIV status at the time of the exposure. In the rare event of HIV seroconversion following an occupational exposure, a negative baseline HIV test is the only way to show that the exposed worker was infected as a result of the exposure.

Baseline HIV testing of the exposed worker is also used to identify individuals infected with HIV at the time of the exposure, allowing decisions to be made regarding the continuation of ART. If the baseline screening HIV test result is reactive, the exposed worker should continue the PEP regimen until the result is confirmed with an HIV-1/HIV-2 Ab differentiation immunoassay or HIV-1 RNA test and linkage to an HIV care provider has been established.

Individuals who decline baseline HIV testing risk the possibility of treatment interruption should they initiate PEP and refuse HIV baseline testing. However, refusal of baseline testing should not be a reason to withhold PEP in the event that an exposed worker had a high-risk exposure that warrants a 28-day course of PEP. Furthermore, the clinician should allow for testing to be performed within 3 days of PEP initiation to allow the exposed worker the opportunity to make an informed decision and to accommodate any anxiety or stress related to a possible HIV exposure.

Baseline Testing of Exposed Individuals

Considerations and Caveats

Suspected seroconversion: If acute HIV infection is suspected at any time, immediate consultation with a clinician experienced in managing acute HIV infection is advised. Clinicians can call the Clinical Education Initiative (CEI Line) to speak with an experienced HIV care provider: 866-637-2342 (press “1” for HIV PEP). The CEI Line is available 24/7.

Source confirmed HIV negative: If the source is confirmed to be HIV negative, the exposed individual’s PEP regimen should be discontinued.

Use of a 3-drug PEP regimen: This committee recommends a 3-drug ARV regimen as the preferred option once the decision has been made to initiate PEP. When the source is known to have HIV, past and current ARV experience, viral load data, and genotypic or phenotypic resistance data (if available) may indicate the use of an alternative PEP regimen. Consult with an experienced HIV care provider.

Drug-drug interactions and adverse effects: Care providers should advise patients not to take divalent cations (aluminum, calcium, magnesium) or iron supplements concurrently with DTG or RAL. Metformin dosing should be limited to 1 g by mouth per day when an individual is taking DTG concurrently.

Care providers should counsel patients about the low risk of gastrointestinal adverse effects with TDF/FTC, such as nausea, abdominal bloating, and vomiting, along with headache. A low risk of neuropsychiatric effects with DTG may also exist. RAL has been rarely associated with rhabdomyolysis [FDA 2021].

Impaired renal function:  Do not initiate TDF/FTC as PEP for any individual with a confirmed CrCl <60 mL/min, and discontinue it in patients with a confirmed CrCl <50 mL/min; in such cases, initiate or switch to a TAF-containing regimen and continue monitoring while completing a 28-day course of PEP [DHHS 2024].

Hepatitis B virus infection: Additional monitoring is required for exposed individuals with HBV infection.

Adherence and completion requirements: The recommended 28-day treatment duration is based on limited animal data and expert opinion [Tsai, et al. 1998]. Nonetheless, adherence to a full 28-day course of PEP and completion of therapy is important to prevent HIV seroconversion after exposure.

Repeated requests for non-occupational PEP: PEP should not be routinely dismissed based on repeated risk behavior or repeat presentation for PEP (see guideline section Counseling and Patient Education > Risk reduction), but clinicians should strongly encourage use of pre-exposure prophylaxis (PrEP) for individuals who repeatedly request PEP.

PEP completion following sexual assault: Limited data exist on the use of antiretroviral therapy (ART) to prevent HIV infection in sexual assault populations. One study demonstrated higher completion rates (66% vs. 42%) among individuals taking TDF/FTC in combination with DTG or RAL than those taking TDF/FTC plus darunavir (DRV) boosted with ritonavir (RTV) [Kumar, et al. 2017], suggesting TDF/FTC in combination with DTG or RAL is better tolerated in this population.

Preferred PEP Regimens for Patients Who Weigh ≥40 kg

The medications that comprise the recommended PEP regimens (and substitutions) listed in Table 2, below, have favorable adverse effect profiles, fewer potential drug-drug interactions, and expected efficacy similar to older PEP regimens that contained ZDV or PIs. Researchers reported increased rates of adherence and regimen completion when the single-tablet regimen of BIC/TAF/FTC was used [Liu, et al. 2022; Mayer, et al. 2022]. For multi-tablet regimens TDF/FTC or TDF/3TC have been used as components of the PEP regimen [Tosini, et al. 2010; Mayer, et al. 2008] with high rates of adherence and low rates of discontinuation. Observational cohorts and a small randomized study reported improved tolerability with TDF/FTC plus RAL [McAllister, et al. 2017; Mulka, et al. 2016; Mayer, et al. 2012], and an observational cohort demonstrated high completion rates with TDF/FTC plus DTG [McAllister, et al. 2017]. Additionally, TDF/FTC has been highly successful in studies of PrEP [Baeten, et al. 2012; Thigpen, et al. 2012; Grant, et al. 2010].

Unlike PIs, which block HIV replication after integration with cellular DNA, all currently recommended PEP medications act before viral integration with cellular DNA, providing a theoretical advantage in preventing establishment of HIV infection.

Alternative PEP Regimens for Patients Who Weigh ≥40 kg

Table 3, below, lists 2 alternative PEP regimens that are acceptable options when a preferred regimen is not available. Observational studies have demonstrated excellent tolerability and completion rates with these regimens [Mayer, et al. 2017; Fätkenheuer, et al. 2016; Valin, et al. 2016]. They are possibly less well tolerated than the preferred regimens of BIC/TAF/FTC and TDF/FTC plus either RAL or DTG, but they are significantly better tolerated than regimens containing ZDV or lopinavir/ritonavir (LPV/RTV).

In most cases, a single-tablet regimen for a patient with adequate kidney function (CrCl >70 mL/min) and no expected drug-drug interactions is preferred. In addition to low discontinuation rates, this option also allows for use of medication assistance programs if a patient has limited medication coverage options.

Drug-drug interactions: The potential for drug-drug interactions in patients receiving PIs or cobicistat (COBI) is increased by the extensive cytochrome P450 interactions. Clinicians should assess for potential interactions before prescribing a PEP regimen.

Other alternative PEP regimens: Other alternative PEP regimens may be acceptable in certain situations. Some clinicians continue to favor the use of ZDV in PEP regimens based on the results of a retrospective study supporting the efficacy of the agent [Cardo, et al. 1997] and from long-term experience in occupational PEP. Clinicians who continue to prescribe ZDV should recognize and inform patients that the drug is associated with significant adverse effects and that better tolerated agents are available.

Use of LPV/RTV has greater potential for drug-drug interactions and adverse effects than RAL, DTG, or DRV/RTV (the preferred alternative boosted PI), with little added efficacy benefit expected. Studies have demonstrated decreasing PI resistance among HIV strains [Paquet, et al. 2011], suggesting there may be a diminishing benefit to choosing LPV/RTV for its activity against resistant HIV strains. DRV/RTV has excellent activity against many PI-resistant strains and is better tolerated than LPV/RTV.

This committee recommends a 3-drug regimen because of the greater likelihood of enhanced effectiveness; however, if tolerability is a concern, use of a 2-drug regimen would be preferable to discontinuing the regimen completely. An early case-control study of occupational exposure demonstrated an 81% reduction in seroconversion with the use of ZDV monotherapy [Cardo, et al. 1997], suggesting that treatment with any active ARV agent is beneficial in reducing risk. Other studies have investigated 2-drug PEP regimens and found excellent tolerability [Kumar, et al. 2017; Mayer, et al. 2008].

PEP Regimens for Patients Who Weigh

No clinical studies are available to determine the best regimens for HIV PEP in children. The recommendations for drug choices and dosages presented here follow current U.S. Department of Health and Human Services recommendations in Guidelines for the Use of Antiretroviral Agents in Pediatric HIV Infection, which are based on expert opinion. The recommended regimens reflect experience with ARV combinations that effectively suppress viral replication in children with HIV and with combinations that are well tolerated and increase adherence to PEP. The chosen preferred regimens have demonstrated good potency and tolerability.

The alternative PEP regimens for children are also based on expert opinion. They all have demonstrated potent antiviral activity. However, the PI-containing regimens are often more difficult to tolerate because of potential gastrointestinal adverse effects. To improve adherence, clinicians can and should prescribe preemptive antiemetics for anticipated gastrointestinal adverse effects.

When choosing a PEP regimen, care providers should consider factors that may affect adherence, such as ARV drug intolerance, regimen complexity, expense, and drug availability.

ARV Medications to Avoid for PEP

Newer ARV medications have demonstrated significantly fewer adverse effects than older ARVs. The medications listed in Table 5, below, should be avoided.

Consultation with an experienced HIV care provider is recommended before using any of the medications listed above for PEP, or before using etravirine or doravirine, for which limited data exist.

PEP During Pregnancy or Breast/Chestfeeding

Use of ARV prophylaxis in pregnancy generally does not increase the risk of birth defects [DHHS 2024]. ARV prophylaxis can prevent HIV transmission during acute infection in pregnancy, when viral loads are extremely high, which is associated with a high risk of infection to the infant [Patterson, et al. 2007]. No severe adverse effects or adverse pregnancy outcomes have been noted among women taking ART for PEP [CDC 2016]. However, no clinical trial data regarding PEP use in pregnant individuals are currently available [CDC 2016], and data are limited on the use of INSTIs during pregnancy [DHHS 2024].

The single-tablet ART regimen of BIC/TAF/FTC has been shown to be safe and effective when used during pregnancy and was associated with high levels of viral suppression and similar perinatal outcomes to those among pregnant individuals without HIV [Holt, et al. 2024; Olivero, et al. 2024; Powis, et al. 2024; Zhang, et al. 2024].

When screening for HIV in pregnant patients, care providers should be aware that detection of early/acute HIV infection requires HIV RNA testing in most instances and should repeat antibody testing as late as the third trimester [Wertz, et al. 2011] when screening for HIV infection in pregnant patients.

Current U.S. Department of Health and Human Services guidelines require dose adjustments for DRV and atazanavir (ATV) [DHHS 2024]:

• DRV: 600 mg twice per day plus RTV (Norvir) 100 mg twice per day
• ATV: 400 mg once per day plus RTV 100 mg once per day in the third trimester

Although birth defects and adverse effects on human fetuses have generally not been associated with the ARV agents that are currently available, exposure of a fetus to ARV agents during pregnancy carries a theoretical risk of embryotoxicity.

ARV medications to avoid as PEP during pregnancy: The ARV medications to be avoided for PEP above also apply to pregnant individuals. Based on animal data, there has been a theoretical concern for teratogenicity of EFV in the first trimester; however, current federal perinatal guidelines do not preclude its use [DHHS 2024; Martinez de Tejada, et al. 2019]. ZDV is still recommended for prevention of perinatal HIV transmission.

PEP during breast/chestfeeding: Initiating PEP in exposed individuals who are breast/chestfeeding requires careful discussion. Both HIV medications may be found in breast/chest milk; therefore, breast/chestfeeding should be avoided for 3 months after the exposure to prevent HIV transmission and potential drug toxicities [American Academy of Pediatrics 2013]. Clinicians should discuss the risks and benefits with the patient. The infant’s pediatrician should be informed of any potential exposure to HIV medications.

Adherence and Completion of the 28-Day PEP Regimen

Reported adherence to a 28-day PEP regimen has historically been modest (40%-60%) [Lunding, et al. 2010; Day, et al. 2006; Parkin, et al. 2000]. However, increased rates of adherence have been reported in studies of PEP regimens that include TDF/FTC or TDF/3TC plus a third agent [Tosini, et al. 2010; Mayer, et al. 2008], and some have reported improved tolerability with use of TDF/FTC plus DTG or RAL [Inciarte, et al. 2023; McAllister, et al. 2017; Mulka, et al. 2016; Mayer, et al. 2012].

Single-tablet regimens: With the availability of several single-tablet regimens, many clinicians prefer them for PEP to optimize adherence or to use commercial medication assistance programs that may be available to uninsured or under-insured individuals. Several published observational prospective cohort studies support this approach:

• In the 3 studies in China, the United States, and Canada discussed above (total 280 participants), once-daily single-tablet BIC/FTC/TAF as PEP was well tolerated, adverse effects were minimal, and discontinuation rates were low. Only 4 participants discontinued the drug, and there were no seroconversions [Tan, et al. 2024; Liu, et al. 2022; Mayer, et al. 2022].
• Three published studies examined the use of fixed-dose TDF/FTC/elvitegravir (EVG)/COBI as PEP in observational prospective cohorts in France, Boston, and Spain. In the French cohort, 92% of participants completed 28 days of PEP, and only 3 individuals switched to another regimen because of adverse effects [Valin, et al. 2016]. Lower rates of completion were noted in the Boston group, with 71% completing the 28-day course as prescribed (no missed doses), 15% stopping or modifying their dosing, and 14% lost to follow-up [Mayer, et al. 2017]. In both cohorts, gastrointestinal adverse effects were the most common. In the study from Spain, 422 participants received TDF/FTC/EVG/COBI following sexual assault; 52% had documented completion of the 28 days of treatment and 71% attended a follow-up clinic appointment [Malinverni, et al. 2021], better rates than those observed in a similar group treated with alternative regimens. There were no documented HIV seroconversions in any of the 3 studies.
• Results of a 2015 open-label, single-arm study conducted at 2 public sexual health clinics and 2 hospital emergency departments in Australia demonstrated high PEP completion rates (92%) and no HIV seroconversions with fixed-dose single tablet TDF/FTC/rilpivirine (RPV). Most participants (86%) reported taking all doses with food, and 95% of those who completed the full course endorsed taking the medication with food. The investigators acknowledged that they studied TDF/FTC/RPV in a population with a low background of transmitted nucleoside reverse transcriptase inhibitor (NRTI) (4.1%) and non-NRTI (3.1%) resistance and that this combination should be used carefully in populations with higher rates of transmitted resistance [Foster, et al. 2015].
• Results of a 2023 open-label, single-arm study conducted at a single emergency department in Barcelona, Spain, demonstrated high PEP completion rates (71%) and no HIV seroconversions with fixed-dose single-tablet doravirine (DOR)/3TC/TDF. Among participants who completed the full 28-day course, adherence was 96% and adverse effects were minimal and self-limited. There were no seroconversions [Inciarte, et al. 2023].

The Centers for Disease Control and Prevention and this committee recommend DTG as a third agent (and alternative to RAL). A recent open-label, single-arm study at 3 sexual health clinics and 2 emergency departments in Australia found completion rates of 90% and no seroconversions with use of DTG plus TDF/FTC as PEP. Adherence was 98%, measured by pill count and consistent with drug levels, and no unexpected or serious adverse effects occurred [McAllister, et al. 2017].

Alternatively, a once-daily PI-based PEP regimen of DRV/RTV plus 2 NRTIs demonstrated lower discontinuation rates than with LPV/RTV or EFV plus 2 NRTIs, without significant adverse effects [Fätkenheuer, et al. 2016]. Together, these study results demonstrate that once-daily PEP regimens (single or multi-tablet) can be well tolerated and have high completion rates.

Regimens containing ZDV and LPV/RTV had lower rates of completion and higher rates of discontinuation because of adverse effects [Leal(a), et al. 2016; Ford(a), et al. 2015]. Many agency guidelines switched first-line recommendations to include RAL as a third agent because it had a more favorable adverse effect profile and fewer drug-drug interactions [McAllister, et al. 2014; Mayer, et al. 2012]. However, given the twice-daily dosing of RAL, nearly one-fourth of a cohort on PEP missed the afternoon dose [Mayer, et al. 2012], which suggests that adherence to a RAL-based regimen is challenging.

Extending PEP Beyond 28 Days

It is rare that PEP is extended beyond the standard 28-day regimen. The only circumstances under which PEP would be extended include the following:

• The exposed individual has an indeterminate HIV test result or is experiencing acute retroviral syndrome at 4 weeks after exposure.
• The exposed individual is pregnant and there is a high probability of HIV exposure, given the risk of viral rebound in pregnancy.

In such cases, the clinician should consult with an experienced HIV care provider. Otherwise, no data are available to support extending PEP beyond 28 days to prevent HIV infection following an exposure within the previous 28 days.

PEP Starter Pack

Starter packs may reduce the time to PEP initiation and have been used in several PEP protocols, including emergency department visits following sexual assault [Kumar, et al. 2017; Muriuki, et al. 2017; Krause, et al. 2014]. If a 28-day supply of medications cannot be provided, then in most cases, a 7-day supply will allow an individual sufficient time to access the additional medications needed to complete the full course of treatment. Patients who receive a 7-day starter pack should be informed that it does not contain the full 28-day course of PEP medications and assisted in creating a plan to obtain the rest of the required medications. A systematic review of starter packs versus full prescriptions of PEP suggested that completion rates and adherence to PEP may be lower in individuals receiving starter packs; thus, it is essential that individuals receiving starter packs be counseled on the importance of following up with a clinician to receive a prescription for the remaining PEP course and for follow-up testing [Ford(b), et al. 2015].

Payment For Occupational PEP

Federal law requires covered employers to ensure that all medical evaluations and procedures, vaccines, and PEP medications (7-day starter pack and access to the full 28-day course) are made available to the employee within a reasonable time, at a reasonable location, and at no cost to the employee (Occupational Safety and Health Administration [OSHA], 1910.1030 Bloodborne Pathogens).

The New York Public Employee Safety Health Act (PESH) and OSHA Bloodborne Pathogen Standards indicate that the covered employer is responsible for all costs associated with an exposure incident. An employer may not require any out-of-pocket expenditures on behalf of the employee, such as requiring the employee to use workers’ compensation if prepayment is required or compelling an employee to use health insurance to cover these expenses, unless the employer pays all premiums and deductible costs associated with the employees’ health insurance.

Employers should determine who will pay for PEP and establish policies for submitting claims to their workers’ compensation plans. Employers should not expect exposed workers to pay out of pocket for PEP, including copays, even if they are reimbursed at a later date.

Payment Assistance For Non-Occupational PEP

Care providers should ensure that a patient can acquire the medications needed to continue PEP through 28 days regardless of insurance coverage status. Options for patients who are uninsured or under-insured include medication assistance programs (MAPs) and health centers specifically funded to provide PEP at no or low cost.

If an individual has prescription drug coverage, third-party reimbursement may cover PEP, depending on the plan’s prescription drug policy. If a medication-dispensing facility does not receive reimbursement for these services, such expenses may be included in their annual Institutional Cost Report as part of indigent care costs. For patients who are paying out of pocket, cost is a factor in selecting a regimen.

MAPs: MAPs are available for individuals who do not have insurance coverage for PEP and meet certain criteria; these programs cover several drugs included in the recommended PEP regimens:

• Single-tablet, fixed-dose bictegravir/tenofovir alafenamide/emtricitabine (brand name Biktarvy)
• Fixed-dose tenofovir disoproxil/emtricitabine (brand name Truvada)
• Dolutegravir (brand name Tivicay)
• Raltegravir (brand name Isentress)
• Single-tablet, fixed-dose elvitegravir/cobicistat/emtricitabine/tenofovir disoproxil fumarate (brand name Stribild), an alternative PEP regimen

Clinicians should work with social workers and support staff to enroll patients without alternative means of coverage or payment for PEP in MAPs. These programs often provide 1 course of PEP. Obtaining future courses may be challenging, so clinicians should consider whether pre-exposure prophylaxis is appropriate for patients who receive PEP from a MAP.

Payment for PEP medications for exposed children: In New York State, all children qualify for health insurance regardless of their immigration status. Payment difficulties may arise for patients who have private insurance with high medication copays.

Payment Methods For PEP Following Sexual Assault

Various methods of payment for PEP are available for victims of sexual assault, including Medicaid, Medicare, or the New York State Office of Victim Services (OVS).

Right to decline provision of private health insurance: Under New York State law, hospitals must notify sexual assault patients, orally and in writing, of their right to decline to provide private health insurance information for billing for a forensic rape examination (FRE). If a sexual assault patient declines to provide such information, the hospital is prohibited from billing the patient or their insurance company for the FRE. Instead, the hospital may bill the OVS for the FRE. A minor patient may sign the FRE claim form so the facility can seek reimbursement for the sexual assault examination through the FRE program; however, it must be reasonable to conclude that the minor understands what they are signing and why.

Hospitals are required to advise sexual assault patients orally and in writing that they may decline to provide information about private health insurance benefits if they believe that provision of such information will substantially interfere with their privacy or safety. If patients so decline, then with the patient’s consent, OVS will be billed directly.

Follow-up PEP costs beyond the initial 7-day period and the costs of follow-up medical treatment needed as a result of the sexual assault will, for insured patients, continue to be reimbursed through the patient’s insurance, Medicaid, or another insurance program because OVS is the payor of last resort; however, OVS may consider the patient’s out-of-pocket responsibility for reimbursement. If a sexual assault patient is not insured or is a minor, a full OVS claim application should be filed. Minors are permitted to sign only the FRE claim form.

Initial and Ongoing Follow-Up

Initial follow-up within 48 hours: Clinicians should follow up with the exposed individual within 48 hours, either by telephone call or in person, to assess PEP tolerability and adherence and to confirm access to the medications required to complete the full 28-day PEP regimen. If the patient has difficulty accessing the prescribed PEP medications, a social worker or patient navigator should be engaged to explore options and assist with medication access.

Follow-up care is necessary for patients taking PEP medications, to monitor for adverse effects and maximize adherence. Patients who report adverse effects by telephone should be evaluated in person if they require a physical examination (e.g., new rash or severe gastrointestinal symptoms such as abdominal pain, nausea, vomiting, and diarrhea). If the patient does not tolerate the recommended regimen well, an early switch to an alternative regimen is encouraged to improve adherence. Consultation with an experienced HIV care provider is advised when a patient’s PEP regimen must be changed.

Discuss the best method of contact for any adolescent or young adult who does not wish to disclose HIV exposure to parent(s) or guardian(s) and make sure to note the confidential phone number or method of contact.

Adherence support: Follow-up should also include discussions of daily adherence and reminders to complete the full 28 days of PEP. Clinicians should be aware of community resources for any medical and supportive counseling and adherence services a patient may need following non-occupational exposure.

• PEP resources for care providers and patients can be found on the NYSDOH website.

Ongoing follow-up: After the initial follow-up within 48 hours, a care provider or member of the PEP care team (such as a registered nurse, social worker, or patient navigator) should follow up with the patient by telephone or in-person visit by week 2 to further assess for adverse effects and confirm access to the medications required to complete the full 28-day course of PEP. Care providers should pay particular attention to any symptoms suggestive of acute retroviral syndrome.

Risk Reduction

Transition to PrEP: Patients who remain at high risk of HIV exposure after completing a course of non-occupational PEP and who are negative for HIV at the time of the 4-week HIV test should be offered PrEP, to begin immediately after the last dose of non-occupational PEP.

In a case-control study in Barcelona of possible predictors of HIV seroconversion among individuals using non-occupational PEP, independent factors associated with HIV seroconversion included being a man who has sex with men (MSM), having a sex partner with HIV, taking a previous course of PEP, and having prior sexually transmitted infections (STIs) [Leal(b), et al. 2016]. Several observational cohort studies noted high rates of HIV seroconversion among PEP users beyond the initial 3-month period after a potential exposure to HIV. These seroconversions are likely due to ongoing risk behaviors that may have been prevented by repeated courses of PEP or, more suitably, use of PrEP. At a large sexual health clinic in London where PEP was prescribed to 530 MSM over a 6-month period in 2013, 183 men received repeat PEP, and the incidence of repeat PEP was 24 per 100 person-years. Among the 57 men who acquired HIV, 12 could not be ruled out as experiencing PEP failure, and HIV incidence was 7.6 per 100 person-years [Whitlock, et al. 2017]. High rates of incident HIV have also been seen among non-occupational PEP recipients in Amsterdam, Australia, Boston, and Switzerland [Hovaguimian, et al. 2021; Jain, et al. 2015; Heuker, et al. 2012; Poynten, et al. 2009].

Follow-Up of Sexual Assault Patients

If a sexual assault patient is too distraught to engage in discussion and decision-making about PEP, the care provider should encourage the individual to take a single dose of PEP and revisit the discussion the following day. The risk of taking one dose is minimal, and the efficacy that would be lost if delayed a whole day may be salvaged. If the individual decides to defer the decision to initiate PEP, a follow-up visit within 24 hours should be scheduled to ensure that PEP is started as soon as possible and no later than 72 hours after exposure.

Resources and support for sexual assault patients: Sexual assault patients may require additional resources and support to ensure adherence to the daily PEP regimen and completion of the 28-day course. In a retrospective cohort study in Nairobi, Kenya, PEP was initiated in only 54% of cases involving sexual assault, and victims had low overall rates of completion of PEP (34%) and low rates of repeat HIV testing at 3 months (10%) [Muriuki, et al. 2017]. Similarly low rates of PEP completion (27%) were noted in sexual assault patients at an academic medical center in Boston, Massachusetts [Krause, et al. 2014].

Specific factors in this population may influence the acceptance of PEP. An analysis of forensic nurse examinations in the Mid-Atlantic region of the United States found that patients with injuries to the anus or genitalia were more likely to initiate PEP than patients with injuries to the face or head [Draughon Moret, et al. 2016]. These data suggest that sexual assault patients may need additional in-person visits or follow-up telephone calls from patient navigators and social workers, and medical monitoring for adverse effects.

The treating clinician, preferably a sexual assault forensic examiner (SAFE), must coordinate care to encourage medical follow-up and adherence to PEP. The rape crisis advocate may become the crucial link between the sexual assault patient and the care provider, clarifying communication and facilitating follow-up care for the patient. When the patient does not have a primary care provider or has difficulty arranging access to a clinician experienced in HIV PEP, this link is especially important. Support from the advocate increases the likelihood that the sexual assault patient will adhere to the PEP regimen and that the primary care provider, PEP prescriber, or SAFE will be notified of medical problems. The advocate can also ensure that problems are addressed expeditiously as they arise.

Tables

• Table 1: Baseline Testing of Exposed Individuals
• Table 2: Preferred PEP Regimens for Patients Who Weigh ≥40 kg
• Table 3: Alternative PEP Regimens for Patients Who Weigh ≥40 kg
• Table 4: PEP Regimens for Patients Aged 2 to 12 Years Who Weigh <40 kg
• Table 5: Antiretroviral Medications to Avoid for PEP
• Table 6: Recommended Monitoring After PEP Initiation
• Table 7: Recommended PEP for Hepatitis B Virus Exposure

Figures

• Figure 1: Sequence of Events Following HIV Exposure, With and Without Administration of PEP
• Figure 2: Occupational HIV Exposure: PEP and Exposure Management When Reported Within 72 Hours
• Figure 3: Non-Occupational HIV Exposure: PEP and Exposure Management When Reported Within 72 Hours
• Figure 4: Sexual Assault HIV Exposure: Post-Exposure Prophylaxis and Exposure Management
• Figure 5: Evaluation of HCV Exposure Risk and Recommended Follow-Up

Boxes

• Box 1: Risk per 10,000 Exposures of Acquiring HIV From an Infected Source and Factors That Increase Risk
• Box 2: Risk of HIV Transmission From a Source With HIV
• Box 3: Non-Occupational Exposure Risks and Indications for Post-Exposure Prophylaxis
• Box 4: Source HIV Testing
• Box 5: Clinician-to-Clinician Communication
• Box 6: HIV Testing When the Source of an Occupational Exposure Is Unable to Consent
• Box 7: PEP Patient Education Checklist

Employer Responsibilities in PEP Management to Prevent HIV Infection Following an Occupational Exposure

NYSDOH AIDS Institute, June 2020

Requirements: Organizations that employ health professionals or others who are at risk for occupational exposure to blood, body fluids, or other potentially infectious materials are generally required to establish policies and procedures that guide the management of such exposures.

Employers must conform to the  (OSHA Bloodborne Pathogens Standard 29 CFR § 1910.1030 and Compliance Directive CPL 02-02-069, 11/27/01, Enforcement Procedures for the Occupational Exposure to Bloodborne Pathogens), which are applicable to New York public employers under the New York Public Employee Safety and Health (PESH) Act (Labor Law § 27-a) and regulations (12 NYCRR Part 800). OSHA and PESH standards regarding occupational exposure to bloodborne pathogens are identical. These regulations require that a management plan is in place.

Employee access to post-exposure services: The employer should ensure that any employee who sustains an occupational exposure has access to post-exposure services within 1 to 2 hours of a reported event. Services must be available 24 hours per day, 7 days per week. Organizations that do not have onsite occupational health services are encouraged to form agreements or contracts with another facility, Emergency Department, or private practitioner for such services.

Definition of individuals covered: New York State regulations apply to staff, employees, or volunteers in the performance of employment or professional duties who work in:

• A medical or dental office
• A facility regulated, authorized, or supervised by the Department of Health, Office of Mental Health, Office for People With Developmental Disabilities, Office of Children and Family Services, Office of Addiction Services and Supports, or the Department of Corrections and Community Supervision
• Emergency response employee (paid or volunteer, including an emergency medical technician, a firefighter, a law enforcement officer or local correctional officer, or medical staff)

Post-exposure policies should define who is included as an “employee” for purposes of providing care. In addition to staff who are employed by an organization (e.g., nurses, laboratory personnel, housekeepers), consideration must be given to whether other individuals (e.g., medical/nursing students, house staff, attending physicians, volunteers, and pre-hospital care personnel) will be covered by the institution’s policy. In addition, the scope of services that will be provided must be delineated (e.g., laboratory testing, occupational health services, prophylactic drugs or vaccines), including whether there are limitations within the categories of individuals covered, particularly regarding workers’ compensation benefits.

Access to services: Exposed workers who sustain an occupational exposure should be ensured access to post-exposure services within 1 or 2 hours of a reported event. This may require 24-hour and weekend coverage. Procedures should identify how workers access services during regular work hours and, if different, how they access services during evening, night, or weekend shifts. Organizations that do not have onsite occupational health services should consider forming agreements or contracts with another facility or private practitioner for such services.

• Post-exposure services for exposures to all bloodborne pathogens include but are not limited to:
• Post-exposure evaluation and follow-up post-exposure vaccinations
• Arrangements for a full course of PEP medications, at no cost to the employee
• Care provided under the supervision of a licensed physician or other licensed healthcare professional
• Availability of a rapid HIV test for source testing
• Supportive counseling

Federal law requires covered employers to ensure that all medical evaluations and procedures, vaccines, and post-exposure prophylaxis are made available to the employee within a reasonable time and at a reasonable location and are made available at no cost to the employee (OSHA, 29 CFR, Part 1910.2030, CPL 2-02.069, 11/27/01, Enforcement Procedures for the Occupational Exposure to Bloodborne Pathogens).

PESH and OSHA’s Bloodborne Pathogens Standards indicate that the covered employer is responsible for all costs associated with an exposure incident. An employer may not require any out-of-pocket expenditures on behalf of the employee, such as requiring the employee to utilize workers’ compensation if prepayment is required or compelling an employee to use health insurance to cover these expenses unless the employer pays all premiums and deductible costs associated with the employees’ health insurance. In addition to services listed above, the NYSDOH AI guideline PEP to Prevent HIV Infection states that the following should be considered by the employer when establishing plans for providing PEP for HIV exposure:

• Who will perform the post-exposure evaluation.
• Who will provide counseling to the exposed worker regarding the exposure and indications for PEP (for off-hour exposures as well).
• How PEP will be made available within 2 hours of an exposure.
• How a 7-day supply of PEP will be made available for urgent use.
• Who will be given authority for releasing drugs for this purpose.
• How the exposed worker will obtain PEP medications to complete the 28-day regimen.

Determining the HIV status of the exposure source: Procedures to facilitate rapid evaluation and voluntary testing for HIV, hepatitis B virus (HBV), hepatitis C virus (HCV), and other bloodborne pathogens and disclosure of related information of the source individual should be in place.

The employer is responsible for establishing and implementing policies to protect the confidentiality of both the exposed employee and the exposure source (New York Public Health Law §§ 2135, 2782; 10 NYCRR § 63.6).

Access to source HIV-related information: New York law and regulations (Public Health Law § 2781(6)(e); 10 NYCRR § 63.8(m)) authorize disclosure of existing HIV-related information to healthcare providers of those who have been exposed in the workplace when significant risk exposure has occurred.

When the source is already known to be infected with HBV, HCV, or HIV, testing for the source individual’s known HBV, HCV, or HIV status does not need to be repeated. Testing for other bloodborne pathogens should still occur.

If the exposed worker is part of the healthcare team, he/she may have access to the medical record and know the HIV status of the source, as well as information about drug resistance. Information related to drug regimens, and, if available, resistance information should be made available to the exposed employee’s healthcare provider to determine the best regimen for the employee. However, initiation of PEP should not be delayed while awaiting this information.

HIV testing of the source: Consistent with recommendations by the Centers for Disease Control and Prevention (CDC), and the U.S. Department of Labor, OSHA mandates that medical facilities subject to OSHA authority use rapid HIV antibody tests when testing the source after potential exposure to a bloodborne pathogen. The CDC recommends testing with an HIV-1/2 antibody/antigen combination immunoassay.

• The source should be tested as soon as possible to determine HIV infectivity.
• Results of the source individual’s HIV testing should be made available to the exposed worker’s healthcare provider. Patient authorization for the release of this information is not required for necessary communication of information between care providers for timely treatment of the exposed worker.

Source has the capacity to consent for HIV testing: Informed consent from the source should be obtained. If consent is not obtained for HIV testing, the employer should document that consent cannot be obtained and testing cannot be performed (see Box 6: HIV Testing When the Source of an Occupational Exposure Is Unable to Consent).

New York regulations [§§ 63.3(d)(7), 63.8(n)] also authorize anonymous testing when no individual authorized to consent on behalf of the source is immediately available.

An anonymous test* may be performed if: The healthcare agent or FHCDA Surrogate, who has the legal authority to consent, is not available or reasonably likely to become available in time for the exposed individual to receive appropriate medical treatment and the exposed individual will benefit medically by knowing the source’s HIV test results or the source is deceased.

*The law requires that results of anonymous source testing are given only to the healthcare provider of the exposed individual solely for assisting the exposed individual in making appropriate decisions regarding post-exposure medical treatment. The results of the test cannot be disclosed to the source or placed in the source’s medical record. The source may be told that the exposure occurred and that an HIV test was performed. The source should be offered confidential testing so that they may have access to information about his/her own HIV status.

Worker’s compensation program: The Workers’ Compensation Law has specific implications for employees exposed to HIV, as well as those rare cases that result in seroconversion. Individuals who manage such exposures should be familiar with these implications because they should be able to counsel employees and refer them for legal and medical assistance accordingly. The organization’s workers’ compensation provider should be contacted as situations arise.

NYS Worker’s Compensation Board:

• Website: http://www.wcb.ny.gov/
• Worker benefits and information regarding how to file a claim: http://www.wcb.ny.gov/content/main/Workers/Workers.jsp
• Advocate for Injured Workers, for questions related to injured workers: (877) 632-4996 (800) 580-6665 Email: [email protected]

Preventing transmission of bloodborne pathogens: As part of the employer’s plan to prevent transmission of bloodborne pathogens, the following measures can be taken to avoid injuries:

• Elimination of unnecessary use of needles or other sharps
• Use of devices with safety features
• Verification of training and compliance with safety features
• Avoidance of needle recapping
• Planning before beginning any procedure using needles or other sharps for safe handling and prompt disposal in sharps disposal containers
• Promotion of education and safe work practices for handling needles and other sharps

For more information about prevention of needlestick injuries, refer to the National Institute for Occupational Safety and Health Alert: Preventing Needlestick Injuries in Health Care Settings.

Even when effective prevention measures are implemented, exposures to blood and bodily fluid still occur. Employers of personnel covered by the OSHA Bloodborne Pathogens Standard are obligated to provide post-exposure care, including prophylaxis, at no cost to the employee. The employer may subsequently attempt to obtain reimbursement from workers’ compensation.

Documentation: Information that should be recorded after an occupational exposure to HIV has occurred includes the following, which the clinician should record in the exposed worker’s confidential medical record:

• Date and time of the exposure
• Details of the procedure being performed and the use of protective equipment at the time of the exposure
• Type, severity, and amount of fluid to which the worker was exposed
• Details about the source individual
• Whether HIV testing of the source was performed
• Medical documentation that provides details about post-exposure management
• If the occupationally exposed individual declines PEP, the clinician should document this decision in the individual’s medical record.

Specific OSHA requirements regarding documentation may be found at Safety and Health Topics: Bloodborne Pathogens and Needlestick Prevention.

Services for Sexual Assault Patients

NYSDOH AIDS Institute, June 2020

New York State (NYS) Public Health Law 2805-i requires that hospitals providing treatment to survivors of sexual assault advise the patient of the availability of services provided by the local rape crisis or victim assistance organization and secure such services as requested by the patient.

Role of the rape crisis advocate: The primary role of the rape crisis advocate is to provide the patient with emotional support, advocacy, information, counseling, and accompaniment services, and to facilitate informed decision-making at a time when the patient may be in crisis. Advocates do not provide healthcare or collect evidence; however, they can enhance the efforts of healthcare staff through the provision of information regarding medical and legal options. For information about rape crisis services, see NYSDOH Sexual Violence Prevention Program. The NYSDOH, with other State agencies, healthcare facilities, and professional organizations, provides technical assistance on sexual assault issues.

Sexual Assault Forensic Examiner (SAFE): The initial response that a survivor of rape or sexual assault receives when seeking healthcare or reporting the crime has a profound influence on that individual’s subsequent recovery. Engagement of healthcare practitioners from the SAFE program helps improve the care that survivors of sexual assault receive. The NYSDOH certifies all appropriately qualified individuals as SAFEs. A SAFE is a specially trained registered nurse, nurse practitioner, physician, or physician’s assistant.

NYS public health law requires that the NYSDOH establish standards for and certify SAFE hospital programs. All SAFE Designated Hospitals have a SAFE available either on site or on-call within 60 minutes of the sexual assault patient’s arrival at the hospital, except under exigent circumstances (NYS Public Health Law 2805-i). In NYS, the standard of care for survivors of rape and sexual assault presenting at healthcare settings includes comprehensive high-quality medical care, collection of forensic evidence, and respectful and sensitive treatment. The NYSDOH recommends the use of SAFEs in all hospitals to assist in meeting this standard. The SAFE should be an active participant in the discussion regarding initiation of HIV post-exposure prophylaxis (PEP). SAFEs help to ensure the best medical, legal, and psychological outcomes for the adult survivor of sexual assault and provide compassionate emotional support. They are trained to provide care to survivors of sexual assault and to collect and preserve forensic evidence to support prosecution if the patient decides to report the crime to law enforcement.

Reimbursement for SAFE services: Provider reimbursement under the Office of Victim Services (OVS) FRE Direct Reimbursement Program is intended to cover the forensic examiner’s services, including pharmaceuticals related to a sexual assault forensic examination. This reimbursement includes the cost of the initial 7-day starter pack of PEP if the care provider determines a risk of HIV exposure. Claim forms for reimbursement under the Direct Reimbursement Program can be found in each Sexual Offense Evidence Collection Kit and be downloaded from the OVS website.

Documentation of a visit to a facility that provides a forensic medical examination satisfies the OVS reporting requirement, thereby providing survivors who are either unwilling or unable to report the crime to the police the opportunity to file a regular compensation claim. Survivors of sexual assault may also contact a Rape Crisis Center or Victim Advocate Program in their county or region for assistance in filing regular compensation claims with OVS, particularly when an emergency award is needed from the OVS (see below). Many of these agencies have 24-hour hotlines. For more information and a list of Victim Advocate Programs and other resources, consult the OVS website.

The OVS has an “emergency award” procedure in addition to its normal compensation process to ensure continued availability of PEP for survivors of sexual assault beyond the initial 7-day starter pack supply. Advocates who know the community connections and procedures to expedite the process should work with the exposed individual. The process for requesting an emergency award is as follows: 1) Claimant files a regular claim application with the OVS, indicating that medication for HIV PEP is necessary, and requests an emergency award. 2) OVS makes an expedited determination for the purposes of the emergency award. 3) If the OVS determines it can grant an emergency award, up to $2,500, then OVS directly reimburses pharmacy providers on behalf of the claimant.