Abuse, Sexual, Suspected — HIV Risk Assessment, HIV-PEP — Clinical Pathway: Emergency Department

Sexual Abuse Clinical Pathway — Emergency Department

HIV Risk Assessment

  • HIV risk assessment scale for presentation < 72 hrs after alleged assault
  • Choose one item in each column; if > 1 applies, select higher score item
  • Total score by adding all four numbers before consulting Special Immunology
  • Consult Special Immunology with any questions regarding treatment plan

Treatment Recommendations

  • 0‐2: Treatment not recommended
  • 3‐5: Consider treatment
  • 6‐17: Treatment highly recommended
Perpetrator Score Patient Score History as Reported by Patient Score Examination Findings Score
Known to be HIV positive 5 Does not recall events around assault 2 Reports history of penetration with possible exposure of blood, semen, vaginal secretions, or rectal secretions to mucous membranes or non‐intact skin 5 Acute vaginal or anal trauma 5
Unknown to patient 3 Unable to provide history due to development or preverbal 1 Does not report history of penetration, but reports possible exposure of blood, semen, vaginal secretions, or rectal secretions to mucous membranes or non‐intact skin 4 Visible semen or other secretions in genital area 4
Known adult 2 Developmentally able to provide complete history 0 Reports exposure of urine, nasal secretions, saliva, sweat, or tears to skin or mucous membranes 0 Visible semen or other secretions on intact skin 1
Known adolescent 1     Reports exposure of blood, semen, vaginal secretions, or rectal secretions to intact skin 0 No visible secretions or acute injury 0
Known child 0     Reports contact that would not result in exposure to body fluids 0    
Behavioral concerns without disclosure 0     Denies sexual contact 0    

HIV Post-Exposure Prophylaxis, HIV-PEP

General

  • Review HIV risk assessment, discuss with child/adolescent, family
  • Indicated if < 72 hrs from high-risk exposure
  • Consult Special Immunology with any questions or based on indications in table below
  • Prescribe 4-day starter pack when outpatient pharmacy is closed
  • Give a 28-day prescription to all patients for complete course
  • STI and HIV Infection Risk Assessment  

Laboratory Evaluation Needed Before Post-exposure Prophylaxis

  • HIV test, by rapid testing, if available
  • Obtain and review CBC, BMP and LFTs before starting HIV-PEP

Most Common Regimens Recommended for 28-day Course

Weight < 30 kg or Unable to Swallow Whole Tabs/Caps
  • Lamivudine, 10 mg/mL
    • 4 mg/kg/dose PO BID
    • Max dose 150 mg
  • and
  • Zidovudine 10 mg/mL
    • 4 - < 9 kg: 12 mg/kg/dose PO BID
    • 9 - < 30 kg: 9 mg/kg/dose PO BID
    • ≥ 30 kg: 300 mg/dose PO BID
  • plus
  • Raltegravir, Chewable Tabs
    • See dosing table below
  • or
  • Lamivudine, 10 mg/mL
    • 4 mg/kg/dose PO BID
    • Max dose 150 mg
  • and
  • Zidovudine, 10 mg/mL
    • 4 - < 9 kg: 12 mg/kg/dose PO BID
    • 9 - < 30 kg: 9 mg/kg/dose PO BID
    • ≥ 30 kg: 300 mg/dose PO BID
  • plus
  • Lopinavir/Ritonavir (Kaletra, [80 mg/20mg]/mL)
    • < 12 mos
      • Lopinavir 16 mg/kg/dose PO BID
    • ≥ 12 mos
      • < 15 kg: Lopinavir 13 mg/kg/dose PO BID
      • ≥ 15 kg: Lopinavir 11 mg/kg/dose PO BID,
        Max 400 mg Lopinavir/dose
  • Age 4 wks to 2 yrs
    • Consult Special Immunology
    • Lopinavir/ritonavir + lamivudine + zidovudine is recommended
  • Severe Anemia or Neutropenia
    • Consult Special Immunology; discuss alternative to zidovudine
Weight 30-35 kg and Able to Swallow Whole Tabs/Caps
  • Dolutegravir
    • 50 mg PO daily
  • plus
  • Lamivudine/Zidovudine (Combivir)
    • 150/300 mg PO BID
  • Renal Dysfunction, GFR < 50 mL/min/1.73 m2
    • Replace Combivir with lamivudine and zidovudine as separate dosage forms
    • Use dose adjusted for renal dysfunction CHOP formulary
  • Severe Anemia or Neutropenia
    • Consult Special Immunology discuss alternative to zidovudine
Weight ≥ 35 kg and Able to Swallow Whole Tabs/Caps
  • Dolutegravir
    • 50 mg PO daily
  • plus
  • Tenofovir DF/Emtricitabine (Truvada)
    • 300/200 mg tab PO daily
  • Renal Dysfunction, GFR < 50 mL/min/1.73 m2
    • Replace Truvada with lamivudine and zidovudine as separate dosage forms
    • Use dose adjusted for renal dysfunction
    • CHOP Formulary

Raltegravir Dosing ≥ 2 Yrs

  • Available as chewable tabs, 25 mg and 100 mg
  • Max dose: 300 mg PO BID
Weight (kg) Dose
10 - < 14 75 mg PO BID
14 - < 20 100 mg PO BID
20 - < 28 150 mg PO BID
28- < 40 200 mg PO BID
≥ 40 kg 300 mg PO BID