68 Hours After Exposure: nPEP, Emergency Contraception, and a Fever
A 34-year-old woman presents to the ED at 23:40, 68 hours after a condom broke during receptive vaginal and anal intercourse with a partner who disclosed afterward that he is HIV-positive and has not been taking medication. She is not using contraception and her last menstrual period was 12 days ago. She reports burning on urination and mild lower abdominal discomfort. Temperature 38.2°C. She takes no medications, has no allergies, and completed the hepatitis B vaccine series as a child. She works two jobs and says she "probably can't come back" for follow-up visits.
1. Does she meet criteria for HIV nPEP, and how do you start it tonight?
Read the worked answer
Yes - she is at 68 hours, inside the 72-hour window, and the exposure is high-risk (receptive anal and vaginal intercourse with a partner with untreated HIV).
Actions tonight, without waiting for results:
- Draw baseline HIV antigen/antibody test, hepatitis B and C serologies, creatinine, CBC, and a pregnancy test. Starting before results return is correct; a positive baseline HIV test changes management to treatment, not to withholding nPEP.
- Start a 28-day three-drug regimen now. A standard preferred option is tenofovir/emtricitabine plus an integrase inhibitor (dolutegravir or raltegravir). Check renal function for TDF dosing and review interactions - polyvalent cation antacids and some supplements must be separated from dolutegravir.
- Give the first dose in the ED and observe for tolerance; counsel on expected side effects so nausea doesn't become a reason to stop.
Reasoning: the benefit of nPEP falls with delay, and 68 hours is near the edge - the single worst decision here is "come back tomorrow for the prescription." Do not send her home with a plan to start after labs.
2. What are your emergency contraception options at 68 hours, and what determines the choice?
Read the worked answer
Emergency contraception is still indicated and time-sensitive in its own right.
- LNG 1.5 mg orally is labeled to 72 hours and is less effective as time passes and with higher body weight/BMI.
- Ulipristal acetate 30 mg is effective through 120 hours and is more effective than LNG on days 3–5, which is exactly where she is. It is the better oral choice at 68 hours.
- Copper IUD placement within 5 days is the most effective option and provides ongoing contraception - but it requires a clinician, an appointment, and her willingness; at 23:40 in an ED it is usually a referral, not tonight's intervention.
Practical points:
- Obtain a pregnancy test tonight; a negative result at 12 days post-LMP does not exclude a conception from an earlier act, and she should repeat testing if menses is late.
- Ulipristal and hormonal contraception: she should not start a hormonal method immediately after UPA; discuss delay and backup.
- Document that she was offered the full range, not just the one your site stocks.
3. Fever, dysuria, and pelvic pain change the plan. What do you do about STI management?
Read the worked answer
Her symptoms move her from prophylaxis to treatment for pelvic inflammatory disease.
- Fever plus lower abdominal/pelvic pain plus dysuria in a woman with a recent high-risk exposure is PID until proven otherwise. Single-dose gonorrhea prophylaxis is inadequate.
- Treat empirically tonight: ceftriaxone 500 mg IM (1 g if weight over 150 kg) plus doxycycline 100 mg PO twice daily plus metronidazole 500 mg PO twice daily for 14 days. Add or substitute per local resistance guidance.
- Collect GC/CT NAAT (vaginal swab preferred), trichomonas testing, syphilis serology, and a pregnancy test; consider HIV testing per baseline panel. Testing does not delay treatment.
- Evaluate for tubo-ovarian abscess or surgical abdomen if pain is severe or she is toxic; consider ultrasound.
Interaction check: doxycycline and her nPEP regimen can coexist; verify the integrase inhibitor timing with any antacids or iron. Because she says she can't return, arrange the full 14-day course at discharge, a telehealth follow-up, and a partner-treatment plan - an untreated PID in a patient with no follow-up is a much larger downstream risk than the STI prophylaxis question.