Prophylaxis, Treatment, and Follow-Up Medical Management
Baseline testing before treatment
Pregnancy test, human immunodeficiency virus (HIV) testing with consent, syphilis serology, nucleic acid amplification testing for gonorrhea and chlamydia at exposed sites, trichomonas, hepatitis B and C serology, and vaccination status. Baseline results guide management and later interpretation.
Sexually transmitted infection prophylaxis
Current Centers for Disease Control and Prevention (CDC) guidance for adult and adolescent survivors: ceftriaxone 500 mg intramuscularly once (1 g if weight 150 kg or greater), doxycycline 100 mg orally twice daily for 7 days, and metronidazole 500 mg orally twice daily for 7 days. In pregnancy or with cephalosporin allergy, substitute per guidance (for example azithromycin, with desensitization considered when ceftriaxone is essential). Doxycycline is avoided in pregnancy. Offer hepatitis B vaccination with or without immune globulin based on immunity, and human papillomavirus vaccination per schedule.
HIV post-exposure prophylaxis
Nonoccupational post-exposure prophylaxis (nPEP) should be started as soon as possible and no later than 72 hours after exposure; the course is 28 days, typically tenofovir/emtricitabine plus dolutegravir or raltegravir. Address adherence, baseline testing, and follow-up serology.
Pregnancy prevention
Levonorgestrel 1.5 mg or ulipristal acetate 30 mg, both more effective the sooner they are taken (ulipristal effective to 120 hours); copper intrauterine device within 5 days is the most effective option. Confirm pregnancy status first and discuss options neutrally.
Follow-up
Rescreen at intervals per protocol for HIV and syphilis, confirm completion of prophylaxis, reassess mental health, and provide a clear contact plan. Loss to follow-up is the norm, so build adherence support and referrals into the initial visit.
Traps
- Initiating nPEP after 72 hours as if it were standard.
- Using outdated single-dose regimens.
- Skipping the pregnancy test.
Rule of thumb: Test, treat, vaccinate, prevent pregnancy, and schedule the return visit before the patient leaves.