Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Nonoccupational exposure to HIV in adults

Judith A Aberg, MD
Demetre C Daskalakis, MD, MPH
Section Editor
John G Bartlett, MD
Deputy Editor
Jennifer Mitty, MD, MPH


Healthcare personnel who are potentially exposed to HIV through an occupational exposure or injury are offered counseling and post-exposure prophylaxis (PEP) with antiretroviral medications. Some evidence of the efficacy of this approach in the occupational setting prompted experts to suggest that a similar management approach should be adopted for persons exposed to HIV through sexual or needle-sharing behaviors [1-3].

The risk of infection and the management of adults with nonoccupational HIV exposure are reviewed here. The management of healthcare personnel exposed to HIV and the risk related to transfusion of blood products are discussed separately. (See "Management of healthcare personnel exposed to HIV" and "Risk of HIV from blood transfusion".)


Four distinct risk groups have been considered in studies of nonoccupational exposure to HIV infection, including men who have sex with men (MSM), injection drug users (IDUs), male and female heterosexuals, and persons exposed to HIV through other routes (eg, human bites). Estimates of exposure risk are based on observational studies and are difficult to quantify since transmission risk also depends on other cofactors that greatly enhance the probability of infection [3-5], as discussed below (table 1).

Sexual exposure — The exact risk of transmission of HIV with sexual exposure is incompletely defined [6,7]. However, the data do suggest that risk of HIV acquisition varies by type of exposure [1,8-14]. For example, receptive anal intercourse, which can lead to mucosal disruption and rectal bleeding, is associated with higher risk compared with other types of sexual exposures, such as oral sex [10].

Among MSM, approximate risk of HIV varies as follows:


Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Sep 2016. | This topic last updated: May 5, 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
  1. Katz MH, Gerberding JL. Postexposure treatment of people exposed to the human immunodeficiency virus through sexual contact or injection-drug use. N Engl J Med 1997; 336:1097.
  2. Katz MH, Gerberding JL. The care of persons with recent sexual exposure to HIV. Ann Intern Med 1998; 128:306.
  3. Tolle MA, Schwarzwald HL. Postexposure prophylaxis against human immunodeficiency virus. Am Fam Physician 2010; 82:161.
  4. Havens PL, American Academy of Pediatrics Committee on Pediatric AIDS. Postexposure prophylaxis in children and adolescents for nonoccupational exposure to human immunodeficiency virus. Pediatrics 2003; 111:1475.
  5. Announcement: Updated Guidelines for Antiretroviral Postexposure Prophylaxis after Sexual, Injection-Drug Use, or Other Nonoccupational Exposure to HIV - United States, 2016. MMWR Morb Mortal Wkly Rep 2016; 65:458.
  6. Roland ME. Postexposure prophylaxis after sexual exposure to HIV. Curr Opin Infect Dis 2007; 20:39.
  7. Bryant J, Baxter L, Hird S. Non-occupational postexposure prophylaxis for HIV: a systematic review. Health Technol Assess 2009; 13:iii, ix.
  8. Pinkerton SD, Martin JN, Roland ME, et al. Cost-effectiveness of postexposure prophylaxis after sexual or injection-drug exposure to human immunodeficiency virus. Arch Intern Med 2004; 164:46.
  9. Pinkerton SD, Martin JN, Roland ME, et al. Cost-effectiveness of HIV postexposure prophylaxis following sexual or injection drug exposure in 96 metropolitan areas in the United States. AIDS 2004; 18:2065.
  10. Vittinghoff E, Douglas J, Judson F, et al. Per-contact risk of human immunodeficiency virus transmission between male sexual partners. Am J Epidemiol 1999; 150:306.
  11. Kaplan EH, Heimer R. A model-based estimate of HIV infectivity via needle sharing. J Acquir Immune Defic Syndr 1992; 5:1116.
  12. Rozenbaum W, Gharakhanian S, Cardon B, et al. HIV transmission by oral sex. Lancet 1988; 1:1395.
  13. Lazzarin A, Saracco A, Musicco M, Nicolosi A. Man-to-woman sexual transmission of the human immunodeficiency virus. Risk factors related to sexual behavior, man's infectiousness, and woman's susceptibility. Italian Study Group on HIV Heterosexual Transmission. Arch Intern Med 1991; 151:2411.
  14. Seidlin M, Vogler M, Lee E, et al. Heterosexual transmission of HIV in a cohort of couples in New York City. AIDS 1993; 7:1247.
  15. Powers KA, Poole C, Pettifor AE, Cohen MS. Rethinking the heterosexual infectivity of HIV-1: a systematic review and meta-analysis. Lancet Infect Dis 2008; 8:553.
  16. Nicolosi A, Corrêa Leite ML, Musicco M, et al. The efficiency of male-to-female and female-to-male sexual transmission of the human immunodeficiency virus: a study of 730 stable couples. Italian Study Group on HIV Heterosexual Transmission. Epidemiology 1994; 5:570.
  17. Comparison of female to male and male to female transmission of HIV in 563 stable couples. European Study Group on Heterosexual Transmission of HIV. BMJ 1992; 304:809.
  18. Chan SK, Thornton LR, Chronister KJ, et al. Likely female-to-female sexual transmission of HIV--Texas, 2012. MMWR Morb Mortal Wkly Rep 2014; 63:209.
  19. Kwakwa HA, Ghobrial MW. Female-to-female transmission of human immunodeficiency virus. Clin Infect Dis 2003; 36:e40.
  20. Kaplan EH, Heimer R. HIV incidence among New Haven needle exchange participants: updated estimates from syringe tracking and testing data. J Acquir Immune Defic Syndr Hum Retrovirol 1995; 10:175.
  21. McQuillan GM, Kruszon-Moran D, Granade T, Feldman JW. Seroprevalence of HIV in the US Household Population Aged 18–49 Years: The National Health and Nutrition Examination Surveys, 1999–2006. J Acquir Immune Defic Syndr 2010; 53:117.
  22. Boily MC, Baggaley RF, Wang L, et al. Heterosexual risk of HIV-1 infection per sexual act: systematic review and meta-analysis of observational studies. Lancet Infect Dis 2009; 9:118.
  23. Attia S, Egger M, Müller M, et al. Sexual transmission of HIV according to viral load and antiretroviral therapy: systematic review and meta-analysis. AIDS 2009; 23:1397.
  24. Wawer MJ, Gray RH, Sewankambo NK, et al. Rates of HIV-1 transmission per coital act, by stage of HIV-1 infection, in Rakai, Uganda. J Infect Dis 2005; 191:1403.
  25. Quinn TC, Wawer MJ, Sewankambo N, et al. Viral load and heterosexual transmission of human immunodeficiency virus type 1. Rakai Project Study Group. N Engl J Med 2000; 342:921.
  26. Donnell D, Baeten JM, Kiarie J, et al. Heterosexual HIV-1 transmission after initiation of antiretroviral therapy: a prospective cohort analysis. Lancet 2010; 375:2092.
  27. Cohen MS, Pilcher CD. Amplified HIV transmission and new approaches to HIV prevention. J Infect Dis 2005; 191:1391.
  28. Leynaert B, Downs AM, de Vincenzi I. Heterosexual transmission of human immunodeficiency virus: variability of infectivity throughout the course of infection. European Study Group on Heterosexual Transmission of HIV. Am J Epidemiol 1998; 148:88.
  29. http://www.cdc.gov/hiv/pdf/PrEPguidelines2014.pdf (Accessed on May 19, 2014).
  30. Connor EM, Sperling RS, Gelber R, et al. Reduction of maternal-infant transmission of human immunodeficiency virus type 1 with zidovudine treatment. Pediatric AIDS Clinical Trials Group Protocol 076 Study Group. N Engl J Med 1994; 331:1173.
  31. Mofenson LM, Lambert JS, Stiehm ER, et al. Risk factors for perinatal transmission of human immunodeficiency virus type 1 in women treated with zidovudine. Pediatric AIDS Clinical Trials Group Study 185 Team. N Engl J Med 1999; 341:385.
  32. Tokars JI, Marcus R, Culver DH, et al. Surveillance of HIV infection and zidovudine use among health care workers after occupational exposure to HIV-infected blood. The CDC Cooperative Needlestick Surveillance Group. Ann Intern Med 1993; 118:913.
  33. Cardo DM, Culver DH, Ciesielski CA, et al. A case-control study of HIV seroconversion in health care workers after percutaneous exposure. Centers for Disease Control and Prevention Needlestick Surveillance Group. N Engl J Med 1997; 337:1485.
  34. Otten RA, Smith DK, Adams DR, et al. Efficacy of postexposure prophylaxis after intravaginal exposure of pig-tailed macaques to a human-derived retrovirus (human immunodeficiency virus type 2). J Virol 2000; 74:9771.
  35. Schechter M, do Lago RF, Mendelsohn AB, et al. Behavioral impact, acceptability, and HIV incidence among homosexual men with access to postexposure chemoprophylaxis for HIV. J Acquir Immune Defic Syndr 2004; 35:519.
  36. Kahn JO, Martin JN, Roland ME, et al. Feasibility of postexposure prophylaxis (PEP) against human immunodeficiency virus infection after sexual or injection drug use exposure: the San Francisco PEP Study. J Infect Dis 2001; 183:707.
  37. Heuker J, Sonder GJ, Stolte I, et al. High HIV incidence among MSM prescribed postexposure prophylaxis, 2000-2009: indications for ongoing sexual risk behaviour. AIDS 2012; 26:505.
  38. Mayer KH, Mimiaga MJ, Gelman M, Grasso C. Raltegravir, tenofovir DF, and emtricitabine for postexposure prophylaxis to prevent the sexual transmission of HIV: safety, tolerability, and adherence. J Acquir Immune Defic Syndr 2012; 59:354.
  39. Sonder GJ, Prins JM, Regez RM, et al. Comparison of two HIV postexposure prophylaxis regimens among men who have sex with men in Amsterdam: adverse effects do not influence compliance. Sex Transm Dis 2010; 37:681.
  40. Diaz-Brito V, León A, Knobel H, et al. Post-exposure prophylaxis for HIV infection: a clinical trial comparing lopinavir/ritonavir versus atazanavir each with zidovudine/lamivudine. Antivir Ther 2012; 17:337.
  41. Landovitz RJ. Occupational and nonoccupational postexposure prophylaxis for HIV in 2009. Top HIV Med 2009; 17:104.
  42. Landovitz RJ, Currier JS. Clinical practice. Postexposure prophylaxis for HIV infection. N Engl J Med 2009; 361:1768.
  43. Chin RL. Postexposure prophylaxis for HIV. Emerg Med Clin North Am 2010; 28:421.
  44. Bamberger JD, Waldo CR, Gerberding JL, Katz MH. Postexposure prophylaxis for human immunodeficiency virus (HIV) infection following sexual assault. Am J Med 1999; 106:323.
  45. Cohen MS, Chen YQ, McCauley M, et al. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med 2011; 365:493.
  46. Landovitz RJ, Combs KB, Currier JS. Availability of HIV postexposure prophylaxis services in Los Angeles County. Clin Infect Dis 2009; 48:1624.
  47. Kuhar DT, Henderson DK, Struble KA, et al. Updated US Public Health Service guidelines for the management of occupational exposures to human immunodeficiency virus and recommendations for postexposure prophylaxis. Infect Control Hosp Epidemiol 2013; 34:875.
  48. Marrazzo JM, del Rio C, Holtgrave DR, et al. HIV prevention in clinical care settings: 2014 recommendations of the International Antiviral Society-USA Panel. JAMA 2014; 312:390.
  49. World Health Organization.Guidelines on post-exposure prophylaxis for HIV and the use of Co-trimoxazole prophylaxis for HIV-related infections among adults, adolescents and children: recommendations for a public health approach. http://apps.who.int/iris/bitstream/10665/145719/1/9789241508193_eng.pdf?ua=1 (Accessed on March 09, 2015).
  50. Else LJ, Taylor S, Back DJ, Khoo SH. Pharmacokinetics of antiretroviral drugs in anatomical sanctuary sites: the male and female genital tract. Antivir Ther 2011; 16:1149.
  51. McAllister J, Read P, McNulty A, et al. Raltegravir-emtricitabine-tenofovir as HIV nonoccupational post-exposure prophylaxis in men who have sex with men: safety, tolerability and adherence. HIV Med 2014; 15:13.
  52. Yanik EL, Napravnik S, Hurt CB, et al. Prevalence of transmitted antiretroviral drug resistance differs between acutely and chronically HIV-infected patients. J Acquir Immune Defic Syndr 2012; 61:258.
  53. Tsai CC, Emau P, Follis KE, et al. Effectiveness of postinoculation (R)-9-(2-phosphonylmethoxypropyl) adenine treatment for prevention of persistent simian immunodeficiency virus SIVmne infection depends critically on timing of initiation and duration of treatment. J Virol 1998; 72:4265.
  54. Cohen MS, Gay C, Kashuba AD, et al. Narrative review: antiretroviral therapy to prevent the sexual transmission of HIV-1. Ann Intern Med 2007; 146:591.
  55. Dumond JB, Yeh RF, Patterson KB, et al. Antiretroviral drug exposure in the female genital tract: implications for oral pre- and post-exposure prophylaxis. AIDS 2007; 21:1899.
  56. Kwara A, Delong A, Rezk N, et al. Antiretroviral drug concentrations and HIV RNA in the genital tract of HIV-infected women receiving long-term highly active antiretroviral therapy. Clin Infect Dis 2008; 46:719.
  57. Dobson E, Luque A, Aslam F, et al. Comparing raltegravir genital tract distribution in HIV-infected men and women. 52nd Interscience Conference on Antimicrobials and Chemotherapy (ICAAC). September 9-12, 2012. San Francisco. Abstract A-1252.
  58. Scheer S, Chu PL, Klausner JD, et al. Effect of highly active antiretroviral therapy on diagnoses of sexually transmitted diseases in people with AIDS. Lancet 2001; 357:432.
  59. Merchant RC, Mayer KH, Becker BM, et al. Predictors of the initiation of HIV postexposure prophylaxis in Rhode Island emergency departments. AIDS Patient Care STDS 2008; 22:41.
  60. Martin JN, Roland ME, Neilands TB, et al. Use of postexposure prophylaxis against HIV infection following sexual exposure does not lead to increases in high-risk behavior. AIDS 2004; 18:787.
  61. Roland ME, Neilands TB, Krone MR, et al. Seroconversion following nonoccupational postexposure prophylaxis against HIV. Clin Infect Dis 2005; 41:1507.
  62. Cohen MS, Kashuba AD, Gay C. HIV antiretroviral postexposure prophylaxis: a cautionary note. Clin Infect Dis 2005; 41:1514.
  63. Masciotra S, McDougal JS, Feldman J, et al. Evaluation of an alternative HIV diagnostic algorithm using specimens from seroconversion panels and persons with established HIV infections. J Clin Virol 2011; 52 Suppl 1:S17.
  64. Nasrullah M, Wesolowski LG, Meyer WA 3rd, et al. Performance of a fourth-generation HIV screening assay and an alternative HIV diagnostic testing algorithm. AIDS 2013; 27:731.
  65. http://www.cdc.gov/hiv/pdf/HIVtestingAlgorithmRecommendation-Final.pdf (Accessed on July 24, 2014).
  66. Panlilio AL, Cardo DM, Grohskopf LA, et al. Updated U.S. Public Health Service guidelines for the management of occupational exposures to HIV and recommendations for postexposure prophylaxis. MMWR Recomm Rep 2005; 54:1.
  67. Du Mont J, Myhr TL, Husson H, et al. HIV postexposure prophylaxis use among Ontario female adolescent sexual assault victims: a prospective analysis. Sex Transm Dis 2008; 35:973.
  68. Cohen MS. HIV postexposure prophylaxis after sexual assault: why is it so hard to accomplish? Sex Transm Dis 2008; 35:979.
  69. Hamlyn E, McAllister J, Winston A, et al. Is screening for sexually transmitted infections in men who have sex with men who receive non-occupational HIV post-exposure prophylaxis worthwhile? Sex Transm Infect 2006; 82:21.
  70. Poynten IM, Jin F, Mao L, et al. Nonoccupational postexposure prophylaxis, subsequent risk behaviour and HIV incidence in a cohort of Australian homosexual men. AIDS 2009; 23:1119.
  71. Lunding S, Katzenstein TL, Kronborg G, et al. The Danish PEP registry: experience with the use of postexposure prophylaxis (PEP) following sexual exposure to HIV from 1998 to 2006. Sex Transm Dis 2010; 37:49.
  72. Donnell D, Mimiaga MJ, Mayer K, et al. Use of non-occupational post-exposure prophylaxis does not lead to an increase in high risk sex behaviors in men who have sex with men participating in the EXPLORE trial. AIDS Behav 2010; 14:1182.
  73. Mehta SA, Silvera R, Bernstein K, et al. Awareness of post-exposure HIV prophylaxis in high-risk men who have sex with men in New York City. Sex Transm Infect 2011; 87:344.
  74. Zablotska IB, Prestage G, Holt M, et al. Australian gay men who have taken nonoccupational postexposure prophylaxis for HIV are in need of effective HIV prevention methods. J Acquir Immune Defic Syndr 2011; 58:424.
  75. Golub SA, Rosenthal L, Cohen DE, Mayer KH. Determinants of high-risk sexual behavior during post-exposure prophylaxis to prevent HIV infection. AIDS Behav 2008; 12:852.
  76. Rodríguez AE, Castel AD, Parish CL, et al. HIV medical providers' perceptions of the use of antiretroviral therapy as nonoccupational postexposure prophylaxis in 2 major metropolitan areas. J Acquir Immune Defic Syndr 2013; 64 Suppl 1:S68.