Harbor:Non-Occupational Exposure

General Guidelines for Harbor-UCLA ED

  • SART candidate if within 96 hours (5d), authorized by law enforcement
  • Call LASD to report and find out what PD precinct needs to come take report and approve SART exam
  • LASD is your liaison to interact with outside law enforcement, call if issues with timeliness
  • Call social work consult, can help with support and resources
  • Consult to Violence Intervention Team
  • Consult SCAN if patient 17yo and younger
    • 12yo or older can consent to exam, otherwise parent/guardian consents
    • Still need to get pediatric patient to assent/agree to exam
  • Psych or disabled patients complicated, work with SART staff/SW
  • Forensic Nurse Specialist (SART Staff) available 24/7 at (562) 497-0147 if any questions/issues
  • Draw labs and STI testing in ED
    • HIV Antibody/Antigen Screen, Hepatitis B Surface Antigen, sHepatitis C Viral Load-PHL, RPR, Pregnancy test, Urine Chlamydia/Neisseria gonorrhoeae RNA, TMA
    • If being consented for HIV PEP, then also need CBC w/ Diff, BMP, LFT
    • CCC for lab f/u and NERF through Cerner to bridge to PCP if DHS and doesn't have a PCP. If already empaneled, message PCP.
    • Outside HIV clinics or OOP network PCP
    • Pediatric patients can utilize HUB clinic for f/u
  • Consider STI prophylaxis, Plan B, Hep B and HPV vaccines, PEP prophylaxis within 72 hours
    • Empiric antibiotic therapy
      • cefTRIAXone 250 mg, IM
        • cefTRIAXone 50 mg/kg, IM, Maximum dose 250 mg
      • azithromycin 1,000 mg, Oral
        • Pediatric dose: azithromycin 20 mg/kg, Oral, For patients who weigh < 45 kg. Maximum dose 1,000 mg per dose.
      • metroNIDAZOLE 2,000 mg, Oral
        • Ped dose: metroNIDAZOLE (metroNIDAZOLE 100 mg/mL oral suspension) 15 mg/kg, Oral, TID, X 7 days, mL, 0 Refill(s) For patients who weigh < 45 kg. Maximum dose 666.67 mg/dose or 2,000 mg/day
    • Emergency contraceptives
      • levonorgestrel 1.5 mg, Oral, Form: Tab, ONCE, STAT
  • HIV post-exposure prophylaxis (PEP) guidelines
    • Do not have to call HIV consult, per Drs. Witt and Wu, unless usual circumstance (e.g. disabled patient unable to swallow pills)
    • Per CDC and LAC DHS best practice: only recommended if <= 72 hours since exposure AND
      • assailant HIV positive
      • assailant HIV status unknown, but patient’s mucous membranes or non-intact skin exposed to
        • blood, semen, vaginal secretions, or bloody body fluids
    • Adult dosing:
      • emtricitabine-tenofovir (Truvada) 1 tabs, Oral, Indication: HIV/PREP Restricted to HIV post-exposure prophylaxis per CDC guidelines
      • raltegravir 400 mg, Oral, Indication: HIV/PREP Restricted to HIV post-exposure prophylaxis per CDC guidelines
    • Pediatric dosing: liquid formulations can only be given by our pharmacy. Call ED pharmacist to bring 2 week supply to bedside for patient.
      • zidovudine Liquid, Indication: HIV/PREP Restricted to patients for HIV post-exposure prophylaxis per CDC guidelines. Target Dose: 4 to 9 kg give 12 mg/kg/dose PO BID; 9 to 30 kg give 9 mg/kg/dose PO BID; >= 30 kg give 300 mg/dose PO BID
      • lamiVUDine 4 mg/kg, Liquid, Indication: HIV/PREP patients younger than 12 years or less than 35 kg for HIV post-exposure prophylaxis per CDC guidelines. Maximum dose 150 mg.
      • lopinavir-ritonavir (lopinavir-ritonavir 400 mg-100 mg/5 mL) Liquid, Indication: HIV/PREP Restricted to patients for HIV post-exposure prophylaxis per CDC guidelines. Target Dose: < 15 kg give 12 mg-3 mg/dose PO BID (0.15 mL/kg/dose); >= 15 kg give 10 mg-2.5 mg/dose PO BID (0.125 mL/kg/dose). Maximum dose 400 mg-100 mg per dose.
    • Need a 2 week prescription and follow up with PEP clinic in 2 weeks for a lab check. Total 4

week course.

    • Vaccines
      • Tdap
      • HPV vaccine for female patients age 9-26 and male patients age 9-21. Not required if patient already completed series of 3 vaccines.
        • human papillomavirus vaccine (human papillomavirus (HPV) vaccine 9-valent) 0.5 mL, Intramuscular, ONCE
      • Hep B vaccines
        • Per CDC guidelines, if patient is
          • vaccinated: give hepatitis B vaccine booster (preferably within 24 hours of exposure)
          • unvaccinated: give the hepatitis B vaccine
          • unvaccinated AND the assailant is known to be hepatitis B surface antigen positive: give both hepatitis B vaccine and hepatitis B immune globulin (within 14 days of sexual exposure)
            • AMB hepatitis B vaccine Adult series (Recombivax HB or Engerix-B)
            • hepatitis B immune globulin (hepatitis B immune globulin injectable solution) 0.06 mL/kg, Intramuscular, ONCE, STAT Give in opposite arm from hepatitis B vaccine
  • Preserve evidence
    • external GU exams only check for hemorrhage
    • obtain dirty catch UA, NPO if oral trauma with possible DNA evidence
      • If patient already ate/drank, then doesn't need to be NPO
      • If patient is NPO, give Rx for oral medications to take later after SART
    • clothes in brown paper bag (not plastic which can degrade DNA, promote bacterial contamination),
    • patient shouldn't wash up,
    • document patient history in quotes
  • Discharging
    • Give patient copy of labs
    • If giving HIV PEP, call ED pharmacist to bring HIV PEP to bedside
      • give adult patient limited 48 hour supply of PEP to go and also Rx
      • give pediatric patient full 2 week supply to go
    • For Rx, give 2 week supply
      • If patient is DHS eligible, send Rx to our pharmacy
      • If patient is OOP, send Rx to Bella Vida Pharmacy (across the street)
      • If pediatric patient, our pharmacy will bring full supply to bedside
    • Provide patients with the PEP discharge instructions (includes clinic list) so they may find clinic for follow up.
    • Pediatric patients follow up in SCAN and HUB clinics
    • Transportation issues - talk to SW and law enforcement
      • Law enforcement usually transports to SART
      • Might get law enforcement transport home if w/in the area.
      • Offer transportation with SW if needed
    • Refer to Trauma Recovery Center
  • SART does not do labs, can give Plan B and STI prophylaxis only. Does not do PEP or medical work up.
    • Case by case basis can come to hospital for exam
    • Prefer that patient's go there for 4 hour exam and evidence collection

Harbor ED Policy


  • High-risk HIV exposure: shared needles with HIV+ person, or partner or assailant in the case of sexual assault has unknown HIV status, is known HIV+ or highly likely to be HIV+ with a high viral load and the sexual activity was associated with a high risk of transmission, e.g., receptive anal intercourse, sexual assault with vaginal trauma, occurring within the prior 72 hours.
    • Sexual assault victims should be offered Tenofovir/Emtricitabine (Truvada) 200/300 mg daily plus Raltegravir 400 mg BID and should be referred immediately to a SART center for STI testing and prophylaxis. Can consider offering Plan B contraception if patient is not NPO for evidence collection.
      • If the patient meets these criteria, then first dose of non-occupational PEP gave be given in ED. We are working on a process to give patient's 48 hours of medications to go home with to tie them over until they can get the 28d course needed from a PEP center.
      • For a patient that seeks post-sexual-exposure/non-occupational HIV prophylaxis (nPEP), the patient should also be referred to a PEP center http://getprepla.com/PEP/Get-PEP-Now/ to obtain the additional medications and follow up labs, such as the Los Angeles LGBT Center. The LA LGBT Gay and Lesbian Center has a program for post-exposure prophylaxis in a number of specific circumstances; patients can be referred within 72 hours of an exposure. Their hours are Mon-Friday 11am-6pm (telephone number is 323-860-5855, and their website is https://lalgbtcenter.org/post-exposure-prophylaxis).
      • If you happen to see a patient who meets the criteria above, then a baseline rapid HIV should be sent to make sure the patient is not already infected, in additional CBC, BMP, LFTs, Hep screen (Hep A IgG, Hep B sAg, sAb, cAb, and Hep C Ab), needs to be sent. Tenofovir DF is contraindicated in patients with renal dysfunction (creatinine clearance ≤59 mL/min). For these cases, please consult the HIV or infectious disease team at your site, or the National Clinical Consultations Center’s PEPline at (888) 448-4911

See Also

References