COMMENTARY

HIV Prophylaxis Following Occupational Exposure: Guideline and Commentary

Barry S. Zingman, MD

Disclosures

January 30, 2013

In This Article

Post-exposure Management and Evaluation

Recommendation: Occupational PEP should be initiated as soon as possible, ideally within 2 hours of the exposure. A first dose of PEP should be offered to the exposed worker while the evaluation is underway. (AII)

There are many factors to consider when deciding whether to implement occupational PEP. The uncertainties that are occasionally associated with a given exposure may complicate the decision-making process, especially for an inexperienced clinician, and may possibly delay prompt initiation of PEP. Figure 1 is meant to serve as a general guide. The sections that follow the figure provide more detail regarding the specific factors that are weighed in decision-making. Optimal management of the exposed worker following an occupational exposure to a bloodborne pathogen balances the benefits of preventing infection with the risks of medication-induced side effects and toxicity.

Figure.

PEP following occupational exposure.
aDepending on the test used, the window period may be shorter than 6 weeks. Clinicians should contact appropriate laboratory authorities to determine the window period for the test that is being used.
bIf the source is known to be HIV-infected, information about his/her viral load, ART medication history, and history of antiretroviral drug resistance should be obtained when possible to assist in selection of a PEP regimen.[9] Initiation of the first dose of PEP should not be delayed while awaiting this information and/or results of resistance testing. When this information becomes available, the PEP regimen may be changed if needed in consultation with an experienced provider.
cSee Appendix A for dosing recommendations in patients with renal impairment.

Management of the Exposed Site

Recommendation: Body sites exposed to potentially infectious fluid should be cleansed immediately. Wound and skin exposure sites should be washed with soap and water. Exposed mucous membranes should be flushed with water. The exposed worker should not attempt to "milk" the wound. (AII)

Exposed sites should be cleansed of contaminated fluid as soon as possible after exposure. Wounds and skin sites are best cleansed with soap and water, avoiding irritation of the skin. Exposed mucous membranes should be flushed with water. Alcohol, hydrogen peroxide, Betadine or other chemical cleansers are best avoided. HCWs should be trained to avoid "milking" or squeezing out needlestick injuries or wounds. Squeezing the wound may promote hyperemia and inflammation at the wound site, potentially increasing systemic exposure to HIV if present in the contaminating fluid.

Evaluating the Exposure

Recommendations:

  • Prompt initiation of PEP is recommended for exposure to blood, visibly bloody fluids, or other potentially infectious material (semen; vaginal secretions; breast milk; and cerebrospinal, synovial, pleural, peritoneal, pericardial, and amniotic fluids) from HIV-infected or HIV-unknown sources in any of the significant exposure situations outlined in Table 2. (AII)

  • Initiation of PEP should be followed by telephone or in-person consultation with a clinician experienced in HIV PEP. Clinicians who do not have access to experienced HIV clinicians should call the National Clinicians' Consultation Center PEP Line at 1-888-448-4911. When using the PEP Line, providers from New York State should identify themselves as such.

Whenever a worker has been exposed to potentially HIV-infected blood, visibly bloody fluids, or other potentially infectious material through the percutaneous or mucocutaneous routes or through non-intact skin (see Table 2), PEP is indicated. For these exposures, prompt initiation of PEP followed by telephone or in-person consultation with a clinician experienced in HIV PEP is recommended (see the section below entitled Resources for Consultation).

Table 2. Exposures for Which PEP Is Indicated

  • Break in the skin by a sharp object (including hollow-bore, solid-bore, and cutting needles or broken glassware) that is contaminated with blood, visibly bloody fluid, or other potentially infectious material, or that has been in the source patient's blood vessel.

  • Bite from a patient with visible bleeding in the mouth that causes bleeding in the exposed worker.

  • Splash of blood, visibly bloody fluid, or other potentially infectious material to a mucosal surface (mouth, nose, or eyes).

  • A non-intact skin (eg, dermatitis, chapped skin, abrasion, or open wound) exposure to blood, visibly bloody fluid, or other potentially infectious material.

HIV Testing of the Source Patient

Recommendations:

  • If the HIV serostatus of the source patient is unknown, consent for voluntary HIV testing of the source patient should be sought as soon as possible after the exposure. (AII) Rapid HIV testing is strongly recommended for the source patient. Organizations subject to OSHA regulations are required to perform rapid HIV testing rather than standard HIV testing. (AIII)

  • In New York State, when the source patient has the capacity to consent to HIV testing, specific informed consent is required; if consent is not obtained, HIV testing cannot be performed. When the source person does not have the capacity to consent, consent may be obtained from a surrogate, or anonymous testing may be done if a surrogate is not readily available. (See Appendix C for information regarding HIV testing when the source patient does not have the capacity to consent.) Clinicians should follow individual institutional policies for obtaining consent.

  • If the source patient consents to HIV testing and the rapid HIV test is positive, this preliminary result should be utilized in decision-making regarding PEP for the exposed worker. The preliminary positive result should be provided to the source patient and followed by confirmatory testing as soon as possible. (AIII) (When anonymous testing is performed, the results of the test cannot be disclosed to the source person or placed in the source person's medical record; see Appendix C.)

  • If the source patient's rapid HIV test result is negative but there may have been exposure to HIV in the previous 6 weeks, a plasma HIV RNA assay should also be obtained. (BIII) In these situations, PEP should be continued until results of the plasma HIV RNA assay are available. (BIII)

  • If the result from testing the source patient is not immediately available or a complete evaluation of the exposure is unable to be made within 2 hours of the exposure, PEP should be initiated while source testing and further evaluation are underway. (AII)

The source patient's HIV serostatus, HIV exposure history, and other HIV-related information are critical factors to evaluate when considering PEP initiation after occupational exposure.

If the source patient is known to be HIV-infected, information about his/her viral load, ART history, and history of antiretroviral drug resistance should be obtained when possible to assist in the selection of a PEP regimen[13]; however, administration of the first dose of PEP should not be delayed while awaiting this information. See the section below entitled Recommended PEP Regimen.

For source patients of unknown HIV serostatus, rapid HIV testing is strongly recommended as soon as possible in order to aid in decision-making regarding PEP. Organizations subject to OSHA regulations are required to perform rapid HIV testing rather than standard HIV testing. Results from rapid testing are usually available in 30 minutes. If the test results are not immediately available, the initiation of PEP should not be delayed pending the test result.

Rapid HIV testing cannot identify the rare source patient who is in the "window period" prior to seroconversion. When the source patient's rapid test result is negative and the clinician has ascertained that the source could have been exposed to HIV in the previous 6 weeks, a plasma HIV RNA assay should also be obtained. In these situations, PEP should be initiated and continued until results of the plasma HIV RNA assay are available.

A sample consent form for testing the source patient for institutions that choose to use it is available at http://www.health.ny.gov/diseases/aids/forms/informedconsent.htm.

Recording Information Following Occupational Exposure

Recommendations:

  • When an occupational exposure occurs, the following information should be recorded in the exposed worker's confidential medical record (AIII):

    • date and time of the exposure

    • details of the procedure being performed and the use of protective equipment at the time of the exposure

    • the type, severity, and amount of fluid to which the worker was exposed

    • details about the source patient

    • whether consent was obtained for HIV testing of the source patient

    • medical documentation that provides details about post-exposure management

  • If the exposed worker declines PEP, this decision should be documented in the worker's medical record.

Specific OSHA requirements regarding documentation may be found at Safety and Health Topics: Bloodborne Pathogens and Needlestick Prevention.

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