Considerations in Occupational Exposure to HIV   TOP

PEP Guidelines

Updated US Public Health Service Guidelines for the Management of Occupational Exposures to HIV and Recommendations for Postexposure Prophylaxis. MMWR Recommendations and Reports. September 30, 2005; 54 (RR-9):1.

Risk of HIV transmission

The risk of transmission continues to be related to exposure to infectious material and the source of that material. Exposure is defined as either percutaneous injury with a contaminated sharp object or exposure of mucous membranes or nonintact skin (skin
that is abraded, chapped or with dermatitis) to infectious material. The current understanding of exposure contingencies is summarized in Occupational Postexposure Table 1.

The risk of HIV transmission (without prophylaxis) is 0.3% (3/1,000) from percutaneous injury and 0.09% (9/10,000) from mucocutaneous exposure. The following are associated with increased risk of transmission: device (needle) with visible blood, needle placed in artery or vein, deep injury, large volume, high viral load.

Efficacy of PEP

The efficacy of AZT monotherapy prophylaxis is estimated to be 80% in retrospective case control series. To date there have been only six recorded prophylaxis failures associated with occupational exposures in the US.

Occupational Postexposure Table 1.   TOP

Occupational Postexposure Table 2.   TOP

* See Occupational Postexposure Table 1 for explanation
† HIV resistance is a concern get expert consultation
‡ PEP is optional based on discussion of risk:benefit

Management of Health Care Workers (HCWs) With Potential HIV Exposure   TOP

The importance of rapid action in the event of a potential exposure cannot be over-emphasized since PEP, if warranted, needs to be initiated within hours.

Assessment

Documentation of the nature and degree of the exposure and the HIV status of the source patient need to be identified. Rapid testing of previously untested source patients is valuable in determining the need for PEP. The need for PEP and potential number of drugs may be determined by using Table 2.

Initiation of HIV PEP

Initiate PEP as soon as possible, preferably within hours after exposure, and continue for 4 weeks. From a practical point of view, PEP should be initiated if the source person is HIV-infected or thought to be infected, especially if the results of HIV serology likely to be delayed. PEP may be discontinued if the source is determined to be uninfected. The current recommended PEP regimens are listed in Table 3.

The following drugs are not recommended because of the potential for adverse events: abacavir, delavirdine, zalcitabine, didanosine with stavudine, and nevirapine. During pregnancy efavirenz should be avoided because of the risk of teratogenic effects and the combination didanosine with stavudine because of toxicity concerns. Additionally, indinavir should be avoided because of side effects in the newborn.

Health care workers taking PEP report adverse reactions at the rate of 17–47%. The most frequently reported reactions were nausea — 27%, malaise and fatigue — 23%. Of 503 HCW who prematurely (<28 days) stopped PEP, 24% did so because of adverse reactions. Regardless, the HCW should be advised on the need to complete the 4–week course of PEP.

Expert Consultation

Consultation with an expert in HIV exposures and PEP is encouraged especially in the following instances:

• Initiation of PEP is delayed to > 24–36 hrs post-exposure
• The status of the source patient is unknown
• The HCW is currently pregnant or is breastfeeding
• The source patient is known to have a resistant HIV strain
• There are toxicity problems in the initiated regimen

Monitoring

• Re-evaluate HCW at 72 hours, especially if additional information becomes available about the status of the source
• HIV serology testing should be conducted at baseline, and then at 6 weeks, 12 weeks, and 6 months after exposure; if the HCW experiences hepatitis C seroconversion after exposure, HIV serology should be conducted 12 months after exposure
• Tests for HIV (P24 Ag or HIV PCR) in HCW are not routinely recommended due to high rates of false positives; these tests should be done if there are symptoms compatible with the acute retroviral syndrome
• Toxicity monitoring
  Laboratory: CBC, liver and renal function tests at baseline and at 2 weeks; HCWs given indinavir should also have urinanalysis monitoring for crystalluria and hematuria
  Self Report: HCWs should be advised to report rash, fever, back or abdominal pain, dysuria, blood in urine, and symptoms of hyperglycemia; they should also be counseled on the possibility of drug interactions and advised to report these should they occur

Prevention Warnings

HCW with exposure to HIV should be counseled on measures to prevent secondary transmission including: avoidance of blood or tissue donations; pregnancy and breastfeeding, especially in the first 6–12 weeks; and the use of condoms for sexual transmission

Seroconversions

Report any Seroconversion to your local Health Department

Occupational Postexposure Table 3.   TOP

Resources for Consultation   TOP

The following resources are available for consultation regarding HIV PEP:

• PEPline
  Telephone: 1-888-448-4911
• HIV Pregnancy registry
  Telephone: 1-800-258-4263, email —registry@nc.crl.com
• FDA (for reporting unusual or severe toxicity to antiretroviral agents)
  Telephone: 1-800-332-1088
• Report HIV infections in HCP and failures of PEP to local Health Department
• HIV/AIDS Treatment Information Service