Resources and Memory //

with occupational work exposure with relatively low risk of transmission. Extensive discussion with patient regarding risk of transmission in regards to Hep B, C and HIV and relative rates given source patient and mechanism. Immunizations UTD as above, specifically TDAP and Hep B vaccinations. Discussed PEP at length with patients and after review of primary risks, benefits and alternative, given relatively low risk of transmission, mutual decision making to defer PEP at this time. Discussed prompt follow up with occupational health for bloodwork and serial serologies as needed. ___________________ NYSDOH AI Recommendations (2014) Indication: Percutaneous or mucocutaneous exposure with blood or visibly bloody fluid or other potentially infectious material. Tenofovir 300 mg PO daily + Emtricitabine 200 mg PO daily or Lamivudine 300 mg PO daily plus Either Raltegravir 400 mg PO twice daily or Dolutegravir 50 mg PO daily HIV Antibody Testing of Healthcare Worker Baseline 4 weeks post-exposure 12 weeks post-exposure When a potential occupational exposure to HIV occurs, every effort should be made to initiate PEP, as soon as possible, ideally within 2 hours. A first dose of PEP should be offered to the exposed worker while the evaluation is underway. In addition, PEP should not be delayed while awaiting information about the source or results of the exposed individual’s baseline HIV test. Decisions regarding initiation of PEP beyond 36 hours post exposure should be made on a case-by-case basis with the understanding of diminished efficacy when timing of initiation is prolonged. CDC Recommendations (2013) * Kuhar DT, Henderson DK, Struble KA, et al. Updated U.S. 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: 875-892. Available at: http://stacks.cdc.gov/view/cdc/20711 Indications: Percutaneous injury or contact of mucous membrane or nonintact skin with blood, tissue, or potentially infectious body fluids, such as semen, vaginal secretions, and visibly bloody fluids and reasonable suspicion that the source patient is HIV-infected. Source Testing: Although concerns have been expressed regarding HIV-negative sources being in the window period for seroconversion, no case of transmission involving an exposure source during the window period has been reported in the United States. Rapid HIV testing of source patients can facilitate making timely decisions regarding use of HIV PEP after occupational exposures to sources of unknown HIV status. Tenofovir 300 mg PO daily + Emtricitabine 200 mg PO daily + Raltegravir 400 mg PO twice daily Duration of PEP: 4 weeks HIV Antibody Testing of Healthcare Worker Baseline 6 weeks post-exposure 12 weeks post-exposure 6 months post-exposure Alternatively, if the clinician is certain that a fourth-generation antibody/antigen combination assay is being used, then HIV testing could be performed at baseline, 6 weeks, and concluded at 4 months post-exposure. PEP should be initiated as soon as possible, preferably within hours rather than days of exposure. Initiation of PEP should not be delayed while awaiting the results of a source patient’s HIV test, nor should it be delayed during consultation with experts to determine ideal PEP regimens. Rationale: Several clinical studies have demonstrated that HIV transmission can be significantly reduced by the post-exposure administration of antiretroviral agents. A dramatic decline in vertical transmission was observed in the AIDS Clinical Trial Group (ACTG) 076 study,1 in which pregnant women and their newborns received monotherapy with zidovudine (ZDV), and in the HIVNET 012 study,2 in which single-dose nevirapine was compared with ZDV. A CDC retrospective case-control study3 of ZDV use after occupational HIV exposure in healthcare workers (HCWs) showed an 81% reduction in risk of HIV infection in persons who received ZDV. Because the ultimate goals of PEP are to maximally suppress any limited viral replication that may occur and to shift the biologic advantage to the host cellular immune system to prevent or abort early infection, the Committee recommends the use of a three-drug PEP regimen for all significant risk exposures. Relative Risks: Estimated Per-Act Probability of Acquiring HIV From a Known HIV-Infected Source by Exposure Act Type of Exposure Risk per 10,000 Exposures Parenteral Blood Transfusion 9,000 Percutaneous (needlestick) 30 Sexual Receptive anal intercourse 138 Insertive anal intercourse 11 Receptive penile-vaginal intercourse 8 Insertive penile-vaginal intercourse 4 Receptive oral intercourse low Insertive oral intercourse low Other Biting Negligible Spitting Negligible Throwing body fluids Negligible (including semen or saliva) http://www.cdc.gov/hiv/law/transmission.htm. Factors that increase the risk of HIV transmission include early and late-stage HIV infection and a high level of HIV in the blood. Factors that reduce the risk of HIV transmission include low level of HIV in the blood and the use of ART.



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