PHS Recommendations for the Management of Health-Care Worker Exposures to HIV: Part 2

Health-care organizations should make available to their workers a system that includes written protocols for prompt reporting, evaluation, counseling, treatment, and follow-up of occupational exposures that may place health-care workers at risk for acquiring any blood-borne infection, including human immunodeficiency virus (HIV). Employers also are required to establish exposure-control plans, including postexposure follow-up for their employees, and to comply with incident reporting requirements mandated by the Occupational Safety and Health Administration. Access to clinicians who can provide postexposure care should be available during all working hours, including nights and weekends.

Antiretroviral agents for postexposure prophylaxis should be available for timely administration (ie, either by providing access to postexposure prophylaxis drugs on site or creating links with other facilities or providers to make them available off-site). Persons responsible for providing postexposure counseling should be familiar with evaluation and treatment protocols and the facility’s procedures for obtaining drugs for postexposure prophylaxis.

Health-care workers should be educated to report occupational exposures immediately after they occur, particularly because postexposure prophylaxis is most likely to be effective if implemented as soon after the exposure as possible. Health-care workers who are at risk for occupational exposure to HIV should be taught the principles of postexposure management, including options for postexposure prophylaxis as part of job orientation and ongoing job training.

Exposure Report

If an occupational exposure occurs, the circumstances and postexposure management should be recorded in the health-care worker’s confidential medical record (usually on a form the facility designates for this purpose). Relevant information includes:

• Date and time of exposure

• Details of the procedure being performed, including where and how the exposure occurred, and if the exposure was related to a sharp device, the type of device and how and when in the course of handling the device the exposure occurred

• Details of the exposure, including the type and amount of fluid or material and the severity of the exposure (eg, for a percutaneous exposure, depth of injury and whether fluid was injected; or for a skin or mucous-membrane exposure, the estimated volume of material and duration of contact and the condition of the skin [eg, chapped, abraded, or intact])

• Details about the exposure source (ie, whether the source material contained HIV or other blood-borne path-ogen[s]), and if the source is an HIV-infected person, the stage of disease, history of antiretroviral therapy, and viral load, if known

• Details about counseling, postexposure management, and follow-up.

Exposure Management

Treatment of an Exposure Site: Wounds and skin sites that have been in contact with blood or body fluids should be washed with soap and water; mucous membranes should be flushed with water. There is no evidence that the use of antiseptics for wound care or expressing fluid by squeezing the wound further reduces the risk for HIV transmission. The use of antiseptics is not, however, contraindicated. The application of caustic agents (eg, bleach) or the injection of antiseptics or disinfectants into the wound is not recommended.

Assessment of Infection Risk: After an occupational exposure, the source-person and the exposed health-care worker should be evaluated to determine the need for HIV postexposure prophylaxis. Follow-up for hepatitis B virus and hepatitis C virus infections also should be conducted in accordance with previously published Centers for Disease Control (CDC) recommendations.

Evaluation of Exposure: The exposure should be evaluated for potential to transmit HIV based on the type of body substance involved and the route and severity of the exposure. Exposures to blood, fluid containing visible blood, or other potentially infectious fluid (including semen; vaginal secretions; and cerebrospinal, synovial, pleural, peritoneal, pericardial, and amniotic fluids) or tissue through a percutaneous injury (ie, needle-stick or other penetrating sharps-related event) or through contact with a mucous membrane are situations that pose a risk for blood-borne transmission and require further evaluation (Figure 1).

In addition, any direct contact (ie, personal protective equipment either was not used or was ineffective in protecting skin or mucous membranes) with concentrated HIV in a research laboratory or production facility is considered an exposure that requires clinical evaluation to assess the need for postexposure prophylaxis.

For skin exposures, follow-up is indicated if it involves direct contact with a body fluid listed above and there is evidence of compromised skin integrity (eg, dermatitis, abrasion, or open wound). If the contact is prolonged or involves a large area of intact skin, however, postexposure follow-up may be considered on a case-by-case basis or if requested by the health-care worker.

For human bites, the clinical evaluation must consider possible exposure of both the bite recipient and the person who inflicted the bite. HIV transmission only rarely has been reported by this route. If a bite results in blood exposure to either person involved, postexposure follow-up, including consideration of postexposure prophylaxis, should be provided.

Evaluation and Testing of an Exposure Source: The person whose blood or body fluids are the source of an occupational exposure should be evaluated for HIV infection. Information available in the medical record at the time of exposure (eg, laboratory test results, admitting diagnosis, or past medical history) or from the source person may suggest or rule out possible HIV infection.

Examples of information to consider when evaluating an exposure source for possible HIV infection include laboratory documentation (eg, prior HIV testing results or results of immunologic testing [eg, CD4+ count]), clinical symptoms (eg, acute syndrome suggestive of primary HIV infection or undiagnosed immunodeficiency disease), and history of possible HIV exposures (eg, injecting-drug use, sexual contact with a known HIV-positive partner, unprotected sexual contact with multiple partners [heterosexual and/or homosexual], or receipt of blood or blood products before 1985).

If the source is known to have HIV infection, available information about this person’s stage of infection (ie, asymptomatic or AIDS), CD4+ T-cell count, results of viral load testing, and current and previous antiretroviral therapy, should be gathered for consideration in choosing an appropriate postexposure prophylaxis regimen.

If this information is not immediately available, initiation of postexposure prophylaxis, if indicated, should not be delayed; changes in the postexposure prophylaxis regimen can be made after postexposure prophylaxis has been started, as appropriate.

If the HIV serologic status of the source person is unknown, the source person should be informed of the incident and, if consent is obtained, tested for serologic evidence of HIV infection. If consent cannot be obtained (eg, patient is unconscious), procedures should be followed for testing source persons according to applicable state and local laws. Confidentiality of the source person should be maintained at all times.

Human immunodeficiency virus-antibody testing of an exposure source should be performed as soon as possible. Hospitals, clinics, and other sites that manage exposed health-care workers should consult their laboratories regarding the most appropriate test to use to expedite these results. An FDA-approved rapid HIV-antibody test kit should be considered for use in this situation, particularly if testing by enzyme immunoassay cannot be completed within 24 to 48 hours.

Repeatedly reactive results by enzyme immunoassay or rapid HIV-antibody tests are considered highly suggestive of infection, whereas a negative result is an excellent indicator of the absence of HIV antibody. Confirmation of a reactive result by Western blot or immunofluorescent antibody is not necessary for making initial decisions about postexposure management but should be done to complete the testing process.

If the source is HIV seronegative and has no clinical evidence of acquired immunodeficiency syndrome (AIDS) or symptoms of HIV infection, no further testing of the source is indicated. It is unclear whether follow-up testing of a source who is HIV negative at the time of exposure, but recently (ie, within the last 3 to 6 months) engaged in behaviors that pose a risk for HIV transmission, is useful in postexposure management of health-care workers; health-care workers who become infected generally seroconvert before repeat testing of a source would normally be performed.

If the exposure source is unknown, information about where and under what circumstances the exposure occurred should be assessed epidemiologically for risk for transmission of HIV. Certain situations, as well as the type of exposure, may suggest an increased or decreased risk; an important consideration is the prevalence of HIV in the population group (ie, institution or community) from which the contaminated source material is derived.

For example, an exposure that occurs in a geographic area where injecting-drug use is prevalent or in an AIDS unit in a health-care facility would be considered epidemiologically to have a higher risk for transmission than one that occurs in a nursing home for the elderly where no known HIV-infected residents are present. Exposure to a blood-filled hollow needle or visibly bloody device also suggests a higher-risk exposure than exposure to a needle that was most likely used for giving an injection. Decisions regarding appropriate management should be individualized based on the risk assessment. HIV testing of needles or other sharp instruments associated with an exposure, regardless of whether the source is known or unknown, is not recommended. The reliability and interpretation of findings in such circumstances are unknown.

Clinical Evaluation and Baseline Testing of Exposed Health-care Workers: Exposed health-care workers should be evaluated for susceptibility to blood-borne pathogen infections. Baseline testing (ie, testing to establish serologic status at the time of exposure) for HIV antibody should be performed. If the source person is seronegative for HIV, baseline testing or further follow-up of the health-care worker normally is not necessary. If the source person has recently engaged in behaviors that are associated with a risk for HIV transmission, baseline and follow-up HIV-antibody testing (eg, 3 and/or 6 months postexposure) of the health-care worker should be considered. Serologic testing should be made available to all workers who are concerned that they may have been exposed to HIV.

For purposes of considering HIV postexposure prophylaxis, the evaluation also should include information about medications the health-care worker may be taking and any current or underlying medical conditions or circumstances (ie, pregnancy, breast feeding, or renal, or hepatic disease) that may influence drug selection. Pregnancy testing should be offered to all nonpregnant women of childbearing age.