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

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.

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