ASK DIS: Needle Stick Injury: HIV Prophylaxis

Risk of seroconversion

Deep injury (odds ratio [OR] 15)
A device visibly contaminated with the patient's blood (OR 6.2)
Needle placement in a vein or artery (OR 4.3)
Terminal illness in the source patient (OR 5.6)
The majority of cases were injured by a hollow bore as opposed to a solid needle

Initial actions following exposure

immediate cleansing of the exposed site.
Small wounds and punctures may be cleansed with an antiseptic such as an alcohol-based hand hygiene agent, since alcohol is virucidal to HIV, hepatitis B virus (HBV), and hepatitis C virus (HCV).
Other antiseptics such as iodophors, chloroxylenol (PCMX) and chlorhexidine (CHG) also inactivate HIV

Testing for HIV

Baseline and follow-up serologic testing for HIV should be performed in all HCP exposed to HIV to see if seroconversion occurred.
The majority of individuals who seroconvert will do so within the first three months.
Testing should be performed even among those who receive PEP

Post Exposure Prophylaxis

offer post-exposure prophylaxis (PEP) using a three-drug regimen to healthcare personnel (HCP) with a percutaneous, mucous membrane, or nonintact skin exposure to body fluids of concern (eg, blood or blood tinged fluids) if the source patient is, or is suspected to be, HIV-infected
PEP should be discontinued if testing shows that the source patient is HIV-negative, unless there is concern that the source is acutely infected with HIV
If the HIV status of the source patient is unknown, offer PEP while awaiting HIV testing if the source has risk factors for HIV infection (eg, injection drug users, men who have sex with men) or symptoms suggesting HIV infection.
If the source patient is unknown, do not administer PEP unless the exposure occurred in a setting where exposure to HIV is likely (eg, a needlestick from a sharps container in an HIV clinic

Timing

PEP should be initiated as soon as possible.
The goal is to start within one to two hours (or earlier) after exposure, often using a "starter pack" with appropriate drugs that are immediately available.
It is likely that a delay in initiating PEP can reduce efficacy
For most HCP, we do not initiate PEP if more than 72 hours have elapsed after the initial exposure; PEP is likely to be less effective when administered after that period of time.
However, we offer three-drug PEP after a longer interval to patients with a very high-risk exposure (eg, sharps injuries from a needle that was in an artery or vein of an HIV-infected source patient).
For such HCP, The United States Public Health Services suggests that PEP can be offered up to one week after the exposure

Selection of antiretroviral therapy

Tenofovir-emtricitabine (300/200 mg once daily) plus raltegravir (400 mg twice daily)
Tenofovir-emtricitabine (300/200 mg once daily) plus dolutegravir (50 mg once daily)

PEP during pregnancy

For pregnant HCP who have an occupational exposure to HIV and choose to initiate post-exposure prophylaxis (PEP), we typically use the same regimen as noted above, namely tenofovir-emtricitabine (available as Truvada) plus raltegravir

Duration of therapy

The recommended duration of PEP is four weeks because a course of zidovudine for this duration appeared protective in some studies; however, the optimal duration of PEP is unknown
PEP should be discontinued if testing shows that the source patient is HIV-negative

Reference:

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