A Guide to Primary Care of People with HIV/AIDS - Canadian Public ...

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A Guide to Primary Care of People with HIV/AIDS Chapter 11: Postexposure Prophylaxis 11 SUGGESTED RESOURCES Guidelines for the Management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis. Available at http://aidsinfo.nih.gov/guidelines/. PEP Steps–a pocket summary of the 2001 PEP Guidelines. Mountain Plains AIDS Education and Training Center. Available at http://www.uchsc.edu/ mpaetc/hivresources.htm or by telephone at 303- 315-2516. Practice recommendations for health-care facilities implementing the U.S. Public Health Service guidelines for management of occupational exposures to bloodborne pathogens. MMWR 2001;50(RR-11):43-44. Available at http: //www.cdc.gov/mmwr/preview/mmwrhtml/ rr5011a2.htm. Recommendations for the Use of Antiretroviral Drugs in Pregnant HIV-1 Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV-1 Transmission in the United States. Available at http://www.hivatis.org. WEBSITES Food and Drug Administration: http://www.fda.gov. Accessed 1/04. Hepatitis information: http://www.cdc.gov/hepatitis. Accessed 1/04. HIV PEP registry, for nonoccupational exposures: http://www.hivpepregistry.org. Accessed 1/04. National Rape, Abuse, & Incest National Network: http://www.rainn.org/. Accessed 1/04. Needlestick website, a web-based expert system to help providers manage and document occupational exposures to blood and bodily fluids: http://www.needlestick.mednet.ucla.edu. Accessed 1/04. New York State Department of Health AIDS Institute, PEP guidelines: http:// www.hivguidelines.org. Accessed 1/04. STD/HIV Prevention Training Centers (PTCs): http: //depts.washington.edu/nnptc Accessed 10/03. Contact State and local health departments for additional information. TELEPHONE National Rape Crisis Hotline: 1-800-658-HOPE. National Clinicians’ Post-Exposure Prophylaxis Hotline (PEPline), expert consultation for providers on occupational exposures to bloodborne pathogens: 1-888-HIV-4911 (1-888-448-4911 or http://www.ucsf.edu/hivcntr/resources/pep. Accessed 1/04. Warmline: National HIV telephone consultation service: 1-800-933-3413 REFERENCES Bell DM. Occupational risk of human immunodeficiency virus infection in healthcare workers: an overview. Am J Med. 1997;102(suppl 5B):9-15. Cardo DM, Culver DH, Ciesielski CA, et al. A case-control study of HIV seroconversion in health care workers after percutaneous exposure. N Engl J Med. 1997;337:1485-1490. Centers for Disease Control and Prevention. Updated guidelines for the management of occupational exposures to HBV, HCV, and HIV and recommendations for postexposure prophylaxis. Public Health Service. MMWR. 2001:50(RR11):1-42. Centers for Disease Control and Prevention. Management of possible sexual, injectingdrug-use, or other nonoccupational exposure to HIV, including considerations related to antiretroviral therapy. Public Health Service Statement. MMWR. 1998; 47(RR-17):1-14. Centers for Disease Control and Prevention. Recommendations for the prevention and control of hepatitis C virus (HCV) infection and HCV-related chronic disease. MMWR. 1998; 47(RR-19):1-39. Gerberding JL. Occupational exposure to HIV in health care settings. N Engl J Med. 2003;348:826-833. New York State Department of Health AIDS Institute. HIV PEP Guidelines. Available at http://www.hivguidelines.org Accessed 1/04. Mayer KH, Anderson DJ. Heterosexual HIV transmission. Infect Agents Dis. 1995;4:273-284. Stephenson J. PEP talk: treating nonoccupational HIV exposure. JAMA. 2003;289:287-288. Werner BG, Grady GF. Accidental hepatitis-Bsurface-antigen-positive inoculations: use of e antigen to estimate infectivity. Ann Intern Med. 1982;97:367-369. 94 U.S. Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau
A Guide to Primary Care of People with HIV/AIDS Chapter 11: Postexposure Prophylaxis CASES 1. An employee states that she has just punctured herself with a needle after drawing a patient’s blood. The patient has already left the clinic and no one knows anything about his medical history. The employee completed the HBV vaccination series and is hepatitis B surface antibody (HBsAb) positive. During the investigation the HIV prevalence in this setting was found to be low. Question: What is the risk of HIV transmission? Answer: The risk of HIV transmission after a puncture wound with a hollow-bore needle is 0.3%. It is important to remember that the risk of infection is higher when there is a large-volume exposure, a deep percutaneous injury, or an injury with a hollow-bore, blood-filled needle, or if the source has advanced HIV disease or has a high level of HIV viremia. The current CDC recommendations advise against HIV PEP when the source is unknown and in settings where the HIV prevalence is low. Question: What counseling and followup should be recommended? Answer: Because of the low prevalence of HIV in this setting, the employee should be advised against taking HIV medications. Also, because she is HBsAb positive she is not a candidate for HBV PEP. The HCP should be advised to refrain from donating blood, plasma, organs, or tissue, to use barrier methods during sexual activities, and to refrain from sharing any injection or other drug use equipment. She should also be counseled about universal precautions and administration should take steps to reduce the risk of future accidental needle sticks. She should be educated about the symptoms of acute HIV and advised to return immediately if those symptoms occur. Mental health counseling should also be offered. A baseline HIV antibody and anti-HCV should be drawn. HIV anibody should be repeated at 6 weeks, 3 months and 6 months after exposure. A 12-month followup is recommended if the source is found to be coinfected with HIV and HCV, or if the exposed becomes infected with HCV following exposure. Anti-HCV and ALT should be repeated within 4-6 months and if positive should be confirmed with supplemental tests. 11 U.S. Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau 95
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