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
INTERVENTIONS FOR PEP
IN HEALTH CARE SETTINGS
What types of exposures merit consideration
of PEP in health care personnel (HCP)?
HCP are at increased risk from percutaneous, mucous
membrane, and nonintact skin exposures to bloodborne
pathogens, including hepatitis B, hepatitis C, and HIV.
The risk of transmission is dependent on many factors,
including the type, amount, route, and severity of
exposure, the infection status of the source, and the HBV,
HCV, and HIV immunity of the exposed worker (see
Tables 11-1 and 11-2).
Table 11-1. High-risk
Occupational Exposures
Exposures with higher risk of
transmission of bloodborne pathogens
Deep percutaneous injury
Injury with a hollow-bore blood-filled needle
Exposure to blood of a patient in an advanced disease stage
(high viral load)
Exposure to a large quantity of blood or body fluids
Table 11-2. Exposures with Low Risk of
Transmission of Bloodborne Pathogens
Exposures with low risk of
transmission (PEP not recommended)
Blood or fluid splashes on intact skin
Minor scratches or abrasions without evidence of percutaneous
penetration
Penetration by small-bore needles without visible blood
An accurate history of the exposure is essential in
determining the real risk of transmission. In studies,
transmission of HIV by occupational exposure has an
estimated 0.3% risk with percutaneous exposure and
0.09% with mucous membrane splash (Bell, 1997).
The risk of infection for HBV (in individuals who have
not been vaccinated to hepatitis B, or who were vaccine
unresponsive) after percutaneous exposure is 37%-62%
when the source is hepatitis B surface antigen (HbsAg)
positive and hepatitis B e antigen (HBeAg) positive, and
the risk of developing clinical hepatitis is 22%-31%.
When the source is HbsAg positive and hepatitis B e
antigen negative, the risk of HBV seroconversion is
1%-6%, and the risk of developing clinical hepatitis is
23%-37%. The risk of transmission is higher, ie 22%-
31%, when the source has clinically evident hepatitis
B hepatitis (Werner and Grady, 1982; CDC, 2001).
Transmission of HCV through occupational exposure
carries an average risk of 1.8%.
What are immediate actions and initial
considerations in PEP following a possible
occupational exposure?
First aid for the HCP is the first immediate action,
followed by collection of information in order to assess
the situation and make rapid decisions regarding
appropriate treatment (see Tables 11-3, 11-4, and 11-5).
Quick, expert action by the care provider is essential
because the effectiveness of PEP is variable and
depends on the inoculum, type of injury, potency of
the PEP regimen, and speed with which treatment is
started. The decision to prescribe medications, as well
as medication administration, should be made within
4 hours of the exposure, and must be made within
72 hours, and preferably sooner because of studies
suggesting that the efficacy of PEP is diminished after
36 hours. Even with optimal implementation, ie within
the first 4 hours, the protection afforded by PEP is not
100%.
What counseling and education should you
give the HCP?
The exposed HCP needs immediate counseling to
assist in coping with the emotional stress of the
exposure, and may require follow up care by a mental
health professional. Psychological services should be
available 24 hours a day, 7 days a week. A local crisis
management team or an employee assistance program
(EAP) may be effective ways to address this need.
The HCP should be told the relative risk of infection
with HIV, HBV, and HCV following exposure, the
effectiveness of PEP, and the risks and benefits of
PEP. Exposed persons should be advised to return
immediately if symptoms of acute HIV seroconversion
occur, including fever, malaise, rash, swollen lymph
nodes, fatigue or myalgias (most likely to occur 2-6
weeks after exposure).
Providers should advise exposed HCPs to prevent
transmitting HIV to others, by means of the following
measures, until the HCP has a negative HIV test 6
months after exposure:
• Refrain from donating blood, plasma, organs, tissue,
or semen.
• Use barrier protection during sexual activity.
• If HCP is female, avoid pregnancy.
• If breast feeding, consider discontinuing, to avoid the
risk of HIV transmission through breast milk.
If exposed to HBV, the HCP should follow infection
control procedures that are in place at the institution.
U.S. Department of Health and Human Services, Health Resources and Services Administration, HIV/AIDS Bureau