HIV Post Exposure Prophylaxis (PEP) for exposed healthcare personnel

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Post-exposure prophylaxis (PEP) is short-term antiretroviral treatment to reduce the likelihood of HIV infection after potential exposure by preventing the establishment of infection or preventing new infection. PEP reduces staff exposure to HIV infections at work and also clears possible HIV infection from infected dendritic cells. Workplace  accidents or injury expose health workers to body fluids of patients. Risk of exposure to blood and blood borne pathogens is slightly higher for healthcare personnel. The risk of infection for HIV from a percutaneous injury is approximately 0-3% and that of mucous membranes or non- intact skin are much lower. PEP is particularly effective within 1-2 hours and not more than 72 hours after exposure.

Cause

  • An exposure considered as possible risk is defined as “an exposure from possibly infected blood, tissue or other body fluids through:
    • A percutaneous injury (e.g. a needle stick or cut with a sharp object) or
    • A mucocutaneous membrane or non-intact (chapped, abraded skin) contact
  • The risk of infection appears to be higher after:
    • Exposure to a large quantity of blood or to other infectious fluids
    • Exposure to the blood of a patient in an advanced HIV disease stage
    • A deep percutaneous injury or an injury with a hollow bore, blood filled needle.

Steps to prevent occupational transmission of HIV

In the event of possible exposure to HIV the following actions should be taken:

  • The wound site should be cleaned with soap and water
  • For mucous membranes, the exposed area should be flushed with plenty of water (e.g. eyes with water or saline)
  • Assess the level of risk: the risk of possible infection from the exposure should be assessed and classified based on the categories below:
  • Very Low Exposure:
    • Exposure of potentially infectious material to intact skin
  • Low Risk Exposure:
    • Exposure to a small volume of blood or body fluids contaminated with blood from asymptomatic HIV-positive patient
    • Injury with a solid needle or any superficial injury or mucocutaneous exposure
  • High Risk Exposure:
    • Exposure to a large volume of blood or potentially infectious fluids
    • Exposure to blood or body fluids contaminated with blood from an HIV positive patient with high viral load
    • Injury with a hollow bore needle/deep and extensive injury from a contaminated sharp instrument
    • Exposure to blood from an HIV drug resistant patient

Investigations

  • Full blood count
  • Liver and renal function tests 
  • Hepatitis B Surface Antigen
  • HIV serology or PCR if available

TreatmentTreatment Objectives 

  • To prevent establishment of HIV infection

Non-pharmacological treatment 

  • Counselling and Testing:
  • Exposed health workers must receive counselling and testing immediately from a trained counsellor. The session is to continue throughout the PEP period and thereafter if necessary. Refusal of HIV  test by any exposed worker should be documented
    • Counsellor must emphasize safe sex including condom use.
    • All known source-patients shall also be counselled and tested for HIV infection if this is not known

Pharmacological Treatment

NOTE: Timing: If PEP is necessary, it should be initiated promptly, preferably within 1-2 hours post–exposure and not more than 72 hours after exposure.

Evidence Rating: [A]

Very Low Risk:

  • Wash exposed area immediately with soap and water

Low Risk:

  • Tenofovir 300mg daily for 28 days 

 

And

  • Emtricitabine 200mg daily for 28 days

Or

  • Zidovudine 300mg 12 hourly for 28 days 

 

And

  • Lamivudine 150mg 12 hourly for 28 days

 

High Risk:

  • Tenofovir 300mg daily for 28 days 

 

And

  • Emtricitabine 200mg daily for 28 days 

 

And

  • Lopinavir/r 400mg/100mg 12 hourly for 28 days

Or

  • Zidovudine 300mg 12 hourly for 28 days 

 

And

  • Lamivudine 150mg 12 hourly for 28 days 

And

  • Lopinavir/r 400mg/100mg 12 hourly for 28 days

Note: If the source patient is HIV/HBV co-infected then a Tenofovir containing regimen should be used.

Follow up

During the period of prophylaxis a number of baseline and follow-up investigations need to be done to determine HIV sero-status, and to monitor the level of drug toxicity. 

Recommended Monitoring of Drug Toxicity & HIV Serology of  Exposed Health Care Personnel

Baseline tests:

Full blood count

Liver and renal function tests, Hepatitis B Surface Antigen

HIV serology or PCR if available

Two weeks:

Full blood count 

Liver and renal function tests

Six weeks:

HIV serology

Three months:

HIV serology

Six months: 

HIV serology

Individuals who sero-convert should have access to comprehensive care and ART services

Reporting and Documentation

All occupational exposures should be reported immediately to the supervisor; circumstances of the exposure and PEP management should be recorded. Details should include:

  • Date and time of exposure
  • Where and how the exposure occurred, exposure site on the body and type of  sharp  device. Type and estimated amount of exposure fluid, severity (depth/extent) of the exposure
  • Source of exposure and whether the source material contained HIV or blood.
  • Clinical status of source patient.
  • Relevant information about exposed health care worker (medical conditions, vaccination including Hepatitis B, and medications, pregnancy or breast-feeding)
  • Document counselling, post exposure management and follow ups