Updated guidelines for HIV post-exposure prophylaxis after occupational exposure

The US Public Health Service Working Group has published updated guidelines for HIV post-exposure prophylaxis after occupational exposures.

This should guide the approach to management of sharps injuries and other non-sharps exposures such as splash of blood to the mouth or eyes, and exposures involving contamination of existing open skin lesions such as recent cuts and grazes, eczematous lesions and the like.

Kuhar DT et al. Updated US Public Health Service Guidelines for the Management of Occupational Exposures to Human Immunodeficiency Virus and Recommendations for Postexposure Prophylaxis. Infection Control and Hospital Epidemiology 2013;  34, 9: 875-92.

HIV PEP 1

 

Much of the paper considers the benefits and disadvantages of one antiretroviral drug or drug combination over another, and the importance of rapid timing and reduction of any delay between injury or exposure and the initiation of post-exposure prophylaxis.

The paper does not differentiate between sharps injury exposure and exposure by contamination with blood or bloodstained body fluids of broken skin or mucous membranes (mouth and eyes), though in all sectors outside healthcare these additional exposure routes are overlooked or dismissed entirely. However, the Clinical Waste Discussion Forum has, for many years, stressed the importance of precautions to prevent exposure by these additional routes, and the procedures to follow if they should occur.

Box 1 from the paper is reproduced here. It contains several thought provoking entries. Most important to us, in the list of situations for which expert consultation for Human Immunodeficiency Virus (HIV) post-exposure prophylaxis (PEP), is the recommended that where injury or exposure has occurred from an unknown source (eg, needle in sharps disposal container or laundry) patients must be referred to a specialist for careful and thorough review on a case-by-case basis.

That should send ripples of alarm through the waste sector, since each and every exposure that occurs to a waste handlers or ancillary worker will fall into that category. No more should exposures be dismissed as trivial, by workers in this sector, or by an A&E nurse who might sarcastically fob off a worker for such a trivial injury that can barely be seen. The mid-way option, to make an appointment with a GP is similarly unacceptable since it incurs often considerable delay and takes the victim no nearer a specialist.

Make a fuss. Be bold and stroppy if necessary, but do not accept anything but immediate review AND urgent referral to a specialist. Of course, that might be difficult, initially since in A&E there may be life threatening cases requiring immediate attention. but an urgent assessment is essential, even if the wound is so small it can now barely be seen. Onward referral to a specialist is essential, and it may be necessary to remind a busy junior A&E doctor that referral is not only desirable but essential., and that it must be an urgent referral since delay can be serious.

There can be no remaining doubt that in the waste and related sectors sharps injury remains common and will fall into an inevitably high-risk category. The risk is yet higher for those managing drug litter or otherwise struck with a discarded needle since the likelihood is that it has been used by an IV drug user. We are aware that the in this group the rate of Hepatitis C and HIV are high, and increasing. No longer should the injury be dismissed as trivial and low risk ‘since the needle is old and any virus will be dead’.

How old?

How do you know?

Which virus?

How much, and how fresh?

Do you want to find out the hard way?

 

Stop what you are doing. Take immediate steps to gently clean the wound – do no squeeze, but encourage it to bleed – or rinse mouth and eyes. Seek immediate medical help in a nearby A&E, and after assessment demand urgent specialist referral. Nothing else will do.

 

 

 

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