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1
Question:

A 28-year-old hospital phlebotomist comes to the occupational health clinic 30 minutes after a needlestick injury following a blood draw from an HIV-positive patient.  The patient is on antiretroviral therapy for a drug-sensitive virus, has an undetectable viral load, and has no history of viral hepatitis.  The phlebotomist has no chronic medical conditions and takes no medications; immunizations, including hepatitis B, are up to date.  Which of the following is most appropriate next step in management of this hospital employee?

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Explanation:

Occupational HIV postexposure prophylaxis

High-risk contact

(prophylaxis recommended)

Exposure of:

  • Mucous membrane, nonintact skin, or percutaneous exposure

Exposure to:

  • Blood, semen, vaginal secretions, or any body fluid with visible blood (uncertain risk: cerebrospinal fluid, pleural/pericardial fluid, synovial fluid, peritoneal fluid, amniotic fluid)

Low-risk contact

(prophylaxis not recommended)

Exposure to:

  • Urine, feces, nasal secretions, saliva, sweat, tears (with no visible blood)

Timing

  • Initiate urgently, preferably in the first few hours
  • Continue for 4 weeks

Regimen

Treatment with ≥3-drug regimen recommended:

  • Two nucleotide/nucleoside reverse transcriptase inhibitors (eg, tenofovir, emtricitabine)

PLUS:

  • Integrase strand transfer inhibitor (eg, raltegravir), protease inhibitor, or nonnucleoside reverse transcriptase inhibitor

HIV postexposure prophylaxis (PEP) antiretroviral therapy is recommended following occupational exposure to blood or potentially infectious body fluids from an HIV-positive source patient via percutaneous exposure or exposure to mucous membranes or nonintact skin.  If the HIV status of the source patient is unknown but the patient has risk factors for HIV, PEP should be initiated while awaiting results of HIV testing.  Although the risk of transmission during sexual contact involving an individual with an undetectable viral load is low and likely negligible, the risk from occupational needlestick injury involving such patients has not been established; therefore, PEP is indicated, regardless of viral load in the source patient.

Standard PEP consists of triple-drug therapy; tenofovir-emtricitabine with raltegravir is preferred due to a low adverse effect profile and few drug-to-drug interactions.  PEP should be started immediately, preferably in the first few hours following exposure, and continued for 4 weeks (Choices A and B).

Initial management of occupational exposure to blood or potentially infectious body fluids also should include thorough washing of exposed skin or wounds with soap and water and irrigation of exposed mucous membranes or eyes.  If possible, workers should be relieved of duties immediately to initiate PEP (eg, operating room personnel should scrub out of the procedure).  In addition, exposed health care workers should undergo HIV testing immediately to establish baseline serologic status; testing should be repeated at 6 weeks and again at 4 months.

(Choice C)  Viral load is unlikely to be elevated immediately after potential inoculation.

(Choice D)  Although monotherapy prophylaxis (eg, zidovudine) has been used with some efficacy, 3-drug therapy is considered superior and is the current standard of care.

Educational objective:
HIV postexposure prophylaxis with 3-drug antiretroviral therapy for 4 weeks is recommended following high-risk occupational exposure to blood or potentially infectious body fluids from an HIV-positive individual.  Therapy should be started as soon as possible, preferably in the first few hours.