2. Objectives
• Describe the modes and risks of transmission
of HIV after exposure
• Outline HIV prevention in care settings and
post exposure prophylactic strategies
• Explain the management of accidental
exposure in the health care setting
• Outline HIV prophylaxis including after rape
3. Introduction
• Health care personnel who have occupational
exposure to blood are at risk for HIV infection
• Prevention of blood exposure, through safer
practices, barrier precautions, safer needle
devices, and other innovations, is the best way to
prevent infection with HIV and other blood borne
pathogens
• Although these strategies have been successful in
reducing the frequency of blood exposure and
needle-stick injuries in the past decade, the
hazard has not been eliminated
4. Universal precautions
• All blood and body fluids assumed to be
infected
• Hand washing access, policies, practices
– After every examination/procedure
• Gloves, needle disposal
• Needle injury surveillance
• Avoid blood/fluid contact with inflamed skin,
eyes, sores
• Supervision,education,motivation
5. HIV infectiousness
• Very low probability, high consequence event
– Percutaneous ~ 0.3% & less for mucus
membranes/skin
• 100x less infectious than hepatitis B, 10x less
than hepatitis C in health care environment
6. HIV infectiousness
• Hepatitis is a better sentinel for blood borne
infection
– Can survive dried blood on surfaces ~ 1 week
• Over 99% of HIV infection in healthcare
workers not from workplace exposure(best
guess)
7. HIV infectiousness
• Best guess, less than 1000, of 70 million HIV
infections, acquired in workplace or from
contact with infected caregivers
• Very few acquisitions from splashing
blood/chance contact—less likely than
lightening strike
• Need more information in high prevalence HIV
areas
8. HIV infected HCWs
• Risks to patients are un-measurably low
• >100x less transmission than hepatitis b
positive surgeon
• Likely no restrictions required
• ARV’s lowers viral load/risk further
• Not required to inform patients
9. Needle stick injury
• Risk increases with hollow bore needle,
increased caliber, severity of injury, visible
blood, viral load/clinical stage of HIV, HIV
prevalence in population
• Risk if patient HIV positive between 1/250
with high risk exposure to <1/5000 with
exposure to a solid surgical needle
• Must be taken seriously
10. Prevention as a way of life for HCWs
• Regular in-service, supervision
• Written programs with HCWs ownership of
processes
• Surveillance and use of data to demonstrate
program success/failure-anecdotes
• Education to ensure infections not acquired
away from work
• HANDWASHING!!!
11. HIV testing after exposure
• The interval between the onset of viremia and
the detection of HIV antibody, with the use of
current enzyme immunoassays for HIV, is a
few days at most.
• If the result of a reliable HIV test in the source
patient is negative, the risk of transmission is
assumed to be zero, unless the patient has
risk factors for infection and the clinical
findings are compatible with acute HIV
infection (e.g., fever, pharyngitis, rash,
lymphadenopathy)
12. Post exposure prophylaxis
• Studies from US and others show that PEP
protection is not absolute
• Probably PEP protects 81%
• 50% staff report side effects and can be life
threatening in rare cases
13. PEP Guidelines
• Encourage bleeding by squeezing site if a
puncture wound. Do not suck blood or
squeeze too much as to bruise. Do not scrub
areas or use nailbrush
• Apply methylated spirit, Betadine, Iodine or
other virucidal disinfectant
• Wash the affected area gently with plenty of
soap and water
14. PEP Guidelines
• Irrigate with water if splashing occurs into eye,
mucous membrane or non-intact skin
• If HAART is necessary, it should be done within
1 to 2 hours of exposure best within 15
minutes
15. PEP Guidelines……
• The source patient shall have blood removed
for quick ELISA. Note that start of ARVS can be
done before the result is available. If consent
cannot be obtained from the patient, a
consultant can be called to order the test.
• If the result of the source patient is negative,
the stat initial dose is enough
• If the result of the source patient is positive
treatment for the staff must continue
16. PEP Guidelines….
• Treatment duration shall be for 4 weeks
• The staff will need to be counseled as soon as
is practical and ELISA taken with the highest
level of confidentiality.
• There shall baseline tests to monitor drug
toxicity at the HAART clinic and repeat after 2
weeks for the staff on treatment.
17. PEP Guidelines…
• HIV serology and or PCR testing shall be done
at the 5th week for the staff on treatment
• A detailed report shall be kept in the HAART
clinic
18. PEP Guidelines…
• HIV serology and or PCR testing shall be done
at the 5th week for the staff on treatment
• A detailed report shall be kept in the HAART
clinic
19. Post Rape HIV Prophylaxis
• When the choice is made to take medications to
prevent HIV infection, treatment should be
initiated as soon as possible, but no later than 72
hours following the assault, and should be
continued for 28 days.
• HIV post exposure prophylaxis should be
provided in the context of a comprehensive
treatment and counseling program that
recognizes the physical and psychosocial trauma
experienced by victims of sexual assault.
20. TREATMENT PROTOCALS FOR POST
EXPOSURE PROPHYLAXIS
Treatment regimen(28 days)
• Zidovudin 300mg twice a day or 200mg 3
times a day
Alternative regimen (28 days)
• Didanosine 200mg twice a day and sitavudine
twice a day and stavudine 40mg twice a day
and consider adding nevirapine
21. TREATMENT PROTOCALS FOR POST
EXPOSURE PROPHYLAXIS…
Testing of the victim;
• HIV antibody-Repeat after 6weeks, 3 months
and 6 months
• Hepatitis virus service antibody test,
Gonnorrhea,chlamydia and syphillis tests, wet
mount for trichomonas, Pregnancy test if
appropriate, Hepatic enzymes levels ( repeat
as clinically indicated), complete blood count-
repeat as clinically indicated)
