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 "Public Health Service Guidelines for the Management of Health-Care Worker Exposures to HIV and Recommendations for Postexposure Prophylaxis"

Source: MMWR Reports and Recommendations: May 15, 1998 / Vol. 47 / No. RR-7 "Public Health Service Guidelines for the Management of Health-Care Worker Exposures to HIV and Recommendations for Postexposure Prophylaxis"  

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Summary

This report updates and consolidates all previous PHS recommendations for the management of health-care workers (HCWs) who have occupational exposure to blood and other body fluids that may contain human immunodeficiency virus (HIV).

Post-exposure Prophylaxis

The report includes recommendations for HIV postexposure prophylaxis (PEP) and discusses the scientific rationale PEP.  The decision to recommend HIV postexposure prophylaxis must take into account the nature of the exposure (e.g., needlestick or potentially infectious fluid that comes in contact with a mucous membrane) the amount of blood or body fluid involved in the exposure. Other considerations include pregnancy in the HCW and exposure to virus known or suspected to be resistant to antiretroviral drugs. Assessments of the risk for infection resulting from the exposure and of the infectivity of the exposure source are key determinants of offering PEP. Systems should be pace for the timely evaluation and management of exposed HCWs and for consultation with experts in the treatment of HIV when using PEP.

Recommendations for PEP have been modified to include a basic 4-week regimen of two drugs (zidovudine and lamivudine) for most HIV exposures and an expanded regimen that includes the addition of a protease inhibitor (indinavir or nelfinavir) for HIV exposures that pose an increased risk for transmission or where resistance to one or more of the antiretroviral agents recommended for PEP is known or suspected.

An algorithm is provided to guide clinicians and exposed health-care workers in deciding when to consider PEP.

Occupational exposures should be considered urgent medical concerns to ensure timely administration of PEP. Health-care organizations should have protocols that promote prompt reporting and facilitate access to postexposure care. Enrollment of HCWs in registries designed to assess side effects in HCWs who take PEP is encouraged.

Efficacy of Post-exposure Prophylaxis (PEP)

Although preventing blood exposures is the primary means of preventing occupationally acquired human immunodeficiency virus (HIV) infection, appropriate postexposure management is an important element of workplace safety. In January 1990, CDC issued a statement on the management of HIV exposures that included considerations for zidovudine (ZDV) use for postexposure prophylaxis (PEP). At that time, data were insufficient to assess the efficacy of ZDV as a prophylactic agent in humans or the toxicity of this drug in persons not infected with HIV. Although there are still only limited data to assess safety and efficacy, additional information is now available that is relevant to this issue.

Failure of ZDV PEP to prevent HIV infection in HCWs

Failure of ZDV PEP to prevent HIV infection in HCWs has been reported in at least 14 instances ( 62-64; G. Ippolito, AIDS Reference Center, Rome, Italy, and J. Hepton-stall, Communicable Disease Surveillance Center, London, United Kingdom, personal communication, 1997). Although eight of the 13 source patients had taken ZDV, laboratory assessment for ZDV resistance of the virus from the source patient was performed in only three instances, two of which demonstrated reduced susceptibility to ZDV. In addition to possible exposure to a ZDV-resistant strain of HIV, other factors that may have contributed to the apparent failures in these instances may include a high titer and/or large inoculum exposure, delayed initiation and/or short duration of PEP, and possible factors related to the host (e.g., cellular immune system responsiveness) and/or to the source patient's virus (e.g., presence of syncytia-forming strains) ( 62 ).

Treatment of an Exposure Site

Wounds and skin sites that have been in contact with blood or body fluids should be washed with soap and water; mucous membranes should be flushed with water. There is no evidence that the use of antiseptics for wound care or expressing fluid by squeezing the wound further reduces the risk for HIV transmission. However, the use of antiseptics is not contraindicated. The application of caustic agents (e.g., bleach) or the injection of antiseptics or disinfectants into the wound is not recommended. 

Exposure-control plans, including postexposure follow-up for their employees, and to comply with incident reporting requirements mandated by the Occupational Safety and Health Administration ( 15 ). Access to clinicians who can provide postexposure care should be available during all working hours, including nights and weekends. Antiretroviral agents for PEP should be available for timely administration (i.e., either by providing access to PEP drugs on site or creating links with other facilities or providers to make them available offsite).

Persons responsible for providing post-exposure counseling should be familiar with evaluation and treatment protocols and the facility's procedures for obtaining drugs for PEP. HCWs should be educated to report occupational exposures immediately after they occur, particularly because PEP is most likely to be effective if implemented as soon after the exposure as possible ( 41,55,56 ). HCWs who are at risk for occupational exposure to HIV should be taught the principles of postexposure management, including options for PEP, as part of job orientation and ongoing job training. Access to clinicians who can provide postexposure care should be available during all working hours, including nights and weekends.

Antiretroviral agents for PEP should be available for timely administration (i.e., either by providing access to PEP drugs on site or creating links with other facilities or providers to make them available offsite). Persons responsible for providing post-exposure counseling should be familiar with evaluation and treatment protocols and the facility's procedures for obtaining drugs for PEP. HCWs should be educated to report occupational exposures immediately after they occur, particularly because PEP is most likely to be effective if implemented as soon after the exposure as possible ( 41,55,56 ).

Timing of PEP Initiation

PEP should be initiated as soon as possible. The interval within which PEP should be started for optimal efficacy is not known. Animal studies have demonstrated the importance of starting PEP within hours after an exposure To assure timely access to PEP, an occupational exposure should be regarded as an urgent medical concern and PEP started as soon as possible after the exposure (i.e., within a few hours rather than days). If there is a question about which antiretroviral drugs to use, or whether to use two or three drugs, it is probably better to start ZDV and 3TC immediately than to delay PEP administration. Although animal studies suggest that PEP probably is not effective when started later than 24-36 hours postexposure , the interval after which there is no benefit from PEP for humans is undefined.

Therefore, if appropriate for the exposure, PEP should be started even when the interval since exposure exceeds 36 hours. Initiating therapy after a longer interval (e.g., 1-2 weeks) may be considered for exposures that represent an increased risk for transmission; even if infection is not prevented, early treatment of acute HIV infection may be beneficial ( 69 ). The optimal duration of PEP is unknown. Because 4 weeks of ZDV appeared protective in HCWs ( 2) , PEP probably should be administered for 4 weeks, if tolerated.

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