One of your office personnel receives a superficial stick from a needle while putting it into a sharps disposal container. Is postexposure prophylaxis (PEP) for HIV warranted?
Another health care worker receives a major blood splash into her eye after dropping a blood tube taken from a source of unknown HIV status. Is PEP called for in this instance?
A child who was rifling through a trash bin accidentally poked himself with an improperly disposed hypodermic needle. Should he be given PEP?
In most cases, HIV PEP is given only to healthcare workers if the settings make exposure to HIV-infected persons likely. Otherwise, it is usually deemed unnecessary. However, a decision for or against PEP is complicated.
Occupational and nonoccupational exposure to HIV can produce fear, anxiety, and stress. Information on the exposure risk is frequently incomplete, the risk of infection is usually low, the degree of protection offered by PEP is not fully defined, and the potential for side effects from the medications is significant.
This article distills the Centers for Disease Control and Prevention’s most recent guidance on HIV PEP.
HIV on the rise again
Antiretroviral therapy has markedly reduced mortality from HIV/AIDS, but the incidence of new cases, after declining in the 1990s, has gradually increased since 2000.1 As described in a previous article in the Journal of Family Practice,2 efforts to control HIV now focus on increased testing of those persons at risk, behavior modification to reduce the chances of infected persons exposing others, and treating HIV-positive pregnant women and providing postnatal prophylaxis to their newly born infants.
Exposure to HIV can occur occupationally, during a sexual assault, or from the failure of barrier protection during sex. Though these types of exposure are not major contributors to HIV incidence, and postexposure prophylaxis is not expected to play a major role in reducing the incidence of disease, it is available to persons potentially exposed to HIV, and it is beneficial to know when it is and is not indicated. Evidence for possible effectiveness of PEP comes from studies of postnatal prophylaxis, animal studies, case control studies and case reports.3
The Centers for Disease Control and Prevention (CDC) has developed 2 sets of recommendations for PEP that take into consideration the type and severity of the exposure and characteristics of the source of the exposure (TABLE 1).3,4
TABLE 1
Recommended HIV postexposure prophylaxis for percutanous injuries and membrane/nonintact skin exposures
| For percutaneous injuries | |||||
| EXPOSURE TYPE | INFECTION STATUS OF SOURCE | ||||
| HIV-POSITIVE, CLASS 1* | HIV-POSITIVE, CLASS 2* | SOURCE OF UNKNOWN HIV STATUS† | UNKNOWN SOURCE‡ | HIV-NEGATIVE | |
| Less severe (eg, solid needle or supercficial injury) | Recommend basic 2-drug PEP | Recommend expanded ≥3-drug PEP | Generally, no PEP warranted however, consider basic 2-drug PEP¶ for source with HIV risk factors** | Generally, no PEP warranted; however, consider basic 2-drug PEP¶ in settings in which exposure to HIV-infected persons is likely | No PEP warranted |
| More severe (large-bore hollow needle, deep puncture wound, blood on device, needle used in artery/vein) | Recommend expanded ≥3-drug PEP | Recommend expanded ≥3-drug PEP | Generally, no PEP warranted; however, consider basic 2-drug¶ for source with HIV risk factors** | Generally, no PEP warranted; however, consider basic 2-drug PEP¶ in settings in which exposure to HIV infected persons is likely | No PEP warranted |
| For mucous membrane and nonintact skin exposures†† | |||||
| Small volume (eg, a few drops) | Consider basic 2-drug PEP¶ | Recommend basic 2-drug PEP | Generally, no PEP warranted** | Generally, no PEP warranted | No PEP warranted |
| Large volume (eg, a major blood splash) | Recommend basic 2-drug PEP | Recommend expended ≥3-drug PEP | Generally, no PEP warranted; however, consider basic 2-drug PEP¶ for source with HIV risk factors** | Generally, no PEP warranted; however, consider basic 2-drug PEP¶ in settings in which exposure to HIV-infected persons is likely | No PEP warranted |
| *HIV-positive, class 1—asymptomatic HIV infection or known low viral load (eg, <1500 ribonucleic acid copies/mL). HIV-positive, class 2—symptomatic HIV infection, AIDS, acute seroconversion, or known high viral load. If drug resistance is a concern, obtain expert consultation. Initiation of PEP should not be delayed pending expert consultation, and, because expert consultation alone cannot substitute for face-to-face counseling, resources should be available to provide immediate evaluation and follow-up care for all exposures. | |||||
| †For example, deceased source person with no samples available for HIV testing. | |||||
| ‡For example, a needle from a sharps container or splash from inappropriately disposed blood. | |||||
| ¶The recommendation “consider PEP” indicates that PEP is optional; a decision to initiate PEP should be based on a discussion between the exposed person and the treating clinician regarding the risks versus benefits of PEP. | |||||
| **If PEP is offered and administered and the source is later determined to be HIV-negative, PEP should be discontinued. | |||||
| ††For skin exposures, follow-up is indicated only if evidence exists of compromised skin integrity (eg, dermatitis, abrasion, or open wound). | |||||
| Source: Centers for Disease Control and Prevention 2005.4 | |||||