The latest U.S. Public Health Service (PHS) guidelines emphasize the importance of strict adherence to (1) the principles of Standard Precautions, (2) prompt reporting of an exposure (3) expert management of occupational exposures, (4) adherence to the recommended HIV PEP regimen, and (5) follow-up of exposed HCP including careful monitoring for adverse events related to PEP and for virologic, immunologic, and serologic signs of infection.8
If the infectious status of the exposure source is unknown, he/she should be tested for serologic evidence of HIV infection. If the source person is seronegative, baseline testing and further follow-up of exposed HCP normally is not necessary. If the exposure source is unknown, the likelihood of exposure to a source at high risk is based on a determination of the risk or prevalence of HIV infection among patients in the exposure setting.
While occupational transmission of HIV is extremely rare, exposure to HIV is considered a medical urgency. PEP is to be initiated within 72 hours (ideally within hours) of exposure.8 Initiation of PEP should not be delayed while awaiting test results. If PEP is initiated and the source person is later determined to be HIV negative, PEP should be discontinued and no further follow-up testing is indicated for expose HCP.
The PHS no longer recommends that the severity of exposure be used to determine the number of drugs to be offered in an HIV PEP regimen. The current PHS recommendation is that a 4-week PEP regimen with 3 (or more) drugs be completed for all occupational exposures to HIV. The current preferred regimen (raltegravir, tenofovir, and emtricitabine) has both a favorable side effect profile and a reasonable dosing schedule.
Complete blood counts and liver function tests should be performed at base line and 2 weeks after exposure (in some cases further testing may be indicated). Follow-up testing to monitor for HIV seroconversion should be performed at 6 weeks, 12 weeks, and 6 months. If a newer fourth-generation combination HIV p24 antigen-HIV antibody test is utilized for follow-up HIV testing, it only needs to be performed at baseline, 6 weeks, and 4 months after exposure.
Expert counseling is recommended for those exposed to the HIV, especially in cases of known or suspected pregnancy, breastfeeding, or serious medical illnesses. Those offered PEP should be provided information about possible drug toxicities and drug-drug interactions. Additional guidance should be given on how to prevent sexual transmission of HIV and about donating blood, plasma, organs, tissue, or semen during the follow-up period.
The patient-care responsibilities do not need to be modified based solely on an HIV exposure; however, they should be advised to seek medical evaluation for any acute illness that occurs during the follow-up period, especially within the first 6 to 12 weeks after exposure when most HIV-exposed persons are expected to seroconvert. If HIV seroconversion is detected, the person should be evaluated according to published recommendations for infected HCP.6,7