UMDNJ Resources

Recommendations to Reduce the Risk of Occupational
HIV Transmission After an Exposure Incident

CASE REVIEW

A 27-year-old medical assistant (MA) presents to Urgent Care for evaluation of a needlestick injury. The injury occurred two days prior, while testing a 35-year-old known HIV+ male with a diabetic lancet. To her knowledge, the patient has never been treated for HIV and is unaware of his CD4+ count and VL. The lancet was visibly bloody, pierced her glove and caused her to bleed.

1. What is her risk for contracting HIV?

    1. Low risk, low volume exposure to a known HIV+ source patient
    2. High risk, high volume exposure to a known HIV+ source patient
    3. Low risk, high volume exposure to a known HIV+ source patient
    4. High risk, low volume exposure to a known HIV+ source patient

The source patient is known to be HIV+ and the device used on this patient was visibly contaminated with blood. The medical assistant did in fact pierce her finger with the bloody lancet and this caused her to bleed. Because the source patient is known HIV+ this is (d) a high-risk exposure with low blood volume

2. Which of the following statements is TRUE about PEP in this instance?

    1. PEP is not indicated because too much time has elapsed since the needle stick injury
    2. PEP is warranted in this case and a 2-drug regimen should be initiated as soon as possible
    3. An evaluation of the source patient’s resistance pattern should be obtained before initiating PEP for this injury
    4. More information is needed before a decision to start PEP can be made

Ideally, PEP should be initiated, as soon after the injury as possible and optimally within the first 36 hours. Studies however have not determined at which point after exposure PEP is no longer effective. Use of the source patient’s viral load and resistance pattern are not prerequisites for starting PEP. In this case, a standard two-drug regimen (b) should be initiated. Should information about the source patient’s status be determined at a later date, the regimen can be changed as appropriate.

3. Which of the following would be an appropriate basic two-drug PEP regimen to prescribe for this patient?

    1. Zidovudine (Retrovir) 300 mg twice daily + Lamivudine (Epivir) 150 mg twice daily
    2. Zidovudine (Retrovir) 300 mg twice daily + Indinavir (Crixivan) 800 mg every eight hours
    3. Zidovudine (Retrovir) 300 mg twice daily + Nevirapine (Viramune) 200 mg twice daily
    4. Combivir (Zidovudine 300 mg + Lamivudine (Epivir) 150 mg) + Efavirenz (Sustiva) 600 mg at hour of sleep

The most appropriate basic two-drug regimen in this case would be (a) Zidovudine (Retrovir) + Lamivudine (Epivir). The use of a PI (Protease Inhibitor) with Zidovudine is inappropriate. Nevirapine is not recommended for use as PEP. Efavirenz (Sustiva) should be avoided during pregnancy and is not a part of the basic regimen. Combivir and Efavirenz are a three-drug regimen.

New information: After extensive counseling, you recommend that the medical assistant take the basic two-drug regimen, but before she leaves, the triage nurse informs you that the following information about the source patient has been obtained from the primary care physician:

    • CD4+ count two months ago 450 cells/mm3: CD4+ nadir 280 cells/mm3
    • Viral load two months ago 60,000 copies/mL
    • The patient has never had an OI
    • The patient is not naïve to therapy: for the past year he has been on Zidovudine (Retrovir), Lammivudine (Epivir), Ritonavir (Norvir), and Indinavir (Crixivan)

4. How does this information affect the PEP regimen you prescribed?

    • No change, the standard basic two-drug PEP regimen is appropriate for this patient
    • A high viral load in the source patient suggests that the he is either non-compliant or resistant to the current treatment regimen and expert advise may be helpful
    • The PEP regimen should be discontinued until résistance testing results are obtained
    • Discontinue the current PEP regimen and begin ddi + tenofovir + efavirenz immediately

A high viral load in the source patient suggests that either the patient has not been adherent to the current treatment or he has developed resistance to this regimen. The time required to evaluate resistance testing in this patient is too long to make a determination for PEP regimen for the injured patient. Starting a three-four-drug PEP regimen (b) should be guided by expert advice. The use of ddI, tenofovir and efavirenz is no longer recommended as appropriate ART treatment.

5. Which of the following is appropriate post-exposure follow-up HIV testing for this patient?

    1. 6 weeks 3 months, 6 months
    2. 6 weeks, 3 months, 6 months, 12 months
    3. Every three months along with CD4+ and VL counts
    4. Every six weeks

CDC recommends (a) HIV Ab testing for 6 months following exposure, (e.g. at 6 weeks, 3 months, 6 months). If the source patient is co-infected with HIV and HCV, however, extended HIV Ab testing is recommended at 12 months if the health care worker contracts Hepatitis C.

Case material from the Northwest AIDS Education and Training Center (NWAETC), as posted on the AETC National Resource Center website, www.aids-etc.org for educational use; adapted by Brenda J. Christian, M.Ed, PA-C, of the UMDNJ-CCOE-Division of AIDS Education for this article.