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

Follow Up After an Exposure Incident

One of the requirements of the OSHA Bloodborne Pathogens Standard is that employers must provide designated employees (e.g., health care workers) with a system for prompt evaluation, counseling, and follow-up after an exposure incident.  First aid should be administered immediately after an exposure. 

• Puncture wounds and exposure to non-intact skin (dermatitis, hangnails, abrasions, chafing, acne, etc) should be washed with soap and water.
• Exposure to oral and nasal mucosa should be decontaminated by flushing with water.
• Eyes should be irrigated with clean water and saline or sterile irrigants that are designed for flushing eyes. 
• The exposure should be reported to the person or department, (e.g., employee health, infection control), which is responsible for managing exposures.

Employee HIV antibody tests should be performed at baseline and periodically for at least six months postexposure, e.g., 6 weeks, 12 weeks, and six months.  HIV testing also should be performed on any health care worker who has an illness compatible with an acute retroviral syndrome, regardless of the interval since the exposure.  HIV antibody testing using enzyme immunoassay (EIA) should be used to monitor for seroconversion.  The routine use of direct assays, (e.g., HIV antigen EIA or polymerase chain reaction for HIV RNA), to detect infection in health care workers is generally not recommended.  The reliability of HIV RNA testing to detect very early infection has not been determined and it is not FDA approved for this purpose.  The employee should be counseled on precautions to prevent secondary transmission of HIV.⁴

Testing to determine the HIV status of an exposure source should be performed as soon as possible.  The exposure source should receive pre and post-test counseling and give consent for HIV testing.  A Food and Drug Administration (FDA) approved rapid HIV-antibody test kit should be considered for use in this situation, particularly if testing by EIA cannot be completed in 24-48 hours.  Five rapid HIV tests have been approved by the United States Food and Drug Administration (FDA) for commercial use:  the Single Use Diagnostic System for HIV-1, (SUDS, Abbott Laboratories, Abbott Park, IL—no longer marketed), OraQuick® HIV-1 and the OraQuick® Advance HIV-1/HIV-2, (OraSure Technologies, Bethlehem, PA), Reveal™ G2 Rapid HIV-1 Antibody Test (MedMira Laboratories, Halifax, Nova Scotia), Uni-Gold™ Recombigen® HIV (Trinity Biotech plc - Wicklow, Ireland), and Multispot HIV-1/HIV-2  (Bio-Rad Laboratories, Hercules, CA).  Additional rapid HIV tests are under consideration by the FDA.   Repeatedly, reactive results by EIA or rapid HIV-antibody tests are considered to be highly suggestive of infection, whereas a negative result is an excellent indicator of the absence of HIV antibody.  Confirmation of a reactive result by Western Blot or immunofluorescent antibody is not necessary to make initial decisions about postexposure management but should be done to complete the testing process and before informing the source person.⁴

Postexposure Prophylaxis

In some instances, appropriate postexposure management includes antiretroviral agents for PEP.  A multinational study found that PEP with zidovudine (ZDV) decreased the risk of HIV infection, following percutaneous exposure by 81 percent.5  However, failures have occurred.  Data published in the 2001 recommendations indicated that in 16 cases ZDV was used as monotherapy, in two cases ZDV was used with didanosine (ddI), and in three cases > 3 drugs were used for PEP.  Resistance testing of virus from the source patient was done in seven instances and in four, the HIV infection transmitted was found to have decreased sensitivity to ZDV and/or other drugs used for PEP. Subsequently an additional report of an occupational HIV seroconversion despite combination HIV PEP has been published.⁴