1. 1 Occupational Exposure to HIV: Universal Precautions and PEP HAIVN Harvard Medical School AIDS Initiative in Vietnam

2. 2 Learning Objectives By the end of this session, participants should be able to: Explain the risk of HIV transmission after a single percutaneous exposure Demonstrate “scoop” technique of recapping needles List the steps involved in post-exposure prophylaxis (PEP) Describe PEP regimens in Vietnam

3. 3 HIV Transmission Through Occupational Exposure HIV transmission as a result of an occupational exposure is a rare event The majority of transmissions occur by exposure to HIV-infected blood The overall risk of HIV transmission depends on the route and severity of exposure

4. 4 Risk of HIV Transmission Blood exposures Risk of HIV Transmission Percutaneous needlesticks 0.3% (95% CI=0.2-0.5%) Mucous membranes 0.09% (95% CI 0.006% -0.5%) Intact Skin 0% (95% CI =0.0%-0.77%)

5. 5 Factors that Increase Risk of Transmission Factors that increase the risk of HIV transmission from a needle stick injury include exposure: through a visibly bloody device through a device used in an artery or vein via a deep injury from a source individual with more advanced HIV disease and a high HIV viral load

6. 6 Body Fluids and Risk for HIV Exposure Potential Risk Blood Cerebrospinal fluid (CSF) Pleural fluid Peritoneal fluid Any body fluid visibly contaminated with blood Negligible Risk* Urine Saliva Sputum Sweat Feces Vomitus * If not visibly contaminated with blood

7. 7 Questions: What does the term “Universal Precautions” mean? What are some examples of Universal Precautions?

8. 8 Universal Precautions (1) #1 Treat ALL blood and body fluids as if they are potentially infectious Follow Universal Precautions #2 Prevent needle sticks Safely manage sharps

9. 9 Universal Precautions (2) Following universal precautions means minimizing exposure to blood and body fluids through: Use of protective barriers Hand hygiene Safe injection practices Environmental control of blood and bodily fluids Sharps management

10. 10 1. Use of Protective Barriers ProcedureGlovesGownGoggles/Face Protection Giving an injectionNo Drawing bloodYesNo Irrigating a woundYes Performing an operationYes Guidelines on when to use protective barriers

11. 11 2. Hand Hygiene Prevents transmission of resistant organisms and infections Before patient care After blood/fluid contact, glove removal Methods: Hand washing Use hand sanitizer 60-95% ethyl or isopropyl alcohol http://www.cdc.gov/handhygiene

12. 12 3. Safe Injection Practices Use a sterile syringe and needle for every infection; use the correct intended medication Place needle in a puncture-proof container right after use Discard sharps waste appropriately

13. 13 4. Environmental Control of Blood and Body Fluids Spills in patient- care areas Clean visible blood/fluid with towel and discard Disinfect area 1:100 dilution (500 ppm) of hypochlorite Spills in laboratory areas Soak towel and blood/fluid spill in disinfectant before discarding Use more potent disinfectant 1:10 dilution (5000 ppm) of hypochlorite

14. 14 5. Sharps Management Injuries can occur whenever a sharp is exposed in the work environment, therefore it is important to: Organize work areas Have sharps containers nearby Avoid hand-passage of sharps Not recap needles, or: recap using a one-handed “scoop technique”

15. 15 “One-hand” Technique of Recapping Needles

16. 16 Post-Exposure Prophylaxis (PEP)

17. 17 Post-Exposure Prophylaxis (PEP) The use of therapeutic agents to prevent infection following exposure to a pathogen Types of occupational exposure include: Percutaneous injury (needle-stick or cut through the skin) Contact of mucous membrane or non-intact skin with bodily fluids that are potentially infectious

18. 18 PEP Rationale (1) Information about primary HIV infection indicates that systemic infection does not occur immediately There is a brief delay between exposure to virus and appearance of HIV in the blood During this “window of opportunity” antiretroviral treatment may prevent systemic infection

19. 19 PEP Rationale (2) Animal models show that following exposure to HIV: immune cells at site of HIV entry become infected within first 24 hours infected cells move to regional lymph nodes over next 24-48 hours within 5 days HIV is detectable in the blood ARVs given soon after exposure may prevent infection by blocking HIV replication in the few cells that are initially infected

20. 20 Efficacy of Antiretroviral Therapy Case Control study: 31 cases, 679 controls Cases acquired HIV following an occupational exposure 94% after needle stick (all hollow needles) 29% of cases received PEP (AZT) vs. 36% of controls Risk for HIV infection reduced by ~81% in HCWs receiving AZT Cardo D. NEJM 1997; 337:1485-90 Human data-CDC Needle Stick Surveillance Group

21. 21 Steps for Post-Exposure Management 1.Treat the exposure site 2.Report the exposure to the manager and complete the report form 3.Assess the risk of exposure 4.Determine the HIV status of the source of exposure 5.Determine the HIV status of the exposed person. 6.Counsel the exposed person. 7.Provide ARV prophylaxis (if indicated)

22. 22 National Guidelines on PEP Regimens (1) MedicationsIndications 2 drug regimen (basic regimen) AZT+ 3TC OR d4t + 3TC All exposures with risk 3 drug regimenAZT+ 3TC OR d4t + 3TC Plus: LPV/r In case source of exposure is known to have or suspected of ARV resistance

23. 23 National Guidelines on PEP Regimens (2) Dosages: AZT: 300mg BID PO 3TC: 150mg BID PO d4T: 30mg BID PO LPV/r: 400mg/100mg BID PO Nevirapine is not recommended due to fulminant liver failure in 4 American HCW taking it for PEP

24. 24 Suggested Post-Exposure Follow-up and Testing Test health care worker for HIV after 4-6 weeks, 3 months, and 6 months Conduct laboratory tests to monitor ARV side effects: CBC, ALT at baseline and after 4 weeks

25. 25 Risk of Seroconversion after Percutaneous Occupational Exposure VirusRangeMean HBV2 – 40 %30% HCV0 – 7 %3 % HIV0.2 – 0.5 %0.3% HBV is 100x more transmissible than HIV!

26. 26 Case Study, Part 1 A nurse sustains a percutaneous (needle stick) injury to her index finger The source patient is a woman who is at the OPC for her second visit and is known to be HIV-infected Her clinical status and CD4 count have not yet been established

27. 27 Case Study: Questions 1.What steps should be taken immediately? 2.You are responsible for counseling the nurse about PEP. What is the risk of acquiring HIV from a known HIV-infected source patient? What questions about the incident could you ask her to assess her risk?

28. 28 Case Study, Part 2 (1) On questioning, the nurse reports that she was wearing gloves when her finger was stuck by a 21-gauge phlebotomy needle that had just been used to draw blood from the vein of the source patient The needle was visibly bloody at the time she was stuck, and she is not sure if it was a ‘deep’ stick or not, but she says “it made my finger bleed” a lot.

29. 29 Case Study, Part 2 (2) She does not think she is pregnant She has never been tested for HIV but has no reason to believe that she might have HIV infection

30. 30 Case Study: Questions 3.What are your PEP recommendations for the nurse? 4.What additional testing and follow- up care should be performed for the exposed nurse? What additional advice and counseling would you offer?

31. 31 Key Points The term “Universal Precautions” means treating all blood and body fluids as if they are infectious Risk of transmission from a single occupational exposure for: HIV = 0.3% HBV = 30% PEP in Vietnam should follow MOH guidelines

32. 32 Thank you! Questions?