Chapter 2The Pre-Travel ConsultationSelf-Treatable Conditions
Occupational Exposure to HIV
RISK FOR HEALTH CARE WORKERS TRAVELING OUTSIDE THE UNITED STATES
The risk of occupational exposure to HIV is most closely related to the activities and duties of the health care worker, but the geographic location and practice setting can also affect the risk of exposure and the quality of postexposure care. Many factors can increase the risk of HIV infection due to occupational exposure in developing countries:
- Less stringent safety regulations or standards
- Unfamiliar practice conditions and equipment
- Limited availability of personal protective equipment or safety-engineered devices
- Increased prevalence of injection therapy and unsafe infection practices in many countries
- Challenging practice conditions that might result in barriers to Standard Precaution adherence (such as natural disasters or conflict zones)
- Performing unfamiliar medical procedures
- High prevalence of HIV infection (diagnosed and undiagnosed)
- Limited access to HIV treatment, resulting in high viral titers in source patients
- Limited resources for postexposure evaluation and treatment
Situations that put the health care worker at risk for HIV exposure can also expose the person to hepatitis B, hepatitis C, and other bloodborne pathogens that are endemic to the region visited.
HIV may be transmitted occupationally to health care workers who are exposed to blood and other potentially infectious bodily fluids via percutaneous injury or splash exposures to mucous membranes or nonintact skin. Unfamiliar practice environments can put the health care worker at increased risk of exposure. In addition to blood, cerebrospinal fluid, synovial fluid, pericardial fluid, pleural fluid, peritoneal fluid, amniotic fluid, semen, and vaginal secretions are considered potentially infectious. Saliva, urine, sputum, nasal secretions, tears, feces, vomitus, and sweat are not considered infectious for HIV unless they are visibly bloody. Typically, exposures occur as a result of percutaneous exposure to contaminated sharps, including needles, lancets, scalpels, and broken glass (from capillary or test tubes). Skin exposures to potentially infectious bodily fluids are only considered to be at risk for HIV infection if there is evidence of compromised skin integrity (for example, dermatitis, abrasion, or open wound).
The global number of HIV infections among health care workers attributable to sharps injuries has been estimated to be 1,000 cases (range, 200–5,000) per year. The risk of HIV transmission after a percutaneous exposure to HIV-infected blood is estimated to be approximately 0.3%, and after a mucous membrane exposure, approximately 0.09%. The risk of infection after percutaneous exposures is considered increased with exposure to larger blood volumes (visible blood on the injuring device, hollow-bore needles, deeper injuries, or procedures that involved direct cannulation of an artery or vein). Higher circulating viral load in the source patient is also thought to increase the risk of transmission, and evidence of this can include elevated plasma viral load (if the patient has been recently tested) or advanced stages of illness. The risk of HIV transmission after nonintact skin exposures has not been quantified but is thought to be less than the risk after mucous membrane exposure.
People working internationally who will be engaging in occupational health care activities should consistently follow standard precautions to reduce the risk of occupational exposure to HIV and other bloodborne pathogens. Standard precautions include the use of personal protective equipment such as gloves, gowns, aprons, surgical masks, and protective eyewear. Additional information about occupational health and safety standards for bloodborne pathogens can be found at http://www.osha.gov/SLTC/bloodbornepathogens/index.html.
In addition, clinicians working internationally should:
- Ensure they are properly trained for all anticipated procedures, considering the locally available equipment.
- Maintain strict safety standards, even if local standards are less stringent.
- Ensure they are immune to hepatitis B and up-to-date on routine vaccinations before departure.
- Consider bringing their own protective equipment or safety-engineered medical devices if they are unsure of availability at their destination.
- Assess the local availability of reliable (or consider bringing) postexposure prophylaxis (PEP) for HIV. The choice of PEP regimen should be based on the most recent guidelines for PEP and expert consultation (see Postexposure Prophylaxis, below).
Health care workers who may have been occupationally exposed to HIV should immediately perform the following steps:
- Wash the exposed area with soap and water thoroughly. If mucous membrane exposure has occurred, flush the area with copious amounts of water or saline.
- If possible, assess the HIV status of the source. Rapid HIV testing is preferred. If the source’s rapid HIV antibody test result is positive, assume that it is a true positive. Exposures originating from source patients who test HIV-negative are considered not to have HIV transmission risk, unless they have clinical evidence of primary HIV infection or HIV-related disease.
- Baseline HIV testing of the exposed health care worker should be performed at the time of the exposure. Before travel, health care workers should assess if reliable HIV testing is routinely available at the destination and, if it is not available, baseline testing before departure might be considered to provide supportive evidence in the event of a trip-related infection.
- Seek qualified medical evaluation as soon as possible to guide decisions on postexposure treatment and testing.
- Contact the National Clinicians’ Postexposure Prophylaxis Hotline (PEPline) toll-free at 888-448-4911 (24 hours per day, 7 days per week) for assistance in assessing risk and advice on managing occupational exposures to HIV and other bloodborne pathogens (http://www.nccc.ucsf.edu/about_nccc/pepline). If the toll-free number is not accessible when calling from another country, the main administrative line for the National HIV/AIDS Clinicians’ Consultation Center is 415-206-8700.
- Consider beginning PEP for HIV (see below).
A number of medication combinations are available for PEP. Since these regimens have known toxicities and may change with updated guidelines, refer to MMWR’s Updated US Public Health Service Guidelines for the Management of Occupational Exposures to HIV and Recommendations for Postexposure Prophylaxis (http://aidsinfo.nih.gov/contentfiles/HealthCareOccupExpoGL.pdf) and seek expert consultation (either with local experts or through the PEPline) for more information about PEP recommendations. Specific regimens should be determined by clinicians familiar with the medications and the health care worker’s medical history. Interactions exist between many antiretroviral medications and other medications. Expert consultants might also consider the possibility that the health care worker was exposed to a drug-resistant HIV strain (for example, if the source patient was treatment-experienced or the local prevalence of resistance is high).
If the exposed person chooses to initiate PEP, he or she must do so as soon as possible. PEP can be stopped if new information changes the assessment; however, waiting to start PEP until all information (HIV test results or the source patient’s medical history) is gathered can decrease its efficacy.
Consider other potential infectious disease exposures from the source material, including hepatitis B virus or hepatitis C virus, and manage as appropriate.
Postexposure Testing and Counseling
People with occupational exposure to HIV should receive standard HIV testing as soon as possible after exposure as a baseline, with follow-up testing at 6 weeks, 3 months, and 6 months. Extended HIV follow-up testing for up to 12 months is recommended for those who become infected with HCV after exposure to a source coinfected with HIV and HCV. Postexposure counseling and medical evaluation should be provided, whether or not the exposed person receives PEP. The US embassy or consulate can assist in finding quality medical care.
Exposed health care workers should be advised to use precautions (abstinence from sexual contact or strict use of barrier protection with sexual activities, avoidance of blood or tissue donations, breastfeeding, or pregnancy) to prevent secondary transmission, especially during the first 6–12 weeks after exposure. When PEP is initiated, exposed health care workers should be counseled regarding drug toxicities, drug interactions, and the importance of adherence to PEP regimens. Drug side effects have historically been a common reason for PEP discontinuation, so monitoring for symptoms and proper management is essential. The emotional consequences of occupational exposures can be substantial and might be further exacerbated by stressors already present in the work environment. Psychological counseling should be considered an essential part of the management of exposures.
- Bell DM. Occupational risk of human immunodeficiency virus infection in healthcare workers: an overview. Am J Med. 1997 May 19;102(5B):9–15.
- Canadian Centre for Occupation Health and Safety. Needlestick injuries. 2005 [cited 2012 May 28]. Available from: http://www.ccohs.ca/oshanswers/diseases/needlestick_injuries.html.
- CDC. NIOSH alert: preventing needlestick injuries in health care settings. Cincinnati: National Institute for Occupational Safety and Health; 1999 [cited 2012 May 28]. Available from: http://www.cdc.gov/niosh/docs/2000-108/.
- CDC. Notice to readers: updated information regarding antiretroviral agents used as HIV postexposure prophylaxis for occupational HIV exposure. MMWR Recomm Rep. 2007 Dec 14;56(49):1291–2.
- CDC. Updated US Public Health Service guidelines for the management of occupational exposures to HBV, HCV, and HIV and recommendations for postexposure prophylaxis. MMWR Recomm Rep. 2001 Jun 29;50(RR-11):1–52.
- Clinical and Laboratory Standards Institute. M29-A3 protection of laboratory workers from occupationally acquired infections: approved guideline. 3rd ed. 2005.
- Gerberding JL. Clinical practice. Occupational exposure to HIV in health care settings. N Engl J Med. 2003 Feb 27;348(9):826–33.
- Henderson DK. Management of needlestick injuries: a house officer who has a needlestick. JAMA. 2012 Jan 4;307(1):75–84.
- International Healthcare Worker Safety Center. EPINet: Exposure Prevention Information Network. Charlottesville, VA: University of Virginia; 2010 [cited 2012 May 28]. Available from: http://www.healthsystem.virginia.edu/pub/epinet.
- Mohan S, Sarfaty S, Hamer DH. Human immunodeficiency virus postexposure prophylaxis for medical trainees on international rotations. J Travel Med. 2010 Jul–Aug;17(4):264–8.
- National HIV/AIDS Clinicians’ Consultation Center. PEPline: the national clinicians’ post-exposure prophylaxis hotline. San Francisco: University of California, San Francisco; 2010 [cited 2012 May 28]. Available from: http://www.nccc.ucsf.edu/about_nccc/pepline/.
- Occupational Safety and Health Administration. Regulations (standards—29 CFR): bloodborne pathogens–1910.1030. Washington, DC: Occupational Safety and Health Administration [cited 2012 Sep 18]. Available from: http://www.osha.gov/pls/oshaweb/owadisp.show_document?p_table=STANDARDS&p_id=10051.
- Panlilio AL, Cardo DM, Grohskopf LA, Heneine W, Ross CS. Updated US Public Health Service guidelines for the management of occupational exposures to HIV and recommendations for postexposure prophylaxis. MMWR Recomm Rep. 2005 Sep 30;54(RR-9):1–17.
- Prüss-Üstün A, Rapiti E, Hutin Y. Estimation of the global burden of disease attributable to contaminated sharps injuries among health-care workers. Am J Ind Med. 2005 Dec;48(6):482–90.
- Sagoe-Moses C, Pearson RD, Perry J, Jagger J. Risks to health care workers in developing countries. N Engl J Med. 2001 Aug 16;345(7):538–41.
- Simonsen L, Kane A, Lloyd J, Zaffran M, Kane M. Unsafe injections in the developing world and transmission of bloodborne pathogens: a review. Bull World Health Organ. 1999;77(10):789–800.
- Uslan DZ, Virk A. Postexposure chemoprophylaxis for occupational exposure to human immunodeficiency virus in traveling health care workers. J Travel Med. 2005 Jan–Feb;12(1):14–8.
- Young TN, Arens FJ, Kennedy GE, Laurie JW, Rutherford G. Antiretroviral post-exposure prophylaxis (PEP) for occupational HIV exposure. Cochrane Database Syst Rev. 2007(1):CD002835.