Occupational Exposure to HIV: Universal Precautions and PEP

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

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

3. Overview of Occupational Exposure to HIV

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

5. Risk of HIV Transmission

6. 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

7. Factors Affecting Risk of HIV Transmission after Percutaneous Exposure

8. Occupational Exposure to HIVin Vietnam In 2000, at a hospital in HCMC, 330 /886 (38%) health workers experienced percutaneous exposure Sohn. 15th IAC: Abstract ThPeC7512.

9. Steps of Universal Precautions

10. Key Definitions: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

11. 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

12. 1. Use of Protective Barriers YES NO NO NO* NO NO YES YES YES YES YES YES

13. 2. Hand Hygiene • Prevents transmission of resistant organisms and infections • Before patient care • After blood/fluid contact, glove removal • Methods: • Hand washin: • Water+soap 10 seconds •  disposal towels • Use hand sanitizer • 60-95% ethyl or isopropyl alcohol http://www.cdc.gov/handhygiene

14. 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

15. 4. Environmental Control of Blood and Body Fluids

16. 5. Sharps Management • Organize work areas: • Have sharps containers nearby • Avoid hand-passage of sharps • Not recap needles, • or: recap using a one-handed “scoop technique”

17. “One-hand” Technique of Recapping Needles

18. Post-Exposure Prophylaxis (PEP)

19. Steps for Post-Exposure Management

20. Exposure to Bodily Fluid and/or Blood (1) If there was a percutaneous exposure: • Flush the wound with tap water • Let the wound bleed for a short time • Clean the wound with soap and water, treat the wound with an antiseptic solution, appropriately bandage the wound • Evaluate the need for PEP

21. Exposure to Bodily Fluid and/or Blood (2) If there was an eye exposure: • Wash the eye(s) with water or NaCl 0.9% solution continuously for 5 minutes • Do not rub your eyes • Evaluate the need for PEP

22. Exposure to Bodily Fluid and/or Blood (3) If there was a mouth and/or nose exposure: • Rinse with NaCl 0.9% solution • DO NOT BRUSH TEETH • Gargle with NaCl 0.9% solution for several times • Evaluate the need for PEP

23. Evaluating the need for PEP (1) • High Risk exposures: • Percutaneous wounds: • Deep with large bleeding, caused by large-bore needles. • Deep and large with bleeding, caused by scalpels or broken blood containing tubes • Large lesions on the skin or mucus membranes (e.g. eye, nose, mouth) exposed to patient's blood or body fluids

24. Evaluating the need for PEP (2) • Low Risk exposures: • Shallow wounds with minor bleeding or no bleeding • Intact mucosa exposed to patient’s blood or body fluids. • No Risk exposures: • Contact of normal skin with patient’s blood or body fluid.

25. PEP Rationale (1)

26. PEP Rationale (2) • ARVs given soon after exposure may prevent infection by: • blocking HIV replication in the few cells that are initially infected • if those cells die then the HIV infection will be eradicated before it starts

27. Post-Exposure Prophylaxys • Timing: as soon as possible • Do not delay to obtain additional information on the source patient • Best if given within hours following exposure • PEP started more than 72 hours after exposure is not likely to be effective. • Duration of prophylaxys: 4 week

28. National Guidelines on PEP Regimens

29. Suggested Post-Exposure Follow-up and Testing (1) 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

30. Suggested Post-Exposure Follow-up and Testing (2) Education and Counseling for HCW: • their risk of infection with HIV, HBV, HCV • symptoms suggestive of ARV toxicity and/or primary HIV infection • prevention of secondary transmission • Use condom with sex-partners

31. Determine the HIV Statusof the Source Patient (1) • Inform the source patient of the incident, counsel, & test (with consent) for HIV, HBV and HCV • Use a rapid HIV antibody testing if possible • Inquire about source patient’s risk factors for HIV and risk of being in the “window period” of an acute HIV infection. • If source patient found to be HIV negative: • Or if it is impossible to take the HIV test for the source patient

32. Determine the HIV Statusof the Source Patient (2) • If source patient is known to be HIV positive: • Define the patient’s clinical and immunological stage of HIV infection through: • a CD4 count • and/or TLC. • Obtain: • HIV viral load data, if available • Obtain information on current and previous antiretroviral therapy • Obtain HIV resistance testing results, if done

33. Prophylaxis with other Etiologies

34. Risk of Seroconversion afterPercutaneous Occupational Exposure HBV is 100x more transmissible than HIV!

35. HBV Prevention • The best way to prevent HBV infection is to vaccinate all health care workers: • 3 times at 0, 1 and 6 months • The Every health care workers working at health settings should take HBV Vaccination

36. TB prevention • TB is the most common OI in Vietnam • In the HIV OPC: • There is a significant percentage of patients will have TB or on TB treatment at any one time • The waiting area and exam rooms are an environment at high risk for TB transmission • Five steps to prevent transmission of TB in HIV care settings (WHO) should be practiced at any health settings

37. Key Points • Universal Precautions helped minimizing exposure to blood/bodily fluids • PEP should be taken as soon as possible, within 72 hours • AZT/d4T+ 3TC is the first line regime for PEP

38. Thank you! Questions?