Management after HIV Occupational Exposure
HIV exposure is divided into occupational exposure and non-occupational exposure. HIV occupational exposure refers to health care workers who are at risk of HIV infection due to contact with blood, tissue or other body fluids of HIV-infected persons during their occupational work.
12.1 Exposure risk assessment
12.1.1 Exposure Sources and Their Risk Levels Sources of exposure identified as infectious include blood, body fluids, semen, and vaginal secretions. Cerebrospinal fluid, joint fluid, pleural fluid, ascites, pericardial fluid, and amniotic fluid are also infectious, but their risk of causing infection is unclear. Feces, nasal secretions, saliva, sputum, sweat, tears, urine, and vomit are usually not considered infectious.
Grading of exposure source risk.
(1) Low infectious: low viral load levels, asymptomatic or high CD4 levels;
(2) High infectiousness: high viral load level, advanced AIDS, primary HIV infection, low CD4 level;
(3) Unknown exposure source status: unknown stage of disease in which the exposure source is located, whether the exposure source is HIV-infected, and unknown viral load carried by the contaminated instrument or object.
12.1.2 Exposure routes and their risk level
The routes of occupational exposure include: injury to the skin by the exposure source (stabbing or cutting, etc.) and contamination of incomplete skin or mucous membranes by the exposure source. If the source of exposure is the blood of an HIV-infected person, then the risk of HIV infection through skin injury exposure is 0.3% and through mucous membrane exposure is 0.09%. The risk of exposure through incomplete skin is unclear and is generally considered lower than that of mucous membrane exposure. High risk exposure factors include: high exposure, direct puncture of blood vessels by contaminated instruments, and deep tissue damage.
12.1.3 Grading of exposure
(1) Primary exposure: The exposure source is body fluid or medical devices or articles containing body fluid or blood; the exposure type is that the exposure source is contaminated with incomplete skin or mucous membrane, but the exposure amount is small and the exposure time is short.
(2) Secondary exposure: the exposure source is body fluids or medical devices or articles containing body fluids or blood; the exposure type is that the exposure source is contaminated with incomplete skin or mucous membranes, the exposure amount is large and the exposure time is long; or the exposure type is that the exposure source pierces or cuts the skin, but the degree of injury is lighter, and it is a superficial skin abrasion or needle puncture injury (not a large hollow needle or deep puncture needle).
(3) tertiary exposure: the exposure source is body fluid or medical devices or articles containing body fluid or blood; the exposure type is the exposure source stabbing or cutting the skin, but the degree of injury is more serious, for deep wounds or cutting objects with obvious visible blood.
12.2 Principles of treatment after HIV occupational exposure
(1) Wash the contaminated area with soap solution and running water;
(2) When contaminating mucous membranes such as the eye, apply a large amount of isotonic sodium chloride solution to repeatedly flush the mucous membrane;
(3) When a wound exists, squeeze the wound gently to squeeze out as much blood as possible from the injury, and then flush the wound with soap and running water;
(4) Disinfect and dress the wound locally with 75% alcohol or 0.5% iodophor.
12.3 Prophylactic anti-retroviral treatment after HIV exposure
12.3.1 Treatment regimen The recommended regimen is: TDF (tenofovir) + 3TC (lamivudine) + LPV/r (clotrimazole) or RAL (raltegravir).
12.3.2 Time to start treatment and duration of treatment
Prophylactic dosing should be administered in the shortest possible time (within 2 h if possible) after HIV exposure has occurred, preferably no more than 24 h, but even if more than 24 h, prophylactic dosing is recommended. The course of the dosing regimen is 28 d of continuous administration.
12.3.3 Indications for prophylaxis
When the HIV infection status is unknown or the source of exposure is unknown, prophylaxis is not usually administered after primary exposure.
Prophylaxis is not usually administered after secondary or tertiary exposures when the HIV infection status is unknown;
Prophylaxis is not usually administered when the source of exposure is unknown.
If the source of exposure is from a person at high risk for HIV, prophylaxis will be administered;
Prophylaxis is used when there is a risk of exposure to HIV-infected individuals.
12.4 HIV post-exposure monitoring
Test for HIV antibodies immediately, 4 weeks, 8 weeks, 12 weeks, and 6 months after HIV exposure has occurred. HIVP24 antigen and HIVRNA assays are generally not recommended.
12.5 Measures to prevent occupational exposure
(1) When performing treatment and nursing work that may come into contact with patients’ blood and body fluids, gloves must be worn and hands should be washed immediately after removing gloves after operation;
(2) In the process of diagnosis, treatment and nursing operations where splashing of blood and body fluids may occur, medical personnel should wear gloves and masks in addition to protective glasses; when there is a possibility of splashing of blood and body fluids over a large area and contamination of the operator’s body, they should also wear isolation clothing with impermeable properties;
(3) medical personnel in contact with the patient’s blood, body fluids in the diagnosis and care operations, if the skin of the hand there is a break, must wear double gloves;
(4) used sharps should be placed directly into a sharps box that cannot be pierced for safe disposal; vacuum blood collectors are recommended for blood draws and butterfly type blood collection needles should be applied; recapping of used disposable needles is prohibited; direct hand contact with used needles, blades and other sharps is prohibited.