By Gary Evans
Worst-case scenario: a healthcare worker experiences a needlestick and is exposed to the blood of an HIV-positive patient. There are a lot of variables, including the severity of the needlestick and the HIV viral titer of the patient, but overall, there is a greater than a 99% chance that seroconversion will not occur.
All things considered, there is a less than 1% chance that the healthcare worker will acquire HIV from a known positive needlestick. Despite those odds, many healthcare workers do not feel particularly lucky right after a needlestick.
At a medical conference, New Zealand needlestick researcher Terry Grimmond, FASM, BAgrSc, GrDpAdEd, described this reaction in a healthcare worker who experienced a needlestick.
“You can’t put a cost on the emotional impact of sharps injuries,” Grimmond said. “I will never forget a healthcare worker who came to me just suffering after she sustained a deep, penetrating injury with a bloody needle. She sobbed and sobbed. She had just been married. She and her husband were trying to have children, and she kept on saying to me, ‘They tell me we’ve got to stop trying until I know my results. How am I going to tell my husband?’”1
Perhaps unsurprisingly, these stats may not be all that reassuring to a healthcare worker in the pain and uncertainty of the moment. A call to the National Clinician Consultation Center (NCCC) Post-Exposure Prophylaxis (PEP) line could be in order.2
“If PEP is going to be started, it has to start within 72 hours,” noted Erin Lutes, MS, RN, PHN, CNS, a clinical nurse specialist at the NCCC at the University of California, San Francisco. “However, it should be started ASAP after an exposure because it’s clear from animal exposure studies that the efficacy of the medication decreases from the time of the exposure.”
Lutes spoke along with NCCC colleague Rebecca Martinez, MS, RN FNP-C, at a recent webinar held by the Association of Occupational Health Professionals in Healthcare.3
Based on the information provided by the NCCC experts, our hypothetical case from an HIV-positive source patient — which is drawn intentionally in broad strokes to illustrate the larger points in this process — likely would call for a rapid HIV test for both the patient and the exposed worker.
“The rationale of testing the exposed person at baseline is to rule out pre-existing infection of HIV, hepatitis B or C,” Lutes explained. “It will not tell us [with certainty] whether someone has [seroconverted] already from the exposure that they’ve just sustained. If the source person is known to be a person living with HIV, we also want a quantitative HIV viral load. This is really important because we know that a higher HIV viral load constitutes a higher risk of transmission of HIV.”
Hepatitis C Cure
The exposed worker and patient also should be tested for hepatitis C virus (HCV) antibodies. If positive, they should follow up with HCV RNA testing. There is no vaccine for HCV, but it is treatable.
“We have a cure for hepatitis C, and unlike HIV — which is a chronic, lifelong condition — once we assess that somebody has either acute or chronic hep C, we can refer them to treatment immediately,” Martinez said.
There is a vaccine for hepatitis B virus (HBV). Healthcare workers are required by federal occupational health laws to take the vaccine. There also are PEP regimens for HBV. The HBV immunization and titer history of the exposed person should be determined. In addition to HIV testing, HBV and HCV testing should be conducted on the source patient. If they come back negative, investigation of the HBV and HCV status of the exposed worker can stop.
As this information is accumulated, a shared decision may be reached to administer PEP, which is standard in a three-drug regimen with some variation possible on the medication.
“I get a fair amount of calls from providers who are under the impression that these medications are extremely toxic,” Lutes said. “It’s not to say that there aren’t any toxicities. That wouldn’t be accurate. There’s a small, real risk of renal and liver toxicities, but patients are monitored while they’re on these medications. They are on these medications for a very short amount of time — 28 days. I’ve also gotten calls where folks think PEP is either six months or a year — or even three days. Others think these medications are completely contraindicated in pregnancy, which is not accurate. These medications can be taken in pregnancy.”
Again, PEP consists of three medications, with one pill containing two of them. “The first two come in one pill, and that’s tenofovir plus emtricitabine,” Lutes said. “It would be those two medications in one pill, one tab daily for 28 days. Plus, either raltegravir, at 400 mg twice a day for 28 days, or you could do dolutegravir, at 50 mg one tab daily for 28 days.”
In general, these PEP drugs inhibit HIV viral pathways, cell penetration, and circulating virus overall. “Most folks tolerate these medications OK,” Lutes said. “The most common side effects are GI upset like nausea, very rarely vomiting, diarrhea, headache, insomnia, fatigue, and bloating.”
The medications can be taken with or without food, but antacids containing magnesium or aluminum should be avoided.
A common question from healthcare workers is: What if a source patient is in the so-called HIV “window period” during which detectable HIV antibodies have not formed but the patient could still be infective?
“To date, no such instances of occupational transmission have been detected in the United States, hence investigation of whether or not a source person might be in the window period is unnecessary for determining whether HIV PEP is indicated unless acute retroviral syndrome is clinically suspected,” Lutes said. Acute retroviral syndrome refers to flu-like symptoms that can occur two to four weeks after HIV infection.
There is good news on another common question: What is the risk of contracting a bloodborne virus from a used needle in a sharps box?
“One statistic that I find very reassuring is that HIV cannot replicate outside of the human host, therefore infectivity is greatly reduced every hour outside of the body,” Lutes explained. “In fact, every nine hours outside of the human body, infectivity is reduced by an entire 90%. We get a lot of calls about found needles and sharps containers, trash cans, etc. There’s actually zero documented cases of HIV transmission from found needles outside of the healthcare setting, and only two cases of HIV transmission from found needles within the healthcare setting ever documented.”
Lutes presented a little myth-busting in addition to common questions. Even after decades, there is a lot of misunderstanding about bloodborne pathogen exposures.
“The first criterion is that there needs to be a body fluid that is considered potentially infectious. That would include blood, vaginal, seminal or rectal fluids, CSF [cerebrospinal fluid], synovial, pleural, peritoneal, pericardial, amniotic fluid, pus, and breast milk — with the caveat that breast milk is only considered potentially infectious for hepatitis B and C if it is visibly bloody,” Lutes said. “The following body fluids are only considered infectious if they are visibly bloody: saliva, sputum, urine, feces, sweat, tears, and nasal secretions.”
For an exposure to occur, one of these potentially infectious fluids must enter someone’s body through a “portal of entry.” Portals of entry include a percutaneous injury like a needlestick; a mucosal exposure, like a splash to the eyes or nose; and a cutaneous exposure, which would be a splash to an open wound or break in the skin. A splash of blood on intact skin is not considered an exposure. However, if the area of skin exposed is chapped, abraded, or has eczema, an evaluation should be conducted.
“Bloodborne pathogens are not spread through sharing utensils, cups, kissing, holding hands, hugging, sweat, non-visibly bloody tears, coughing, sneezing, or sharing a toilet,” Lutes said.
With so many variables and conditions to consider, a call to the NCCC PEP line can require some detective work. For example, the speakers described a call from a dental office that asked about administering HIV PEP. A dental assistant felt “pressure” on a middle finger from a dental burr. The patient was a 56-year-old woman who said she was in a monogamous relationship and denied any history of injecting drugs.
The first thing to determine is whether an exposure occurred, which raised these questions for the hotline consultants:
- Was there a break in the glove?
- Was there a break in the skin?
- Was there visible blood in the patient’s mouth at any point in the procedure?
“If you determine that there was no exposure, then there’s nothing to do from a bloodborne pathogen perspective,” Lutes noted. “There’s no HIV, hepatitis B, post-exposure prophylaxis. There’s no baseline, no follow-up testing. The case is closed. However, for this case, it does seem like we need a little bit more information about whether or not this was an exposure.”
The dental burr was not visibly bloody at the time of the injury, so it is not clear from the initial information if an exposure occurred.
“Was there a portal of entry?” Lutes asked. “We asked the clinician to clarify — was there a break in the glove, was there a break in the skin? There was no break in the glove — she actually filled it with water to check. They also used a magnifier to examine her finger, and no wound was observed. Because there was no portal of entry, this cannot be an exposure, so this case is closed.”
Hypothetically, if there had been a break in the dental worker’s skin, the next question would have been: Was there any visible blood in the mouth of the patient at any time during the procedure?
“This is really important for dental procedures,” Lutes said. “If they said ‘no,’ then we would close the case for HIV, as non-visibly bloody saliva does not transmit HIV.”
However, the risk of HBV and HCV transmission from non-visibly bloody saliva is considered negligible but possible. Had there been an exposure to the dental worker, the question of HBV and HCV transmission would have to be determined in the absence of clear data. The Centers for Disease Control and Prevention makes no specific recommendations regarding follow-up.
“The PEP line does not routinely recommend follow-up testing in these scenarios, but we don’t take the position that such testing should not occur,” Lutes said. “The advantages of follow-up testing include that it could provide reassurance for the exposed person. We’re not legal experts, of course, but it would be documentation of lack of transmission for liability.”
The disadvantages of follow-up testing in this hypothetical case include that some confusion and stress likely would spring from no established path to resolution.
“This has a very negligible risk, yet there’s going to be months of follow-up testing, addressing potential false-positive results, possibly increasing work-related stress, creating a period of modified sexual practices or interactions in family planning in certain instances, and increasing overall healthcare cost and time away from work,” Lutes said.
REFERENCES
- Evans G. Sharps injuries: Emotional, statistical challenges. Hospital Employee Health. Jan. 1, 2020. https://www.reliasmedia.com/ar...
- National Clinician Consultation Center. PEP: Post-exposure prophylaxis. 2024. https://nccc.ucsf.edu/clinicia...
- Association of Occupational Health Professionals in Healthcare. Making blood borne pathogen exposure management easy: Practical advice from the NCCC PEPLine. Jan. 25, 2024. https://aohp.org/aohp/EDUCATIO...
Worst-case scenario: a healthcare worker experiences a needlestick and is exposed to the blood of an HIV-positive patient. All things considered, there is a less than 1% chance that the healthcare worker will acquire HIV from a known positive needlestick. Despite those odds, many healthcare workers do not feel particularly lucky right after a needlestick.
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