PATHCHAT Edition No. 30
Please contact your local Ampath pathologist for more information.
Author: Dr. Marcelle Myburgh, MBChB, FC Path SA (Viro), MMed Path (Med Virol), Dip HIV Man (SA), MBA (GIBS)
Introduction
🔹 Why PEP is Critical:
- Healthcare workers (HCWs) are at risk of occupational exposure to HIV, hepatitis B virus (HBV), and hepatitis C virus (HCV) through:
- Needlestick injuries.
- Exposure to mucous membranes (e.g., eye splash).
- Contact with non-intact skin.
- PEP can reduce infection risk when administered promptly.
✅ Potentially Infectious Body Fluids:
- Blood, tissue, cerebrospinal fluid (CSF).
- Synovial, pleural, peritoneal, pericardial, amniotic fluid.
- Semen and vaginal secretions.
🚫 Non-Infectious Body Fluids (Unless Blood-Contaminated):
- Saliva, sweat, tears, urine, vomit, nasal secretions, stool.
- PEP is NOT required after exposure to these fluids unless visibly blood-contaminated.
Steps to Follow After Occupational Exposure
✅ Step 1: Immediate Wound Care
- Wash the affected area thoroughly with soap and water for at least 30 seconds.
- Do not squeeze or scrub the wound.
- For mucosal exposure (eye splash), irrigate with sterile water or saline.
✅ Step 2: Initiate HIV PEP Immediately
- Take the first dose of antiretrovirals (ARVs) immediately—do not wait for HIV test results.
✅ Step 3: Conduct Laboratory Tests on Source Patient & Injured HCW
- Obtain consent before testing.
🔹 Required Tests for the Source Patient:
- HIV (>18 months old): 4th generation HIV ELISA test.
- HIV (<18 months old): 4th generation HIV ELISA; if positive, also perform HIV PCR.
- If known HIV-positive on ARVs: Request HIV viral load test.
- HBV: Hepatitis B surface antigen (HBsAg).
- HCV: Hepatitis C antibody test (if positive, request HCV PCR).
🔹 Required Tests for the Injured HCW:
- HIV (baseline): 4th generation HIV ELISA test.
- HBV: Hepatitis B surface antibody (HBsAb).
- HCV: If the source is HCV-positive, perform baseline HCV antibody and ALT.
📌 If a rapid HIV test is performed on the source patient, confirm with a 4th generation HIV ELISA (p24 antigen + antibody test).
HIV Exposure: Result Interpretation & PEP Guidelines
✔ If the Source Patient is HIV-Negative & HCW is HIV-Negative:
- PEP is not required (unless acute HIV infection is suspected or the HCW opts for PEP).
✔ If the Source Patient is HIV-Positive & HCW is HIV-Negative:
- PEP is required for 28 days with three ARVs.
- If the source patient is on ARVs with an undetectable HIV viral load, PEP is still required.
- If the source patient is HIV-positive on ARVs with a detectable viral load, consult an expert for resistance-based PEP regimen adjustments.
✔ If the HCW is HIV-Positive at Baseline:
- No PEP required.
- Refer for HIV management and care.
Hepatitis B Exposure: Result Interpretation & PEP Guidelines
✔ If the Source Patient is HBsAg-Positive or Unknown & HCW is HBsAb >10 mIU/mL:
- No PEP required—HCW is immune.
✔ If the Source Patient is HBsAg-Positive or Unknown & HCW is HBsAb <10 mIU/mL:
- HCW is not immune; administer PEP.
✅ PEP for Non-Vaccinated or Partially Vaccinated HCWs:
- Hepatitis B immune globulin (HBIG) (500 IU) IM injection.
- Hepatitis B vaccine (Engerix-B®, H-B-Vax II®, Heberbiovac HB®).
- Complete HBV vaccination series (2nd dose at 1 month, 3rd dose at 2 months).
✅ PEP for HBV Vaccine Non-Responders:
- Two doses of HBIG (500 IU) IM injection, one month apart.
Hepatitis C Exposure: Result Interpretation & PEP Guidelines
✔ If the Source Patient is HCV Antibody-Negative:
- No action required.
✔ If the Source Patient is HCV Antibody-Positive (Regardless of PCR Result):
- No PEP is available.
- Monitor the injured HCW for HCV infection.
Step 5: Determine the PEP Regimen
🔹 First-Line HIV PEP Regimen:
- Truvada® (Tenofovir 300 mg/Emtricitabine 200 mg) – One tablet daily.
- Isentress® (Raltegravir 400 mg) – One tablet twice daily.
🔹 Second-Line HIV PEP Regimen (If First-Line Cannot Be Used):
- Combivir®/Duovir®/Lamzid® (Zidovudine 300 mg/Lamivudine 150 mg) – One tablet twice daily.
- Aluvia® (Lopinavir/Ritonavir 400/100 mg) – Two tablets twice daily.
✅ PEP Timing:
- Must be started ASAP, preferably within 1–2 hours.
- Effective up to 72 hours after exposure.
- Not recommended more than 7 days post-exposure.
Step 6: Follow-Up Testing for Injured HCW
✅ Testing Schedule After Known HIV, HBV, or HCV Exposure:
✔ At 6 Weeks:
- HIV: 4th generation HIV ELISA.
- HCV: ALT (if elevated, perform HCV PCR).
✔ At 3 Months:
- HIV: 4th generation HIV ELISA.
- HCV: ALT (if elevated, perform HCV PCR).
✔ At 6 Months:
- HIV: 4th generation HIV ELISA.
- HCV: ALT & HCV antibody test (if positive or ALT elevated, perform HCV PCR).
- HBV: HBsAg, HBcAb.
📌 Post-HBV vaccination: Check HBsAb 1–2 months after the last vaccine dose.
Key Takeaways for Clinicians
✅ Wash the wound immediately with soap and water—DO NOT DELAY.
✅ Start PEP immediately, ideally within 1–2 hours.
✅ HIV PEP must be continued for 28 days.
✅ HBV PEP is needed only for non-immune HCWs exposed to HBsAg-positive sources.
✅ There is no PEP for HCV; exposed individuals require follow-up monitoring.
✅ Follow-up HIV, HBV, and HCV testing is essential for all HCWs with exposure.