Dr. Bill Valenti
Infection Control & HIV

The risk of HIV transmission in health care settings from patients to health care workers has been a concern since the early days of the HIV epidemic.

Although the risk of infection from patients to health care workers is low... 0.3%... health facilities still need policies and procedures to prevent and manage exposures.

Recently, the Centers for Disease Control reported that AZT prophylaxis reduces the risk of transmission to the health care worker by 79%. (see below)

Prevention Strategies: Policies, Procedures, Education

Prevention of Exposure

Of course, Universal Precautions are an important part of a strategy for HIV prevention in health care workers. Health care workers still need policies and procedures to manage needle stick accidents involving an HIV positive source patient.

Prevention of Infection After Exposure

Policies and procedures are required for post-exposure prophylaxis (PEP). These policies and procedures should include a mechanism for evaluating accidents (hollow bore needles present a risk, solid needles less so), testing the needle stick source patient for HIV, employee testing for HIV, AZT use for the employee if necessary, and employee follow-up.

Antiretroviral Prophylaxis

At the present time most HIV experts feel that not only is AZT warranted after HIV-positive needle sticks, but that an one or 2 additional anti-viral should be given as well. This is because of the high degree of AZT resistance in most strains of HIV as aresult of AZT monotherapy over the past several years. Note that recommendations for combination antiretroviral therapy after occupational exposure is 'official' now (see below).

Limitations/ Unresolved Issues

Despite the benefits of PEP (see below), some unresolved issues remain regarding management of occupational exposures to HIV.

• Post-exposure prophylaxis (PEP) is now a standard of care. Some organizations need to catch up to this standard.
• There are often delays in getting PEP to the health care worker. PEP should be started ASAP
• State laws regarding HIV testing of source patients are not consistent, but vary. As a result, HIV test results are not always available in the time required to make decisions regarding PEP.
• The benefits of PEP will result in some state legislatures taking a closer look at policies for informed consent for HIV testing in the case of occupational exposure.

Better Tests for the Future

The rapid HIV test is coming. AWARE ® is a 15-minute test that is performing well in pre-clinical trials.

CDC Web Site: takes you to all CDC publications The CDC homepage

Case Control Study of HIV Seroconversion in Health Care Workers
After Percutaneous Exposure to HIV-Infected Blood

Morbidity and Mortality Weekly Report 44, No. 50: 929-932, (December 22) 1995.

This file is an Adobe Acrobat file, if you need the Acrobat Reader you can download it from http://www.cdc.gov/epo/adobe/adobe.html

This was a retrospective case control study.

Factors associated with HIV transmission were:

• deep injury,
• device visibly contaminated with source patient's blood,
• needle being placed directly into vein or artery,
• patient had terminal illness.

CDC estimates that the overall risk of HIV transmission via needlestick is 0.3%. If AZT prophylaxis is used, the risk of acquiring HIV via needle stick was reduced by 79%.

1. Hopefully CDC's new recommendations for combination antiretroviral prophylaxis ASAP after the needle puncture will reduce this even further (see below).

New CDC Recommendations for Prophylaxis After Occupational Exposure to HIV

CDC now recommends a minimum of 2 and, in some cases, 3 drugs after know HIV positive needle stick accidents (AZT + 3TC (epivir). As a third drug, they recommend indinavir (crixivan), if AZT resistance is likely.

The links below contain more information on Management of occupational exposures

Morbidity and Mortality Weekly Report 45, No 22: 468-472, (June 7) 1996.

Community Health Network's Policy for Needle Stick Prophylaxis

Strategies to Reduce Occupational Exposure to HIV

Safety devices for needles have been shown to reduce the risk of occupational exposure. The CDC has reported that the use of safety devices for phlebotomy and for suturing in some surgical procedures were associated with a decrease in needle puncture injuries.

See Morbidity and Mortality Weekly Report 46, No 2: 21-29, (January 17) 1997.

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