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129
HIV Curriculum for the Health Professional
How to Prevent Exposure health care worker only from getting blood on the skin
or in cuts. They do not protect against percutaneous
Exposure can be prevented through the use of standard
injuries. Percutaneous injuries most often occur when
precautions supplemented by simple infection control
the phlebotomist is inexperienced, in a hurry, or tired, or
measures (Figure 1). The most effective infection control
when the patient is uncooperative.
measure that health care workers can take is handwashing
with soap and water or alcohol-based disinfectant
Handling Potentially Infectious Items
products before and after all patient contact. For effective
Contaminated waste, such as disposable needles, dis
cleaning, the hands and forearms should be wet, and
posable syringes, and bloody bandages, should be
soap should be applied over all surfaces by using friction;
discarded appropriately. Needles should be discarded into
they should then be rinsed completely of soap by using
sealed puncture-resistant containers. Needles should
running water and dried with a paper towel. If paper
not be removed from the syringe and should never be
towels are not available, a cloth towel that is laundered
recapped, bent, or broken. If possible, needles with a
after each use can be used. Communal towels should
safety device should be used (retractable, self-blunting, or
never be used. If paper towels and cloth towels are not
shielded needles). Puncture-resistant containers should
available, allow the hands and forearms to air-dry. Wet
be kept within easy access of medical procedure areas,
hands should not be dried on clothes. Soap bars can be
thereby decreasing the handling of needles and sharps
used but should be cut into small pieces and put into soap
and reducing the risk of accidental injury.
dishes that allow water drainage. When running water is
not available, hands can be washed using soap and a clean
Reusable needles and syringes should be disinfected after
bowl of water and then rinsed using a clean water source
each use. The needles and syringes should be washed as
that is poured from a cup or bucket over the arms and
quickly as possible after use to prevent the formation
forearms. The water in the bowl should be discarded after
of clots, which can be difficult to remove. Two methods
each use, and the bowl should be washed. An alcohol-
exist for cleaning used needles and syringes. For the first
based hand rub can be prepared by combining 2 mL of
method, take the needle and syringe apart and clean
glycerin, propylene glycol, or sorbitol and 100 mL of 60%-
them with soap and water, paying special attention to the
90% alcohol. To use this hand rub, pour 3-5 mL into the
area around the fittings. Put the needle and syringe back
palm of one hand and vigorously rub it into all parts of
together. Fill the syringe with water through the needle,
both hands until dry.
shake it, and expel the water through the needle; repeat
these steps until the water that is expelled looks clear. For
Protective Barriers
the second method, fill a clean cup with undiluted bleach.
Examples of protective barriers include gloves, gowns,
Fill the syringe with the bleach through the needle, and
goggles, and masks. Using all these barriers in all situa
let the syringe and needle sit in the bleach-filled cup for
tions is impractical; one should use judgment as to when
30 seconds. After the 30 seconds has elapsed, expel the
they are needed. A procedure in which the eyes could be
bleach from the syringe through the needle, and rinse
splashed (such as removing a chest tube or preparing
the syringe with water at least three times to remove all
a body for embalming) calls for gloves, gown, and eye
bleach. The bleach in the cup should be discarded and not
protection. Gloves should be changed and hands should
reused.
be washed between patients. Gloves should never be
washed, because washing can cause breakdown of the
Bloody bandages should be discarded according to local
gloves. If barriers such as gloves and gowns are not
guidelines. All trash should be discarded into leakproof
available, other items may be used as a barrier. For
plastic bags. Heavily contaminated trash containing wet,
example, a clean, thick cloth can be used to put pressure
bloody bandages or other infectious fluids should be put
on a bleeding wound. Precautions should always be taken
into a separate plastic bag before being put into a general
to avoid contact of blood with the skin, eyes, and mucous
trash container. Soiled linens and clothes do not need to
membranes. Hands should be washed with soap and
be separated from other linen or laundry before washing.
water after all direct patient contacts.
Laundry workers should always wear gloves when hand
ling dirty laundry. Spills of blood or other infectious fluids
If a phlebotomy is to be performed, using gloves is the
should be cleaned while wearing gloves, using a solution
only necessary barrier. Remember that gloves protect a
130
Prevention of Sexual Transmission of HIV/AIDS
of one part household bleach to 10 parts water. If gloves the exposure, and details about the exposure source.
are not available, use some type of barrier between the The wound or skin site should be washed immediately
hands and the spill, such as paper towels. Hands should with soap and water, and exposed mucous membranes
be washed with soap and water immediately after the should be flushed with water. The use of caustic agents
cleanup. or antiseptics or disinfectants at the wound site is not
recommended. Squeezing the site to encourage bleeding
HIV Exposure in the Health Care does not decrease the risk seem of transmission. The
Setting source patient and the health care worker should then be
tested for HIV and for hepatitis B and C, and the need for
Background
HIV PEP should be assessed.
Health care workers are often at risk of exposure to HIV
and other infectious diseases because of the environment
Management of Exposure
in which they work. Following standard precautions
The exposure should be assessed for potential to transmit
easily minimizes this risk. All health care settings should
HIV on the basis of the type of fluid, the route of the
have a written plan of action that conforms to national
exposure, and the severity of the exposure (Appendix 1).
guidelines for handling HIV exposures. All health care
Exposure to fluids containing visible blood or other
workers should be familiar with this plan of action
fluids that transmit or contain HIV should be considered
and should know where to find a copy of it. The plan
sources of possible infection. Evaluation of human
should include instructions for reporting the exposure,
bites should take into account the HIV status of both
instructions for managing the exposure; information on
the person who was bitten and the biter. Transmission
testing and counseling; and information on postexposure
through a bite is rare, but if a bite draws blood, PEP may
prophylaxis (PEP; treatment to try to prevent the acquisi
be considered.
tion of HIV infection), follow-up, and monitoring.
The person who is the source of the exposure should be
Data on time to HIV seroconversion are limited because
evaluated for the presence of HIV (Appendix 2). The
of the low prevalence of infection after work-related
evaluation should include information on risk factors
exposure among health care workers. Among those health
for HIV, questions about HIV-related symptoms, and
care workers who do seroconvert, available data indicate
HIV testing. If the source is known to be HIV infected,
that 81% will seroconvert at a mean interval of 65 days
information about viral load and CD4+ count should
after exposure and an estimated 95% will seroconvert by
be obtained. This information may be used in the
6 months after initial exposure.
consideration of PEP, but PEP should not be delayed
pending these results. Changes to PEP can always be
In theory, there is a short time between HIV exposure
made after treatment has begun. If the source of the
and infection during which transmission of HIV may be
exposure is unknown, an epidemiologic evaluation should
prevented. In the first 24 hours after exposure, HIV attacks
be performed. An epidemiologic evaluation includes
dendritic-like cells in the mucous membranes and skin.
assessing the geographic area in which the exposure
Within 5 days after exposure, these infected cells then
occurred for its prevalence of HIV. The geographic area
make their way to the lymph nodes and eventually to the
would include the country, the province, the city, the
peripheral blood, where viral replication becomes rapid.
village, the hospital, and the hospital ward. If HIV exists
According to this theory of pathogenesis, preventing HIV
at a high rate in any of these areas, the exposure should
infection should be possible if antiretrovirals are used
be considered high risk and PEP should be started.
before 24-48 hours after exposure. Animal studies have
Testing of needles and other sharp instruments for
indicated that PEP is not effective when it is received
the presence of HIV is not recommended because the
morelater than 72 hours after the exposure.
reliability of this type of testing is unknown.
Reporting Exposures
Occupational exposure to HIV among pediatricians was
All exposures to potentially infectious fluids should be
previously underestimated. New studies suggest that
reported so that appropriate action can be taken. The
pediatricians represent a high-risk group.
report should include the date and time of the exposure,
details of the procedure being performed, details of
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HIV Curriculum for the Health Professional
132
Prevention of Sexual Transmission of HIV/AIDS
resistance may be an issue, a protease inhibitor should be pharyngitis, and lymphadenopathy) should be tested
added. for HIV, even if more than 6 months has elapsed since
the known exposure. HIV antibody tests using enzyme
Pregnant women should be informed of the possible immunoassay should be used to test for seroconversion,
risks of receiving and of not receiving PEP. Education and Western blot can confirm any positive results. Direct
should include information on the limited data available virus assays such as cultures or PCR are not recommended
about the effects of many of these medications on the in cases of exposed health care workers because few
fetus. Efavirenz is teratogenic (causing birth defects) actually acquire the virus this way and direct virus assays
in primates and thus is not recommended for use in are expensive.
pregnant women. Indinavir can cause hyperbilirubinemia
and renal stones and should be used cautiously in If PEP is used in health care workers, it is important to
pregnant women. Reports of the development of fatal monitor the individual with laboratory tests for drug-
and nonfatal lactic acidosis with concomitant use of d4T associated toxic effects. Baseline screening including a
and ddI during pregnancy suggest that this combination complete blood count and liver and renal function tests
should be used only when the benefits are believed to should be performed prior to starting therapy and again
outweigh the risks. Studies with women who received 2 weeks after the initiation of therapy. Serum glucose
ZDV after 14 weeks of gestation suggest that the drug is should be tested in individuals receiving a protease
safe. The decrease in risk of transmission of HIV to the inhibitor. Some patients cannot complete the course of
fetus outweighs any risk associated with receipt of ZDV. medication required for PEP because of medication side
effects, including nausea and diarrhea. Administration of
The education and information provided to the pregnant antiemetics and antidiarrheals often helps to prevent or
woman should also include that the fact that there is an relieve these symptoms.
increased risk of infecting the baby via breast-feeding if
seroconversion occurs during breastfeeding. If possible, Counseling
the woman should exclusively bottle -feed her baby, and if Health care workers who are exposed to HIV need to
it is not possible she should exclusively breast-feed. be counseled about the effect that the exposure will
have on their lives. This includes the possibility of HIV
PEP should be started as soon as possible. If the HIV seroconversion, the importance of starting prophylaxis,
status of the source is not known, the basic regimen may and behavioral changes that will have to be made for at
be started based on the source and geographic prevalence
of HIV. The regimen can be stopped when it is proven that
APPENDIX 1. Factors to be assessed after possible
the source is not HIV infected. Some animal studies have
occupational exposure to HIV1
shown that PEP is not effective when started more than
Type of Exposure
24-36 hours after exposure. However, in current practice,
PEP is begun as late as 72 hours after exposure when the Percutaneous injury
risk of transmission is high. Once PEP is started, it should Mucous-membrane exposure
be given for at least 4 weeks. Antiretroviral adherence Non-intact skin exposure
Bites resulting in blood exposure to either person involved
rates of at least 95% or more are required to achieve
the maximum benefits from treatment regimen. It is Type and Amount of Fluid/Tissue
important to provide education, counseling, and support Blood
related to adherence. Fluids containing blood
Potentially infectious fluid or tissue (semen, vaginal
secretions, and cerebrospinal, synovial, pleural, peritoneal,
Follow-Up and Monitoring pericardial, and amniotic fluids)
HIV counseling, medical follow-up, and HIV testing after Direct contact with concentrated virus
exposure should be carried out for at least 6 months after Infectious Status of Source
exposure. Recommended testing intervals are 6 weeks,
Presence of HIV antibody
12 weeks, and 6 months after exposure. Seroconversion
after 6 months is rare. However, any health care worker Susceptibility of Exposed Person
who experiences acute retroviral syndrome (fever, rash, HIV immune status
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HIV Curriculum for the Health Professional
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Prevention of Sexual Transmission of HIV/AIDS
APPENDIX 5. Recommended HIV post-exposure prophylaxis for mucous-membrane exposures and non-
intact skin* exposures1
HIV Infection Status of Source
Exposure HIV-Positive HIV-Positive HIV Status of Source Unknown HIV-
Type Class 1* Class 2* Is Unknown+ Source Negative
Small Volume Consider basic Basic 2-drug PEP Generally, no PEP Generally, no PEP No PEP
2-drug PEP** warranted; however, warranted; however,
consider basic 2-drug consider basic 2-drug
PEP** if source has HIV PEP** in settings where
risk factors++ exposure to HIVinfected
persons is likely
Large Volume Basic 2-drug Expanded 3-drug Generally, no PEP Generally, no PEP No PEP
PEP PEP warranted; however, warranted; however,
consider basic 2-drug consider basic 2-drug
PEP** if source has HIV PEP** in settings where
risk factors++ exposure to HIVinfected
persons is likely
* For skin exposures, follow-up is indicated only if there is evidence of compromised skin integrity (e.g. dermatitis, abrasion, or open wound).
HIV-Positive Class 1: Asymptomatic HIV infection or known low viral load (e.g. <1,500 copies/ml). HIV-Positive Class 2: Symptomatic HIV infection,
AIDS, acute seroconversion, or known high viral load. If drug resistance is a concern, obtain expert consultation. Initiation of PEP should not be delayed
pending expert consultation, and, because expert consultation alone cannot substitute for face-to-face counseling, resources should be available to provide
immediate evaluation and follow-up care for all exposures.
+ Source is of unknown HIV status (e.g. deceased source person with no samples available for HIV testing).
Source is unknown (e.g. splash from inappropriately disposed blood).
Small volume (i.e. a few drops)
** The designation consider PEP indicates that PEP is optional and should be based on an individualized decision by the exposed person and the treating
clinician.
++ If PEP is offered and taken and the source is later determined to be HIV-negative, PEP should be discontinued.
Gloves should be worn for most procedures (e.g., 7. Perform baseline HIV testing for the exposed health
venipuncture). care worker
Goggles should be worn if there is a risk of 8. Evaluate the risks and benefits of receiving post
splashing with body fluids. exposure prophylaxis (PEP).
Gown should be worn. 9. Initiate PEP if warranted within in 72 hours of the
Mask should be worn to prevent contamination of exposurethe health care worker needs to be an
sterile sites with respiratory secretions. active participant in the decision of whether to start
PEP.
4. Environmental cleaning. 10. Repeat the HIV testing for at least 6 months after
Needles/sharps disposal: needles should never the exposure, usually at the intervals of 6 weeks, 12
be recapped, bent, or broken; they should weeks, and 6 months.
be discarded into sealed, puncture-resistant
containers.
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