MANAJEMEN TERKINI

HIV NEEDLE STICK INJURY

Prof. NASRONUDIN, MD., PhD, Internist., Infectiologist, FINASIM
Tropical and Infectious Disease Division, Department of Internal Medicine,
Medical Faculty – UNAIR Hospital – Dr Soetomo Hospital
 INTRODUCTION
AS A HEALTHCARE WORKER, YOU ARE EXPOSED TO MANY RISKS,
INCLUDING THE POSSIBILITY OF NEEDLE STICK INJURIES

THIS TYPE OF INJURY OCCURS WHEN A NEEDLE OR OTHER SHARP

OBJECT PUNCTURES THE SKIN AND EXPOSES YOU TO BLOOD OR OTHER
INFECTIOUS MATERIALS

NEEDLE STICK INJURIES POSE A SIGNIFICANT RISK FOR HIV

TRANSMISSION, AND IT IS VITAL TO TAKE THE APPROPRIATE
MEASURES TO PREVENT INFECTION AND SEEK TIMELY CARE IF
NECESSARY
 HEALTHCARE WORKERS /HEALTHCARE PERSONEL
EXPOSURE – NEEDLE STICK INJURY

AN EXPOSURE THAT MIGHT PLACE HCP AT RISK FOR HBV, HCV, OR HIV INFECTION

• A PER-CUTANEOUS INJURY (E.G., A NEEDLE-STICK OR CUT WITH A SHARP OBJECT

• CONTACT OF MUCOUS MEMBRANE OR NON-INTACT SKIN )E.G., EXPOSED SKIN

THAT IS CHAPPED, ABRADED, OR AFFLICTED WITH DERMATITIS

WORLDWIDE, THE 1st DOCUMENTED CASE OF HIV TRANSMISSION FORM PATIENT TO

HCW WAS A UK NURSE WHO SUSTAINED A NEEDLE-STICK INJURY WHILS OBTAINING
BLOOD FROM THE ARTERIAL LINE OF AN AFRICAN PATIENT WITH AIDS
Source : Wyżgowski P, Rosiek A, Grzela T, Leksowski K. Occupational HIV risk for health care workers: risk factor and the risk of infection in the course of professional activities. Ther Clin Risk Manag. 2016
Jun 14;12:989-94. doi: 10.2147/TCRM.S104942. PMID: 27366077; PMCID: PMC4913970.
UNDERSTANDING THE RISK OF HIV NEEDLE STICK INJURIES
HEALTHCARE WORKERS WHO HANDLE NEEDLES AND OTHER
SHARPS ARE AT HIGH RISK FOR NEEDLE STICK INJURIES

THE RISK OF CONTRACTING HIV THROUGH A NEEDLE STICK

INJURY IS RELATIVELY LOW, BUT IT IS STILL A SIGNIFICANT
CONCERN
ACCORDING TO THE CENTERS FOR DISEASE CONTROL AND
PREVENTION (CDC), THE AVERAGE RISK OF HIV TRANSMISSION
AFTER A NEEDLE STICK EXPOSURE IS APPROXIMATELY 0.3%
NEEDLE STICK INJURIES CAN ALSO RESULT IN THE
TRANSMISSION OF OTHER BLOODBORNE PATHOGENS, SUCH
AS HEPATITIS B AND C
Sorce : Alfulayw KH, Al-Otaibi ST, Alqahtani HA. Factors associated with needlestick injuries among healthcare workers: implications for prevention. BMC Health Serv Res. 2021 Oct 9;21(1):1074. doi:
10.1186/s12913-021-07110-y. PMID: 34627244; PMCID: PMC8502299.
 NEEDLE-STICK INJURIES
• MOST FREQUENTLY DURING AND AFTER AN INJECTION

• RECAPPING, CARRYING NEEDLES AND SYRINGES

• PATIENT MOVEMENT (CHILDREN)

• INNAPROPRIATE DISPOSAL
Source : Jahangiri M, Rostamabadi A, Hoboubi N, Tadayon N, Soleimani A. Needle Stick Injuries and their Related Safety Measures among Nurses in a University Hospital, Shiraz, Iran. Saf Health Work. 2016;7(1):72-77. doi:10.1016/j.shaw.2015.07.006
ESTIMATED
RISK OF
INFECTION
FOLLOWING
NSI
Source :
1. Lyall KND. Needle Stick and Post Exposure Prophylaxis. 2015.Clinical Microbiologist at Lyall Clinical and Endocrinology Lab, Ludhiana
2. Afridi AA, Kumar A, Sayani R. Needle stick injuries--risk and preventive factors: a study among health care workers in tertiary care hospitals in Pakistan. Glob J Health Sci. 2013;5(4):85-92. Published
2013 Apr 14. doi:10.5539/gjhs.v5n4p85
DETERMINANTS OF RISK OF TRANSMISSION
PREVALENCE OF VIRUS IN PATIENT POPULATION

TYPE OF EXPOSURE – PERCUTANEOUS/MUCO-CUTANEOUS

EXTENT OF INJURY – SUPERFICIAL/DEEP

TYPE OF DEVICE – HOLLOW BORE/SOLID NEEDLE

PLASMA VIRAEMIA OF SOURCE

IMMUNE STATUS OF HCW

IMMEDIATE AFTERCARE AND USE OF PEP

 AT RISK EXPOSURE
PRECUTANEOUS
SPLASH RISK OF MORE WITH
er
INJURY

HOLLOW NEEDLE >

NON INTACT SKIN LARGER VOLUME
SOLID SHARP

VISIBLE BLOOD MUCOUS MEMBRANE SEVERE INJURY

DEEP INJURY

DEVICE IN PTS ARTERY

OR VEIN Source : Lyall KND. Needle Stick and Post Exposure Prophylaxis. 2015.Clinical Microbiologist at Lyall Clinical and Endocrinology Lab, Ludhiana
 PREVENT NEEDLE-STICK
• ORGANIZING PHYSICAL LAYOUT OF INJECTION WORK AREA

• MINIMIZE HANDLING OF INJECTION EQUIPMENT

• DO NOT CARRY, DO NOT RECAP OR BEND

• CLEANING THE INJECTION ENVIRONTMENT – BEFORE AND AFTER

INJECTION
• FOLLOWING PROPER DISPOSAL PROCEDURES FOR SHARPS TO PREVENT
INJURIES TO PUBLIC
• TRAINING ON HOW TO HANDLE SHARPS SAFELY AND WHAT TO DO IN
THE EVENT OF A NEEDLE STICK INJURY
Source : Allo. Treating HIV Needle Stick Injuries: The Best Practices for Prevention and Care. Diakses pada https://www.allohealth.care/healthfeed/stds/hiv-needle-stick-injury-treatment. 2023
CREATING SAFE WORK ENVIRONMENTS TO
REDUCE THE RISK OF NEEDLE STICK INJURIES
• THE BEST WAY TO PREVENT NEEDLE STICK INJURIES IS
TO CREATE A SAFE WORK ENVIRONMENT.

• THIS CAN INVOLVE PROVIDING APPROPRIATE TRAINING

AND EDUCATION TO HEALTHCARE WORKERS ON THE
SAFE HANDLING AND DISPOSAL OF SHARPS, AS WELL AS
THE USE OF APPROPRIATE PERSONAL PROTECTIVE
EQUIPMENT (PPE).
Source : Cheetham S, Ngo HT, Liira J, Liira H. Education and training for preventing sharps injuries and splash exposures in healthcare workers. Cochrane Database Syst Rev. 2021;4(4):CD012060. Published 2021 Apr 14. doi:10.1002/14651858.CD012060.pub2
STANDARD PRECAUTIONS

BARRIERS
HAND WASHING
PROTECTION

SAFE HANDLING OF
SHARP ITEMS,
SAFE TECHNIQUES
SPECIMENS, SPILL OF
BLOOD / BODY FLUID

USE OF
DISPOSABLE/STERILE
ITEMS

ONE-HANDED SCOOP
TECHNIQUE
STEPS TO TAKE IMMEDIATELY AFTER A NEEDLE STICK INJURY
• STOP THE PROCEDURE IMMEDIATELY

• IMMEDIATELY CLEAN EXPOSURE SITE – THE MOST IMPORTAND PART OF PEP

• SKIN WOUNDS SHOULD BE WASHED WITH SOAP AND RUNNING WATER

• CAUSTIC AGENTS (BLEACH) MAY DO MORE HARM THAN GOOD

• WASH THE AFFECTED AREA THOROUGHLY WITH SOAP AND WATER

• EYES IRRIGATED WITH A LITER OF SALINE

• REPORT TO THE CASUALTY MEDICAL OFFICER

• PROMPTLY NOTIFY YOUR SUPERVISOR. EMPLOYER SHOULD ALREADY HAVE A PROTOCOL IN PLACE FOR HANDLING NEEDLE
STICK INJURIES, WHICH MAY INCLUDE ARRANGEMENTS FOR TESTING AND POST-EXPOSURE PROPHYLAXIS (PEP)

• FILL OUT THE NEEDLE STICK INJURY FORM

Source :
1. Carter, Gregory & Lawrence, Carrie & Woodward, Brennan & Ohmit, Anita. (2020). Accessing Medical Care After a Needlestick Injury: First Responders’ Perception of HIV Risk and Attitudes Toward Syringe Service Programs. Journal of Community Health.
THE IMPORTANCE OF TESTING FOR HIV AFTER A NEEDLE STICK INJURY
TESTING FOR HIV IS CRUCIAL AFTER A NEEDLE STICK INJURY TO DETERMINE YOUR RISK OF INFECTION

THE TESTING PROCESS USUALLY INVOLVES A SCREENING TEST, FOLLOWED BY AN ADDITIONAL TEST IF THE FIRST ONE
IS POSITIVE

THIS IS DONE TO CONFIRM THE DIAGNOSIS AND RULE OUT ANY FALSE POSITIVES

THE TEST CAN BE DONE AS EARLY AS TWO WEEKS AFTER EXPOSURE, MOST HEALTHCARE PROVIDERS RECOMMEND
WAITING THREE MONTHS BEFORE TESTING. IF THE TEST RESULTS COME BACK POSITIVE FOR HIV, NEED TO BEGIN
TREATMENT IMMEDIATELY, NEED TO DEVELOP A COMPREHENSIVE CARE PLAN

EVEN IF THE INITIAL TEST COMES BACK NEGATIVE, STILL RECOMMENDED TO GET RETESTED AT THE THREE-MONTH
MARK TO ENSURE ACCURACY. ADDITIONALLY, IMPORTANT TO SEEK MEDICAL ATTENTION IMMEDIATELY AFTER A
NEEDLE STICK INJURY TO REDUCE THE RISK OF INFECTION AND RECEIVE APPROPRIATE TREATMENT.

PREVENTATIVE MEASURES, SUCH AS WEARING GLOVES AND USING SAFETY DEVICES. IMPORTANT FOR HEALTHCARE
PROVIDERS TO PRIORITIZE SAFETY MEASURES TO PROTECT BOTH THEMSELVES AND THEIR PATIENTS
Source : Carter, Gregory & Lawrence, Carrie & Woodward, Brennan & Ohmit, Anita. (2020). Accessing Medical Care After a Needlestick Injury: First Responders’ Perception of HIV Risk and Attitudes Toward Syringe Service Programs. Journal of Community Health
 POST EXPOSURE
PROPHYLAXIS FOR HIV
ANTIRETROVIRAL THERAPY FOR POST-EXPOSURE PROPHYLAXIS (PEP)
• POST-EXPOSURE PROPHYLAXIS (PEP) IS A TREATMENT THAT CAN BE USED TO
PREVENT HIV INFECTION AFTER EXPOSURE. PEP INVOLVES TAKING ANTIRETROVIRAL
MEDICATION FOR 28 DAYS AFTER EXPOSURE TO REDUCE THE RISK OF INFECTION.
WHILE IT IS NOT GUARANTEED TO PROTECT AGAINST HIV INFECTION, IT MAY
PROVIDE A LEVEL OF PROTECTION FOR HEALTHCARE WORKERS WHO HAVE
EXPERIENCED A NEEDLE STICK INJURY

• IT IS IMPORTANT TO NOTE THAT PEP SHOULD BE STARTED AS SOON AS POSSIBLE

AFTER EXPOSURE

• DELAYING THE START OF PEP CAN DECREASE ITS EFFECTIVENESS IN PREVENTING HIV
INFECTION

• IT IS IMPORTANT TO CONTINUE TO TAKE PRECAUTIONS TO PREVENT HIV

TRANSMISSION EVEN WHILE ON PEP
Source :
1. Allo. Treating HIV Needle Stick Injuries: The Best Practices for Prevention and Care. Diakses pada https://www.allohealth.care/healthfeed/stds/hiv-needle-stick-injury-treatment. 2023
 HOW PEP WORKS AND ITS EFFECTIVENESS IN
PREVENTING HIV INFECTION
• THE ANTIRETROVIRAL MEDICATIONS USED IN PEP WORK BY PREVENTING
THE VIRUS FROM MULTIPLYING IN THE BODY.
• BY DOING SO, IT REDUCES THE AMOUNT OF VIRUS IN THE
BLOODSTREAM, WHICH CAN RESULT IN A LOWER RISK OF INFECTION.
• THE EFFECTIVENESS OF PEP IN PREVENTING HIV TRANSMISSION
DEPENDS ON VARIOUS FACTORS, INCLUDING THE TIMING OF TREATMENT,
THE VIRAL LOAD OF THE SOURCE PERSON, AND THE ADHERENCE TO THE
TREATMENT REGIMEN.
• ACCORDING TO THE CDC, THE ESTIMATED EFFECTIVENESS OF PEP IN
PREVENTING HIV INFECTION AFTER OCCUPATIONAL EXPOSURE IS
APPROXIMATELY 81%.

Source :
1. DeHaan E, McGowan JP, Fine SM, et al. PEP to Prevent HIV Infection. Baltimore (MD): Johns Hopkins University; August 11, 2022.
 RATIONALE FOR HIV PEP
HIV INFECT DENDRITIC CELLS THE REGIONAL LYMPH NODES BEFORE BECOMING SYSTEMIC

AZT BLOCKS INEFECTIVITY OF HIV INFECTED DENDRITIC CELLS

GOAL OF PEP : HALT VIRAL REPLICATION BEFORE SYSTEMIC INFECTION IS

ESTABLISHED

RETROSPECTIVE STUDY : RISK OF SEROCONVERSION : 81% LOWER IN HCP’s WHO TOOK

AZT PEP

SEVERAL ANIMAL STUDIES SHOWING EFFICACY

Source :
1. DeHaan E, McGowan JP, Fine SM, et al. PEP to Prevent HIV Infection. Baltimore (MD): Johns Hopkins University; August 11, 2022
 FOR HIV-VIRUS TIME IS ESSENCE

PEP MAY HAVE SOME

ANIMAL STUDIES SHOW
BENEFIT UP TO 36 HOURS
THAT PEP SHOULD BE GIVEN
BUT SEEMS TO BE
WITHIN 2-8 HOURS OF
INNEFECTIVE IF GIVEN LATER
EXPOSURE FOR MAXIMAL
EFFECT

PEP SHOULD BE STARTED AS SOON AS POSSIBLE AFTER EXPOSURE AND IDEALLY

WITHIN 72 HOURS. THE LONGER YOU WAIT TO START TREATMENT, THE LESS
EFFECTIVE IT IS LIKELY TO BE. IT IS IMPORTANT TO COMPLETE THE ENTIRE 28-DAY
COURSE OF MEDICATION TO ENSURE THE BEST POSSIBLE OUTCOME
Source :
1. Lyall KND. Needle Stick and Post Exposure Prophylaxis. 2015.Clinical Microbiologist at Lyall Clinical and Endocrinology Lab, Ludhiana
2. Allo. Treating HIV Needle Stick Injuries: The Best Practices for Prevention and Care. Diakses pada https://www.allohealth.care/healthfeed/stds/hiv-needle-stick-injury-treatment. 2023
PEP-HIV CLASSIFICATION OF EXPOSURE - NACO

EXPOSURE CODE (EC) EXPOSURE

EC 1 MUCOUS MEMBRANE / SKIN INTEGRITY

COMPROMISED, SMALL VOL, FEW DROPS
SHORT DURATION

EC 2 1. MUCOUS MEMBRANE / SKIN

INTEGRITY, LARGE VOLUME, LONG
DURATION (SEVERAL MINUTES OR
MORE)
2. PERCUTANEOUS EXPOSURE, LESS
SEVERE (SOLID NEEDLE/SUPERFICIAL
SORATCH)
EC 3 PERCUTANEOUS, MORE SEVERE HOLLOW
NEEDLE, MAJOR WOUND, BLOODY
DEVICE
Source : Lyall KND. Needle Stick and Post Exposure Prophylaxis. 2015.Clinical Microbiologist at Lyall Clinical and Endocrinology Lab, Ludhiana
PEP-HIV CLASSIFICATION OF SOURCE - NACO
SOURCE CODE (SC) HIV STATUS OF SOURCE

SC 1 HIV+, LOW TITER EXPOSURE,

ASYMPTOMATIC WITH HIGH CD4
COUNTS
SC 2 HIV+, HIGH TITER EXPOSURE
(ADVANCED AIDS, PRIMARY HIV
INFECTION/HIGH VIRAL LOAD OR
LOW CD4 COUNTS)
UNKNOWN STATUS OR SOURCE IS UNKNOWN

Source : Lyall KND. Needle Stick and Post Exposure Prophylaxis. 2015.Clinical Microbiologist at Lyall Clinical and Endocrinology Lab, Ludhiana
 PEP-HIV TREATMENT - NACO
EXPOSURE CODE (EC) SOURCE CODE (SC) TREATMENT
EC 1 SC 1 PEP MAY BE WARRANTED
EC 1 SC 2 CONSIDER BASIC REGIME
EC 2 SC 1 RECOMMEND BASIC REGIME
(MOST EXPOSURES IN THIS
CATEGORY)
EC 2 SC 2 RECOMMEND EXPANDED
REGIME
EC 3 SC 1 OR 2 RECOMMEND EXPANDED
REGIME
2/3 UNKNOWN CONSIDER BASIC REGIME
Source : Lyall KND. Needle Stick and Post Exposure Prophylaxis. 2015.Clinical Microbiologist at Lyall Clinical and Endocrinology Lab, Ludhiana
 ANTIRETROVIRAL FOR PEP
REVERSE TRANSCRIPTASE INHIBITORS RTI

NUCLEOSIDE REVERSE TRANSCRIPTASE INHIBITORS (NRTI) ZIDUVIDINE, LAMUVIDINE

NON NUCLEOSIDE (NNRTI) – NEVIRAPINE (NOT RECOMMENDED)

PROTEASE INHIBITORS (PI)-NELFINAVIR, INDINAVIR

SINGLE DRUG V/S MULTIPLE DRUGS FOR PEP – NO DIRECT SUPPORTIVE EVIDENCE

THEORETICAL ADVANTAGE OF ADDING AN AGENT AT A DIFFERENT LEVEL

Source : DeHaan E, McGowan JP, Fine SM, et al. PEP to Prevent HIV Infection. Baltimore (MD): Johns Hopkins University; August 11, 2022.
 PEP HIV – DRUG REGIMENS
BASIC REGIMEN EXPANDED REGIMEN

• ZIDOVIDINE 200 mg • BASIC REGIMEN

TID • INDINAVIR 800 mg
• LAMIVUDINE 150 mg TID or NELFINAVIR
BID FOR 4 WEEKS 750mg TID or
SELQUINAVIR
(SOFTGEL) 1200 mg
TID

Source : Lyall KND. Needle Stick and Post Exposure Prophylaxis. 2015.Clinical Microbiologist at Lyall Clinical and Endocrinology Lab, Ludhiana
 LABORATORY TESTING
FOLLOWING A POTENTIAL HIV EXPOSURE, LABORATORY TESTING IS INDICATED FOR
SEVERAL REASONS :

1 • IDENTIFICATION OF BASELINE HIV INFECTION AMONG THE SOURCE

AND EXPOSED PERSON

2 • MONITORING OF HIV ACQUISITION BY THE EXPOSED PERSON

• IDENTIFICATION
3 OF OTHER
TRANSMITTED CO-INFECTIONS
BLOODBORNE OR SEXUALLY

• MONITORING FOR ANTIRETROVIRAL DRUG SIDE EFFECTS.

4 RECOMMENDATIONS FOR BASELINE TESTING AND CONTINUED

MONITORING FOR BOTH THE SOURCE PATIENT AND THE EXPOSED
PERSON
Source : Allo. Treating HIV Needle Stick Injuries: The Best Practices for Prevention and Care. Diakses pada https://www.allohealth.care/healthfeed/stds/hiv-needle-stick-injury-treatment. 2023
 FOLLOW-UP CARE AND MONITORING FOR
HIV-POSITIVE NEEDLE STICK INJURIES

● IF YOU HAVE A NEEDLE STICK INJURY AND TEST POSITIVE FOR

HIV, YOU WILL NEED TO BEGIN TREATMENT IMMEDIATELY, AND
YOUR HEALTHCARE PROVIDER WILL WORK WITH YOU TO
DEVELOP A COMPREHENSIVE CARE PLAN.
● THIS CAN INCLUDE ONGOING TESTING AND MONITORING TO
ENSURE THAT YOUR MEDICATION IS WORKING EFFECTIVELY, AND
YOUR VIRAL LOAD REMAINS UNDER CONTROL.
Source : Allo. Treating HIV Needle Stick Injuries: The Best Practices for Prevention and Care. Diakses pada https://www.allohealth.care/healthfeed/stds/hiv-needle-stick-injury-treatment. 2023
 EVALUATION FOR
PATIENTS WITH
CONFIRMED HIV
INFECTION (BOTH
ANTIBODY/ANTIGEN
AND PCR TESTING
POSITIVE) AT ANY VISIT

Source : Gupta, Amita, and Michael Melia. "Post-exposure Prophylaxis." Johns Hopkins HIV Guide,. 2021. Johns Hopkins Guides
 RAISING AWARENESS ABOUT THE
RISKS OF HIV NEEDLE STICK INJURIES
• FINALLY, IT IS ESSENTIAL TO RAISE AWARENESS ABOUT THE RISKS OF HIV
NEEDLE STICK INJURIES AND THE STEPS THAT HEALTHCARE WORKERS CAN
TAKE TO PROTECT THEMSELVES AND PREVENT TRANSMISSION.

• THIS CAN INVOLVE PROVIDING TRAINING AND EDUCATION TO HEALTHCARE

WORKERS, PROMOTING SAFE WORK PRACTICES, AND ADVOCATING FOR POLICY
CHANGES THAT PRIORITIZE WORKPLACE SAFETY
 SUMMARY
• AS A HEALTHCARE WORKER, YOU ARE EXPOSED TO MANY RISKS, INCLUDING THE POSSIBILITY OF
NEEDLE STICK INJURIES

• THE RISK OF CONTRACTING HIV THROUGH A NEEDLE STICK INJURY IS RELATIVELY LOW, BUT IT IS
STILL A SIGNIFICANT CONCERN

•THE BEST WAY TO PREVENT NEEDLE STICK INJURIES IS TO CREATE A SAFE WORK ENVIRONMENT. THIS CAN
INVOLVE PROVIDING APPROPRIATE TRAINING AND EDUCATION TO HEALTHCARE WORKERS ON THE SAFE
HANDLING AND DISPOSAL OF SHARPS, AS WELL AS THE USE OF APPROPRIATE PERSONAL PROTECTIVE
EQUIPMENT (PPE).

•POST-EXPOSURE PROPHYLAXIS (PEP) IS A TREATMENT THAT CAN BE USED TO PREVENT HIV INFECTION
AFTER EXPOSURE. PEP INVOLVES TAKING ANTIRETROVIRAL MEDICATION FOR 28 DAYS AFTER EXPOSURE TO
REDUCE THE RISK OF INFECTION. WHILE IT IS NOT GUARANTEED TO PROTECT AGAINST HIV INFECTION, IT
MAY PROVIDE A LEVEL OF PROTECTION FOR HEALTHCARE WORKERS WHO HAVE EXPERIENCED A NEEDLE
STICK INJURY

•IF YOU HAVE A NEEDLE STICK INJURY AND TEST POSITIVE FOR HIV, YOU WILL NEED TO BEGIN TREATMENT
IMMEDIATELY, AND YOUR HEALTHCARE PROVIDER WILL WORK WITH YOU TO DEVELOP A COMPREHENSIVE
CARE PLAN. THIS CAN INCLUDE ONGOING TESTING AND MONITORING TO ENSURE THAT YOUR MEDICATION IS
WORKING EFFECTIVELY, AND YOUR VIRAL LOAD REMAINS UNDER CONTROL
THANKYOU