1 Occupational Exposure to HIV: Universal Precautions and PEP HAIVN Harvard Medical School AIDS Initiative in Vietnam

2 By the end of this session, participants will be able to: Explain the risk of HIV transmission after a single per-cutaneous exposure Demonstrate “scoop” technique of recapping needles List the steps involved in post-exposure prophylaxis (PEP) Describe PEP regimens in Vietnam Learning Objectives

3 Overview of Occupational Exposure to HIV

4 Potential Risk Blood Cerebrospinal fluid (CSF) Pleural fluid Peritoneal fluid Any body fluid visibly contaminated with blood Negligible Risk* Urine Saliva Sputum Sweat Feces Vomitus Body Fluids and Risk for HIV Exposure * If not visibly contaminated with blood

5 Blood exposures Risk of HIV Transmission Percutaneous needle-sticks 0.3% Mucous membranes0.09% Intact Skin0% Risk of HIV Transmission

6 Factors that increase the risk of HIV transmission from a needle stick injury include exposure: through a visibly bloody device through a device used in an artery or vein via a deep injury from a source individual with more advanced HIV disease and a high HIV viral load Factors that Increase Risk of Transmission

Factors Affecting Risk of HIV Transmission after Percutaneous Exposure Risk factor Adjusted Odds Ratio The needle went deep into the healthcare worker 1.5 Visible blood was seen on the needle before the percutaneous exposure 6.2 Source patient was terminally ill 5.6 Needle was in source patient’s artery or vein 4.3

8 Occupational Exposure to HIV in Vietnam In 2000, at a hospital in HCMC, 330 /886 (38%) health workers experienced percutaneous exposure Type of Exposure% Hollow needles53 Surgical needles24 When injecting medications19 Re-cap needles16 Sohn. 15 th IAC: Abstract ThPeC7512.

9 Steps of Universal Precautions

Key Definitions: Universal Precautions (1) #1 Treat ALL blood and body fluids as if they are potentially infectious Follow Universal Precautions #2 Prevent needle sticks Safely manage sharps

11 Following universal precautions means minimizing exposure to blood and body fluids through: 1.Use of protective barriers 2.Hand hygiene 3.Safe injection practices 4.Environmental control of blood and bodily fluids 5.Sharps management Universal Precautions (2)

1. Use of Protective Barriers Procedure GlovesGown Goggles/ Face Protection Giving an injection Intravenous injection, blood drawing, blood and fluid transfusion Irrigating a wound Performing an operation YES NO* NO YES NO

13 Prevents transmission of resistant organisms and infections Before patient care After blood/fluid contact, glove removal Methods: Hand washin: Water+soap  10 seconds  disposal towels Use hand sanitizer 60-95% ethyl or isopropyl alcohol 2. Hand Hygiene

14 Use a sterile syringe and needle for every infection; use the correct intended medication Place needle in a puncture-proof container right after use Discard sharps waste appropriately 3. Safe Injection Practices

4. Environmental Control of Blood and Body Fluids Spills in patient-care areas Spills in laboratory areas  Wearing gloves to visible blood/fluid with towels  Soak towel and blood/fluid spill in disinfectant before discarding Disinfect area :  1:100 dilution (500 ppm) of hypochlorite Disinfect area:  1:10 dilution (5000 ppm) of hypochlorite

16 Organize work areas: Have sharps containers nearby Avoid hand-passage of sharps Not recap needles, or: recap using a one-handed “scoop technique” 5. Sharps Management

17 “One-hand” Technique of Recapping Needles

18 Post-Exposure Prophylaxis (PEP)

Steps for Post-Exposure Management Treat the exposure site Bước 1 Report the exposure to the manager and complete the report form Bước 2 Assess the risk of exposure Bước 3 Determine the HIV status of the source of exposure Bước 4 Determine the HIV status of the exposed person Bước 5 Counsel the exposed person Bước 6 Provide ARV prophylaxis (if indicated) Bước 7

20 If there was a percutaneous exposure: Flush the wound with tap water Let the wound bleed for a short time Clean the wound with soap and water, treat the wound with an antiseptic solution, appropriately bandage the wound Evaluate the need for PEP Exposure to Bodily Fluid and/or Blood (1)

21 If there was an eye exposure: Wash the eye(s) with water or NaCl 0.9% solution continuously for 5 minutes Do not rub your eyes Evaluate the need for PEP Exposure to Bodily Fluid and/or Blood (2)

22 If there was a mouth and/or nose exposure: Rinse with NaCl 0.9% solution DO NOT BRUSH TEETH Gargle with NaCl 0.9% solution for several times Evaluate the need for PEP Exposure to Bodily Fluid and/or Blood (3)

23 High Risk exposures: Percutaneous wounds: Deep with large bleeding, caused by large- bore needles. Deep and large with bleeding, caused by scalpels or broken blood containing tubes Large lesions on the skin or mucus membranes (e.g. eye, nose, mouth) exposed to patient's blood or body fluids Evaluating the need for PEP (1)

24 Low Risk exposures: Shallow wounds with minor bleeding or no bleeding Intact mucosa exposed to patient’s blood or body fluids. No Risk exposures: Contact of normal skin with patient’s blood or body fluid. Evaluating the need for PEP (2)

25 PEP Rationale (1)

26 ARVs given soon after exposure may prevent infection by: blocking HIV replication in the few cells that are initially infected if those cells die then the HIV infection will be eradicated before it starts PEP Rationale (2)

27 Timing: as soon as possible Do not delay to obtain additional information on the source patient Best if given within hours following exposure PEP started more than 72 hours after exposure is not likely to be effective. Duration of prophylaxys: 4 week Post-Exposure Prophylaxys

RegimeMedicationsIndications 2 drug (basic regimen) AZT+ 3TC OR d4t + 3TC All exposures with risk 3 drug AZT+ 3TC OR d4t + 3TC Plus: LPV/r In case source of exposure is known to have or suspected of ARV resistance National Guidelines on PEP Regimens

29 Testing: Test health care worker for HIV after 4-6 weeks, 3 months, and 6 months Conduct laboratory tests to monitor ARV side effects (CBC, ALT): at baseline and after 4 weeks Suggested Post-Exposure Follow-up and Testing (1)

30 Education and Counseling for HCW: their risk of infection with HIV, HBV, HCV symptoms suggestive of ARV toxicity and/or primary HIV infection prevention of secondary transmission Use condom with sex-partners Suggested Post-Exposure Follow-up and Testing (2)

31 Inform the source patient of the incident, counsel, & test (with consent) for HIV, HBV and HCV Use a rapid HIV antibody testing if possible Inquire about source patient’s risk factors for HIV and risk of being in the “window period” of an acute HIV infection. If source patient found to be HIV negative: Or if it is impossible to take the HIV test for the source patient Determine the HIV Status of the Source Patient (1)

32 If source patient is known to be HIV positive: Define the patient’s clinical and immunological stage of HIV infection through: a CD4 count and/or TLC. Obtain: HIV viral load data, if available Obtain information on current and previous antiretroviral therapy Obtain HIV resistance testing results, if done Determine the HIV Status of the Source Patient (2)

33 Prophylaxis with other Etiologies

34 VirusRangeMean HBV2 – 40 %30% HCV0 – 7 %3 % HIV0.2 – 0.5 %0.3% Risk of Seroconversion after Percutaneous Occupational Exposure HBV is 100x more transmissible than HIV!

35 The best way to prevent HBV infection is to vaccinate all health care workers: 3 times at 0, 1 and 6 months The HBV Prevention Every health care workers working at health settings should take HBV Vaccination

36 TB is the most common OI in Vietnam In the HIV OPC: There is a significant percentage of patients will have TB or on TB treatment at any one time The waiting area and exam rooms are an environment at high risk for TB transmission Five steps to prevent transmission of TB in HIV care settings (WHO) should be practiced at any health settings TB prevention

37 Universal Precautions helped minimizing exposure to blood/bodily fluids PEP should be taken as soon as possible, within 72 hours AZT/d4T+ 3TC is the first line regime for PEP Key Points

38 Thank you! Questions?