Rapid response lowers HIV needlestick risk

Rural hospitals may not have PEP on stock

AIDS has forever altered the way health care workers view the threat of infectious disease. Although HCWs had long been at risk of contracting tuberculosis, hepatitis B, and other serious diseases, the AIDS epidemic in the 1980s brought a new level of fear — and a focus on the need for workplace protections.

As the AIDS epidemic changes, the challenge for hospitals is to continue to identify potential occupational exposures to HIV and to offer prompt post-exposure prophylaxis.

"There are changing demographics. There are still higher rates [of HIV infection] in cities, but there are increasing numbers of cases in rural vs. urban areas," says Lisa Panlilio, MD, medical epidemiologist with the Centers for Disease Control and Prevention (CDC).

Yet a small, unpublished study of rural hospitals found that many did not have adequate supplies of antiviral drugs that could be used for post-exposure prophylaxis (PEP) following a needlestick.

"There are a number of smaller hospitals and other settings where these drugs are not readily available and that's a concern," says Ronald H. Goldschmidt, MD, director of the National HIV/AIDS Clinicians' Consultation Center at the University of California at San Francisco, which runs the PEPLine advice call line for clinicians and conducted the study. Goldschmidt also is vice-chair of the department of family and community medicine at the University of California at San Francisco.

A low prevalence of HIV/AIDS in the community does not equate to zero risk, he cautions. "Most communities have someone who has [a risk from] substance abuse or sexual exposure to others," he says.

Nationwide, advances in needle safety, post-exposure prophylaxis, and other protective measures have significantly reduced the risk of HIV infection from a needlestick. Overall, there have been 57 cases of documented occupationally acquired AIDS/HIV infection. Another 140 health care workers contracted HIV, which is considered a "possible" but not confirmed case of occupational transmission.

No new cases of HIV seroconversion from bloodborne pathogen exposures have occurred since 2000. Only one possible occupational transmission has occurred in that time, according to the CDC.

The decline in seroconversions "indicates some really dramatic changes in health care," says Goldschmidt. The most obvious were glove use and safer needle devices. Hospitals installed more sharps containers and made them more convenient. Needleless IV systems virtually eliminated exposures from that source.

Meanwhile, antiviral medications have dramatically improved the lives of people with HIV infection, which means they are less likely to be treated in the hospital and overall they have a lower viral load.

"Overall, I think this is a huge success for a very strong CDC program toward reducing transmission in the health care setting," says Goldschmidt.

Rapid HIV testing lowers cost

Employee health continues to play an important role in lowering risk through post-exposure prophylaxis and rapid HIV testing.

The CDC still estimates the risk of contracting HIV from a needlestick to be three out of 1,000. The actual risk may be less than that, says Panlilio. But she also cautions that the CDC data on occupationally acquired HIV may be an undercount, as some health care workers may not report their positive HIV status even from an occupational exposure.

Starting post-exposure prophylaxis as soon as possible after an exposure remains an important way to prevent seroconversion.

"There's consultation that's available 24 hours a day [from PEPLine] and there are treatments that are readily available that every hospital should have," says Goldschmidt. "It remains important to start early.

"The CDC guidelines say [to start PEP within] 72 hours, but that doesn't mean you have 72 hours to give it. You should start as soon as possible," he says. "After 72 hours, there's no evidence that it helps."

For many health care workers, that means taking antiviral medications while awaiting the results of source patient testing. Rapid HIV testing is at least as accurate as the standard test and offers clear advantages, says Goldschmidt.

"[With rapid testing], you avoid the risks associated with taking post-exposure when it isn't really needed," says Panlilio. "It does a lot for reassuring workers that the employer is concerned about them as well."

BJC Healthcare in St. Louis converted its 13 hospitals to rapid HIV testing in 2004. Now, only 5% of workers who had a needlestick require PEP, compared to 26% who were started on PEP while awaiting test results.

Although the rapid HIV test is more expensive than the standard test, it has saved $500 to $1,000 per needlestick in costs for antiviral medications, additional lab time, follow up of employees, and physician consultation, says Jo Grayson, RN, occupational health supervisor at Christian Hospital Northeast in St. Louis and a member of the occupational health group that worked on the switch to rapid tests.

"The employees love it for the simple fact that they know they don't have to go on the medicines," she says. "They know within 30 minutes to an hour what the results are."

At BJC, employees can call an after-hours hotline when they have a blood or body fluid exposure. Occupational health nurses are on-call and will help them through the post-exposure procedure, she says.

Meanwhile, new CDC recommendations on routine testing of patients for HIV status may alter the future of source testing. That would increase the likelihood that health care workers will know the HIV status of a patient when an exposure occurs.

[Editor's note: More information about the National HIV/AIDS Clinicians' Consultation Center at the University of California at San Francisco is available from www.ucsf.edu/hivcntr. The PEPLine number for consultation on post-exposure prophylaxis is (888) 448-4911.]