Prompt testing, follow-up key to exposure control

Checklist documents info exchange

The moments after a needlestick are filled with stress and anxiety for health care workers. Is the source patient HIV-positive? Do they need to take post-exposure prophylaxis (PEP)? How will they feel when they take the drugs?

Answering those questions with prompt testing and good follow-up and counseling of health care workers is a crucial component of a bloodborne pathogen program, sharps safety experts say.

Katherine West, MSEd, CIC, an infection control consultant with Infection Control/Emerging Concepts in Manassas, VA, is concerned that many hospitals are not providing rapid HIV tests or thorough counseling. West created an informed consent form that includes a checklist for physicians to document the items covered in counseling. (See checklist.)

"I don't think all of that counseling that the CDC [the Centers for Disease Control and Prevention] has in its guidelines is really taking place," she says.

The CDC emphasizes the importance of counseling in its updated guidelines on managing the occupational exposure to HIV, stating, "Health care personnel with occupational exposure to HIV should receive follow-up counseling, post-exposure testing, and medical evaluation regardless of whether they receive PEP."1

The CDC says health care workers with exposures involving patients who are known or suspected to be HIV-positive should be advised to use precautions to prevent secondary transmission, such as avoiding unprotected sex, pregnancy, blood or tissue donation, or breast-feeding, for six to 12 weeks following the exposure. They also should be informed about the possible toxicities and interactions involving PEP and the need for monitoring the drugs, as well as the importance of adhering to the regimen.

In fact, those guidelines are imperative because the U.S. Occupational Safety and Health Administration (OSHA) expects hospitals to follow them, West says. "OSHA is enforcing those guidelines," she says. "The 'should' becomes a 'shall' and the 'may' becomes a 'must.'"

Hospitals need to ensure that the appropriate counseling occurs on every shift, so employees do not have to wait until regular office hours to receive follow-up, West stresses.

Even after counseling, health care workers often have lingering questions and concerns. About 15% of the calls to the National Clinicians' Post-Exposure Prophylaxis Hotline (PEPLine) come from employees with questions, says Ronald H. Goldschmidt, MD, director, National HIV/AIDS Clinicians' Consultation Center (NCCC), which runs the PEPLine, and vice chair of the department of family and community medicine at the University of California at San Francisco.

Some want a second opinion to make sure they are taking the appropriate PEP drug regimen. Some feel they did not receive adequate information or that the person conducting the follow-up wasn't knowledgeable about post-exposure issues. Sometimes, they simply have additional questions: Can I have sexual relationships with my partner? (Yes, but protected.) Do I really have to keep taking the medicines for four weeks? (Yes, if the medicines are indicated.) How soon can I be sure I'm not infected? (In general, in three months.)

"There needs to be someone around in the hospital who has been designated with the task of providing this type of counseling and is familiar with most of the information regarding exposure risk, so they can help put the exposure into context for the health care provider," says Goldschmidt. That person also may need access to an infectious disease expert who is knowledgeable about specific PEP drugs, especially if the source patient was already on antivirals and may have built up resistance to some drugs.

A second phase of follow-up also needs to occur, notes Goldschmidt. If the health care worker takes PEP, the CDC recommends additional follow up within 72 hours after the exposure to evaluate any additional information about the exposure or the source patient. The toxicity of PEP also should be evaluated at the time the drugs are first administered and two weeks later, according to the CDC.

Rapid HIV tests ease concerns

Many hospitals still are not using rapid HIV tests, and that may cause health care workers to take PEP drugs unnecessarily, West reports. The CDC recommends starting PEP as soon as possible after an exposure, "preferably within hours rather than days."

But that imperative to start PEP quickly — with the lack of rapid HIV test results — places health care workers in a difficult position, she says. "These tests are accurate, they're inexpensive, and you've got the answer on the source patient in an hour," she says.

Health care workers can expect PEP side effects such as nausea and diarrhea; those can be managed with other medications, such as antiemetics. But some of the drugs have the potential to cause serious adverse effects, such as liver or kidney damage. They may have hazardous interactions with other drugs, including over-the-counter medications.

"The selection of a drug regimen for HIV PEP must balance the risk for infection against the potential toxicities of the agent(s) used," the CDC advises. "Because PEP is potentially toxic, its use is not justified for exposures that pose a negligible risk for transmission."

West notes that little is known about the long-term ramifications of taking the drugs. Employees need to be well informed as they decide whether to start PEP. "It's the employee's decision, after counseling, whether they wish to take the drugs," she notes.

In fact, of 1,350 health care workers exposed to a known HIV-positive patient from 1995 to 2004, only 58% started PEP, according to CDC exposure data from 95 hospitals.

The increased use of rapid HIV tests will prevent some health care workers from taking PEP unnecessarily, Goldschmidt agrees. Based on calls to the PEPLine, hospitals have provided employees with the information needed to make the choice.

"We're impressed overall that good counseling is happening and good decisions are being made," he says.

[Editor's note: Guidance is available from PEPLine at (888) 448-4911.]

Reference

1. Centers for Disease Control and Prevention. Updated U.S. Public Health Service guidelines for the management of occupational exposures to HIV and recommendations for post-exposure prophylaxis. MMWR 2005; 54(RR09):1-17.