New HIV testing eases HCW fears
But state stigma’ laws create PEP barriers
The aftermath of a needlestick is fraught with anxiety, but thanks to advances in HIV testing and treatment, health care workers can get swift and clear post-exposure guidance. A new drug regimen lowers the risk of contracting HIV, with fewer side effects.
But the mostly positive news about changes in post-exposure prophylaxis (PEP) is clouded by one drawback: Many states have neglected to update their HIV testing laws in light of new developments — laws that were mostly written in the 1990s when fear of HIV greatly exceeded our knowledge or ability to treat it.
"That was an era when the stigma of having HIV was enormous," says Ronald H. Goldschmidt, MD, director of the national HIV/AIDS Clinicians’ Consultation Center at the University of California-San Francisco, which runs the PEPline advice call line for clinicians (1-888-HIV-4911). "There’s been such a societal and cultural shift that dealing with the stigma has become a lesser issue."
In fact, in 2006, the Centers for Disease Control and Prevention recommended routine, universal testing of everyone ages 13 to 64 in health care settings, with an "opt-out" option, and annual HIV testing of people at high risk. With that policy, the HIV status of a source patient in an occupational exposure might already be known.
But can you reveal the HIV status to the health care worker who sustained a needlestick? That depends upon state law. "When the CDC came out with its 2006 recommendations, they really were at odds, to various degrees, with the laws of about 48 of the states," says David M. Korman, JD, program manager for Special Projects at the Pennsylvania/MidAtlantic AIDS Education and Training Center at the University of Pittsburgh.
For example, many state laws required pre-test counseling, while CDC recommended HIV testing as a part of the general consent on admission to the health care facility.
Certify a significant exposure’
In practice, hospitals seek ways to maneuver within the law while responding to the post-exposure needs. That may mean putting health care workers on post-exposure prophylaxis immediately while waiting for consent to test to the source patient’s blood.
In Pennsylvania, the health care worker must ask a physician to certify that there was a "significant exposure." The law allows the physician 72 hours to provide that written certification — even though CDC recommends starting PEP as soon as possible after an exposure.
The health care worker then would have baseline HIV testing. If that is positive, the source patient’s blood is not involuntarily tested — even though different strains of HIV have been identified and physicians now know that co-infection can occur. Pennsylvania law allows only involuntary testing of existing blood and not involuntarily drawing a source patient’s blood after an exposure.
The risk of seroconversion after being stuck with a needle containing HIV-positive blood is low (estimated at 3 in 1,000), but that doesn’t lessen the anxiety that health care workers feel, says Korman. In a German study of health care workers who sustained a needlestick injury, 80% reported feeling a high level of anxiety if the source patient was known to be HIV-positive.1
"We demand a lot of our health care workers," says Korman. "We shouldn’t aggravate their mental or physical state [in the post-exposure response]."
Arizona updated its HIV testing law this year to make it easier to respond to needlesticks. After a licensed health care provider confirms that a "significant exposure" occurred, the health care worker can be told the source patient’s known HIV status or can request HIV testing of an existing blood sample. Source patients cannot be required to give a blood sample for testing.
The law change had widespread support from hospital organizations, nurses, emergency physicians and first responders, and advocates in the HIV community did not oppose it, says David Landrith, vice president of policy and political affairs for the Arizona Medical Association in Phoenix.
"We dealt with it upfront as a medical issue that needed changing because the medicine had changed," he says. "The arguments really were on our side."
With better treatment options, early diagnosis has become more important than ever, he notes. Knowledge of the source patient’s HIV status also could affect the choice of post-exposure prophylaxis.
New PEP regimen is safer
Beyond the source-patient testing issues, advances in technology have transformed post-exposure follow-up.
In August 2013, the CDC issued new guidelines for post-exposure prophylaxis, which recommended a three-drug combination (emtricitabine plus tenofovir DF, or Truvada combination tablet, and raltegravir) for most exposures. (See HEH, October 2013, p.109.)
"One of the best things about the new drug recommendations for PEP is how safe and well tolerated they are," says Goldschmidt.
It’s still important to know the status of the source patient. "Part of risk assessment involves knowing as much as one can about the source," he says. But if the information is not available, the PEP regimen is less onerous than in the past, he says.
Rapid HIV tests provide information about the source patient within two hours, which gives many health care workers piece of mind after a needlestick and helps guide treatment, Goldschmidt says. "If you know someone is rapid-test positive, that clarifies the dialogue with the exposed person about how important it is to take PEP," he says.
If the rapid test is negative, it is possible the source patient is in the window between infection and the test’s capability to detect the infection. "The chance of that is extremely small and the chance of that person being infective is extremely small," he says.
To assuage those fears, there are "fourth-generation" HIV tests that narrow the window to about two to four weeks.
- Wicker S, Stim AV, Rabenau HF, et al. Needlestick injuries: Causes, preventability and psychological impact. Infection 2014; 42:549-552.