PEP recommendations after occupational exposure

In the occupational setting, the source is usually able to be identified and tested for HIV, and PEP is usually only prescribed or continued for those who have definitely been exposed to HIV. If the source is unable to be tested immediately, the exposed healthcare worker should be commenced on PEP without waiting for the results if the source is at high risk of being HIV positive. If the source is unable to be identified or tested, then the risk of the source being HIV positive must be assessed from any epidemiological or other information available. The use of PEP should be decided on a case-by-case basis, and it is recommended that an expert is always consulted in this situation.

The risks carried by exposures that occur in the occupational setting are outlined in Table 5. However, the risk is most likely significantly lower than this as these data predate effective antiretroviral therapy (ART). There has only been one confirmed case of occupational HIV transmission in the United States since 1999.17 This may be due to a number of factors, including change in practices to reduce the risk of needlestick injury and a greater proportion of patients on treatment with undetectable viral load. There is now strong evidence that the risk of sexual transmission of HIV is significantly reduced when the source has undetectable viral load.18 It is presumed that the same applies for percutaneous transmission; however, this will never be able to be studied.

It is reasonable to always offer PEP to a healthcare worker who has had a significant exposure to a source who is HIV positive, even if the source has an undetectable HIV viral load.

Table 5. PEP recommendations after OCCUPATIONAL exposure to a known HIV-positive source

  PEP recommendation
Type of exposure with known HIV positive source Estimated risk of HIV transmission per exposure if source NOT on antiretroviral treatment Source not on treatment or on treatment with detectable or UNKNOWN viral load Source viral load KNOWN to be undetectable
NSI or other sharps exposure 1/440 3 drugs Consider 2 drugs
Mucous membrane and non-intact skin exposure < 1/1000 3 drugs Consider 2 drugs

* PEP may be recommended if needle and syringe contained fresh blood and sufficiently penetrated the skin.