Richard S. Ferri, PhD, ANP, ACRN, FAAN

One of the biggest concerns many nurses have is being exposed to the human immunodeficiency virus (HIV) in the workplace. This is a very real and understandable fear, but it is important to appreciate that rate of occupational exposure is relatively low. The total number of healthcare workers occupationally infected with HIV is 132 persons in the US. This number includes all healthcare workers and nursing represents 24.2% (or 32 out of the 132) of all infected workers.

While the actual number of nurses and other healthcare workers is very low, it is prudent for all nurses to become informed about HIV exposure potential, postexposure prophylaxis (PEP) treatment options, and their workplace’s preparation to respond to the issue.

Timing is essential to obtain the full benefit of postexposure treatments to prevent HIV disease. Literally, it is a matter of hours before postexposure treatment becomes less effective. The time to make a decision about what you would want to do is before a crisis occurs and before emotions are high. Make a decision as an informed consumer and not in a state of fear.

Of course the best method is the oldest with the prevention of body fluid exposure in the first place by using the appropriate standards and practices. However, we all know that accidents do happen. Blood and percutaneous injury, along with contact with a mucous membrane or nonintact skin is considered an occupational exposure. Other body fluids, such as saliva, tears, and nonbloody feces and urine, do not constitute an occupational risk. Also, while HIV-infected breast milk has been implicated in HIV transmission from mother to child, there is no occupational risk. Remember not all exposures carry the same risk and need to be individually assessed.

Exposure Level

The exposure should be evaluated according to the type of exposure (nonpenetrating vs. penetrating) and the source patient’s HIV status if known.

For exposure to a mucosal membrane, see the recommendations listed in Table 1.

The rate and degree of exposure increase when there is a percutaneous injury. Breaking the integrity of the skin with a sharp object is a much more effective mode of HIV transmission than a mucosal splash. Percutaneous injury is also subdivided into various categories as shown in Table 2.

Postexposure Prophylaxis Treatment

The use of zidovudine (trade name – AZT) has been shown to reduce the occupational transmission of HIV in healthcare workers by 81%. Factors implicated in PEP failure include high titers of HIV, large inoculum of HIV, delayed start of treatment, inadequate length of treatment, and the presence of resistant strains of HIV.

Postexposure treatment is based on the level or exposure. Remember, an occupational exposure is an urgent medical matter. Treatment should be started within one hour postexposure and not more than 24 hours post injury.

The basic PEP protocol is zidovudine 300 mg BID with lamivudine 150 mg BID (or the use of the combination formulation, Combivir BID). Treatment should be for at least four weeks. If the injury, according to Tables 1 and 2, is sufficient enough to be considered “recommend” or “strongly recommend” then the basic PEP protocol should be expanded to include indinavir 800 mg every eight hours or nelfinvir 750 mg TID. This should also be done for at least four weeks.

Issues for Nurses Today

The first major issue for every nurse is to come to an informed conclusion on what to do if you experienced an occupational exposure to HIV tomorrow. Know how you would proceed before a crisis and stick to your plan.

Nurses should also know about their workplace policy and procedure on occupational exposure. The bottom line question is simple — Does your institution have the postexposure drugs recommended by the Center for Disease Control and Prevention available for you — even at three o’clock in the morning?

Richard S. Ferri, PhD, ANP, ACRN, FAAN, is president of an independent consulting firm in the areas of HIV/STD clinical management and in private practice specializing in HIV/STD and men’s health in Provincetown, MA.

Bibliography

Tokars JI, Marcus R, Culver DH, Schable CA, McKibben PS, Bandea Cl, et al. Surveillance of HIV infection and zidovudine use among health care workers after occupational exposure to HIV-infected blood. Ann Intern Med 1993; 118:913-919.

Gerberding JL. Incidence and prevalence of human immunodeficiency virus, hepatitis B virus, hepatitis C virus, and cytomegalovirus among health care personnel at risk for blood exposure: final report from a longitudinal study. J Infect Dis 1994; 170:1410-1417.

Cardo DM, Culver DH, Ciesielski CA, Srivastava PU, Marcus R, Abiteboul D. Case-control study of HIV seroconversion in health care workers after percutaneous exposure. N Engl J Med 1997; 337:1485-1490.

Department of Health. Guidelines on post-exposure prophylaxis for health care workers occupationally exposed to HIV. London: DoH, 1997.

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