DEFINITIONS AND EPIDEMIOLOGY
Until an effective human immunodeficiency virus (HIV) vaccine is in widespread use, controlling the HIV epidemic will require prevention of exposure to the virus. Universal access to onsite rapid HIV testing with early initiation of therapy for infected persons, universal precaution training, safer sex education, safe blood supply and needle exchange programs, and the consideration of pre-exposure antiviral prophylaxis (PrEP) in high-risk situations, are all are important aspects of effective and necessary preventive strategies. However, in cases where exposure has already occurred, it is possible to decrease the risk of transmission of HIV infection through the use of postexposure prophylaxis (PEP).
The best documented success of HIV PEP has been through the prevention of maternal to child transmission, which in many regions has come close to eliminating new infant infections. In the landmark National Institutes of Health-funded Pediatric Acquired Immunodeficiency Syndrome (AIDS) Clinical Trials Group 076 trial, a three-arm intervention with zidovudine (AZT), prenatal, intrapartum, and postpartum, significantly decreased the risk of neonatal HIV infection by two-thirds, from 25.5% to 8.3%.1 Subsequent studies indicated that a significant portion of the decrease in transmission risk was based on the receipt of postnatal medication. Even in situations where mothers did not receive any prenatal antiretroviral therapy, administering antiretroviral medication to HIV-exposed newborns within 48 hours of life decreased the risk of transmission by up to 50%.2 The Centers for Disease Control and Prevention (CDC) estimates that such efforts have prevented nearly 22,000 cases of perinatal HIV transmission in the United States between 1994 and 2010.3 HIV-related PEP is now used routinely in hospitals following occupational exposure and in emergency departments following accidental or unprotected exposure to body fluids, termed nonoccupational exposure when exposure occurs outside of work. It is important for all healthcare providers to be aware of current PEP recommendations and to know how to rapidly access such information to minimize the likelihood of acquisition of the virus. This chapter discusses HIV PEP as it relates to both occupational (oPEP) and nonoccupational (nPEP) exposure to HIV.
OCCUPATIONAL POSTEXPOSURE PROPHYLAXIS
During 1985 through 2013, the CDC reported 58 confirmed and 150 possible cases of occupationally acquired HIV in healthcare workers (HCWs). Of those 58 confirmed cases, 49 were related to a percutaneous puncture or cut, and all were exposed to HIV-infected blood. A total of 57 of these 58 cases occurred between 1985 and 1998. Since 1999, the only confirmed case occurred in a laboratory technician, who in 2008 sustained a needle puncture while working with a live HIV culture.
The risk of occupational exposure is highest in surgical staff, due to the use of hollow-bore percutaneous needles in the operating room.4 Surgeons represent 25% of the 400,000 sharps injuries occurring annually to healthcare workers in the United States.5 Laboratory personnel have also been identified as being at ...