The human immunodeficiency virus, also known as HIV infection, is a retrovirus that causes AIDS (acquired immune deficiency syndrome). The retrovirus primarily attacks the body's immune system, making the patient extremely vulnerable to opportunistic infections (infections that occur in individuals with weakened immune systems).
HIV is transmitted from person to person via bodily fluids including blood, semen, vaginal discharge, and breast milk. It can be spread by sexual contact with an infected person, by sharing needles/syringes with someone who is infected, or, less commonly (and rare in countries, such as the United States, where blood is screened for HIV antibodies), through transfusions with infected blood. HIV has also been found in saliva and tears in very low quantities in some AIDS patients. However, contact with saliva, tears, or sweat has never been shown to result in HIV transmission.
Although healthcare workers are exposed to the virus at work, it is unlikely that they will acquire the virus from a patient, especially if they follow universal precautions, which should be taken with all patients. Healthcare personnel should assume that the blood and body fluids from all patients are potentially infectious.
Since December 2001, there have been 57 documented reports of healthcare workers acquiring HIV from a patient. To prevent transmission of HIV to healthcare personnel in the workplace, the U.S. Centers for Disease Control and Prevention (CDC) offers precautionary guidelines.
For healthcare workers, the main risk of HIV transmission is through accidental injuries from needles or other sharp medical instruments that may be contaminated with the virus. However, even this risk is small. Researchers estimate that about 0.3-1% of healthcare workers exposed to the virus by an accidental needle stick or puncture develop HIV.
This is largely because action can be taken to reduce the risk of transmission immediately after exposure. Healthcare workers who are exposed to the virus can receive post-exposure prophylaxis (PEP), which consists of antiretroviral therapy (ART) to prevent the individual from acquiring HIV. However, antiretrovirals can have serious side effects and patients should evaluate the risks and benefits with their healthcare providers.
Current antiretroviral drugs cannot cure HIV infection or AIDS, and they cannot reduce the risk of transmitting disease to someone else. They can suppress the virus, even to undetectable levels, but are unable to completely eliminate HIV from the body.
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risks of transmission
Most cases of HIV transmission in occupational settings occur after exposure to HIV-infected blood by a percutaneous injury on the skin. This is most commonly caused by needles, medical instruments, or bites that break the skin. Researchers estimate that about 0.3-1% of healthcare workers who were exposed to the virus via a needle stick or puncture develop HIV.
The virus can also be transmitted if blood from an HIV patient's open sore or wound comes into contact with an open sore or wound on the healthcare provider.
There are a small number of instances when HIV has been acquired through contact with mucous membranes (like the eyes). For instance, if an HIV patient's blood splashes into a healthcare worker's eye, there is a chance of transmission. Research suggests that the risk of HIV infection after mucous membrane exposure is less than 1 out of 1,000.
management immediately after exposure
Healthcare workers who are exposed or suspect they were exposed to HIV should follow the protocol of their healthcare facilities.
First Aid should be provided immediately after the injury. Wounds and areas of skin that were exposed to body fluids should be washed thoroughly with soap and water. Mucous membranes (like the eyes) that were exposed to the virus should be flushed with water.
The exposure should be evaluated for potential to transmit HIV infection, based on the severity of exposure (how much bodily fluid the person came into contact with) and specific bodily fluid that the individual was exposed to.
The exposed healthcare worker should be tested for HIV infection if he/she consents to testing. However, it generally takes about two to eight weeks for the body to produce antibodies to the virus, which is needed for an accurate test result. It may take some patients three months or longer to develop the antibodies. Therefore, a protocol called post exposure prophylaxis (PEP) should be provided within 72 hours of exposure if the individual was exposed to an HIV-infected patient or if it is strongly suspected that the patient is HIV-positive.
The patient who is suspected of having HIV should only be tested after obtaining informed consent. Testing should also include appropriate counseling and care referral. The test results must remain confidential.
Exposure risk reduction education should occur with counselors who are evaluating the events that preceded the exposure.
An exposure report should be made and sent to the U.S. Centers for Disease Control and Prevention (CDC).
post‑exposure prophylaxis (pep)
Post-exposure prophylaxis (PEP) is short-term antiretroviral treatment that is administered to reduce the likelihood of HIV infection after potential exposure. Healthcare facilities should provide treatment to personnel as part of a universal precautions program that is designed to reduce staff exposure to infectious hazards at work.
It is estimated that PEP can reduce the rate of infection among exposed healthcare workers by as much as 79%. According to the World Heath Organization (WHO), availability of PEP to healthcare workers will help increase staff motivation to work with HIV-infected patients, and may help to retain staff who are worried about the risk of HIV exposure at work.
PEP should begin as soon as possible after exposure. While there is no time limit in most country recommendations, treatment is most effective when it is initiated within two to four hours of exposure. Combination therapy, usually with two or three antiretrovirals, is recommended because it has shown to be more effective than a single agent.
The specific regimen and dosage depends on the patient's overall health, severity of exposure, availability of antiretrovirals, and known or possible cross-resistance to different drugs. In general, the recommended combination therapy is 250-300 milligrams of zidovudine (Retrovir®) twice daily with 150 milligrams of lamivudine (Epivir®) twice daily. If a third drug is needed, 800 milligrams of indinavir (Crixivan®) three times daily or 600 milligrams of efavirenz (Sustiva®) once daily (not recommended for pregnant women) is recommended.
Treatment should last a minimum of two weeks and no longer than four weeks. Healthcare workers should have access to one month's worth of antiretroviral therapy.
There are many side effects of antiretroviral treatment, including dizziness, confusion, fatigue, headache, difficulty sleeping, nausea, vomiting, and diarrhea. Studies have shown that about 22% of those receiving PEP stopped taking the medications before the four-week course is completed because of the side effects. Treatment is less effective if discontinued prematurely.
Long-term side effects may cause serious medical problems, including changes in metabolism like abnormal lipid and glucose metabolism, which may cause changes in the body shape due to loss and/or accumulation of body fat.
non‑occupational post exposure prophylaxis (npep)
In January 2005, the U.S. Department of Health and Human Services (DHHS) announced that non-occupational post exposure prophylaxis (nPEP) should be available to all individuals who are exposed to HIV, not just healthcare workers.
While the DHHS does not recommend for or against the use to nPEP, it encourages healthcare providers and patients to weigh the risks and benefits with individual patients who may have been exposed to HIV in the last 72 hours. When the risk of transmission is negligible or when patients seek care more than 72 hours after a substantial exposure, nPEP is not recommended because it is not usually effective. The sooner treatment is started, the more likely it will prevent HIV transmission.
However, healthcare providers might wish to consider prescribing nPEP for patients who seek care more than 72 hours after substantial exposure if the benefit of treatment outweighs the risks for side effects from treatment.
Treatment should last a minimum of two weeks and no longer than four weeks. Treatment is less effective if discontinued prematurely.