What is the most appropriate treatment for a medical student who sustained a needlestick injury while caring for a patient with Human Immunodeficiency Virus (HIV) infection?

From the Guidelines

The most appropriate treatment for a medical student who sustained a needlestick injury while caring for a patient with HIV infection is immediate initiation of post-exposure prophylaxis (PEP) with a three-drug antiretroviral regimen, as recommended by the 2018 guidelines of the International Antiviral Society-USA panel 1.

Key Considerations

• The recommended regimen typically includes tenofovir disoproxil fumarate (TDF) 300 mg plus emtricitabine (FTC) 200 mg once daily (or as the combination pill Truvada), along with raltegravir 400 mg twice daily or dolutegravir 50 mg once daily.
• This medication regimen should be started as soon as possible, ideally within 2 hours of exposure, and continued for 28 days.
• Before starting PEP, baseline HIV testing of the medical student should be performed, along with testing for hepatitis B and C.
• The source patient's viral load and antiretroviral medication history should be obtained if possible to guide therapy selection.
• The exposed student should also receive follow-up HIV testing at 6 weeks, 3 months, and 6 months post-exposure.

Rationale

• PEP works by preventing viral replication in the early stages of infection before HIV becomes established in the body.
• The three-drug regimen is recommended because it provides broader coverage against potential resistant strains and has been shown to be more effective than single or dual-drug regimens in preventing seroconversion after occupational exposure, as supported by the 2016 recommendations of the International Antiviral Society-USA panel 1.
• The 2018 guidelines 1 also emphasize the importance of starting PEP as soon as possible after exposure to maximize effectiveness.

Additional Recommendations

• The medical student should be educated on the risks of exposure, safe handling of sharps, immunization, standard precautions, and safe work habits.
• The student should also be informed about the importance of follow-up testing and the potential side effects of PEP.
• The incident should be documented, and the student's employer should have a policy in place for managing occupational exposures to HIV and other bloodborne pathogens, as outlined in the 2007 guidelines for infection prevention and control in pediatric ambulatory settings 1.

From the FDA Drug Label

Tenofovir disoproxil fumarate is a nucleotide analog HIV-1 reverse transcriptase inhibitor and is indicated: in combination with other antiretroviral agents for the treatment of HIV-1 infection in adults and pediatric patients 2 years of age and older weighing at least 10 kg. Recommended tablet dosage in adults and pediatric patients weighing at least 35 kg: One tenofovir disoproxil fumarate tablet 300 mg tablet once daily taken orally without regard to food.

The most appropriate method of treatment for the medical student to prevent HIV infection after a needlestick injury is post-exposure prophylaxis (PEP) with antiretroviral medication, such as tenofovir disoproxil fumarate. The student should be started on a 28-day course of PEP as soon as possible, ideally within hours of the exposure.

• The recommended dosage is one 300 mg tablet once daily.
• It is essential to note that PEP should be started promptly, and the student should be closely monitored for any signs of HIV infection or side effects from the medication 2.

From the Research

Treatment for HIV Exposure

The most appropriate method of treatment for a medical student who sustained a needlestick injury while caring for a patient with Human Immunodeficiency Virus (HIV) infection is postexposure prophylaxis (PEP) 3, 4, 5, 6, 7.

Postexposure Prophylaxis (PEP)

• PEP is a form of secondary HIV prevention that may reduce the incidence of HIV infections 6.
• The decision to initiate PEP needs to be made in consultation with the patient, the family, and a clinician with experience in treatment of persons with HIV infection 3.
• PEP should be considered after significant occupational and non-occupational exposures 5.
• Antiretroviral therapy used for PEP is associated with significant toxicity, and the risk should be weighed against the potential benefits 3, 5.

Administration of PEP

• PEP should be started as soon as possible after an exposure, no later than 72 hours, and continued for 28 days 3, 7.
• Many clinicians would use 3 drugs for PEP regimens, although 2 drugs may be considered in certain circumstances 3.
• The simplest and least toxic regimens are to be preferred 7.
• Twice daily regimens should be used when possible, and may improve compliance 6.

Follow-up Care

• Careful follow-up is needed for psychologic support, encouragement of medication adherence, toxicity monitoring, and serial HIV antibody testing 3, 7.
• All patients should receive medical evaluation including HIV antibody tests, drug toxicity monitoring and counseling periodically for at least 6 months after the exposure 7.