What is the immediate management and post-exposure prophylaxis (PEP) regimen for healthcare workers who experience a sharps injury with potential Human Immunodeficiency Virus (HIV) and Hepatitis C Virus (HCV) exposure?

Sharps Injury Management and Bloodborne Pathogen Conversion Rates

Healthcare workers experiencing sharps injuries should immediately wash the wound with soap and water, report the exposure urgently, and initiate HIV post-exposure prophylaxis (PEP) within hours if indicated, as the risk of HIV transmission from a percutaneous injury with HIV-positive blood is approximately 0.3%, while HCV transmission risk is substantially higher at 1.8%, and no specific post-exposure prophylaxis exists for HCV. 1

Immediate Wound Management

First Actions at the Exposure Site:

• Wash wounds and skin sites immediately with soap and water 1
• Flush mucous membranes with water 1
• Do NOT apply caustic agents like bleach or inject antiseptics into the wound 1
• Do NOT express fluid by squeezing the wound, though antiseptics may be used for routine wound care 1

Transmission Risk by Pathogen

HIV Conversion Risk:

• Percutaneous exposure to HIV-positive blood carries approximately 0.3% transmission risk 2
• Risk varies based on depth of injury, visible blood on device, needle used in source patient's artery/vein, and source patient's viral load 3

HCV Conversion Risk:

• Percutaneous exposure to HCV-positive blood carries approximately 1.8% transmission risk 2
• HCV poses higher transmission risk than HIV from needlestick injuries 2

HBV Conversion Risk:

• Hepatitis B carries the highest transmission risk among bloodborne pathogens from sharps injuries 2
• Risk can exceed 30% if source is HBsAg-positive and HBeAg-positive without post-exposure prophylaxis 1

HIV Post-Exposure Prophylaxis Protocol

Timing is Critical:

• Initiate PEP as soon as possible, ideally within 2-4 hours, but no later than 72 hours post-exposure 1, 3
• Do NOT delay PEP while awaiting source patient HIV test results 1, 3
• Animal studies demonstrate PEP effectiveness diminishes significantly after 24-36 hours 1
• Consider PEP even if presenting after 36 hours for high-risk exposures 1

First-Line PEP Regimen (2025):

• Bictegravir/emtricitabine/tenofovir alafenamide (single tablet) OR
• Dolutegravir plus (tenofovir alafenamide or tenofovir disoproxil fumarate) plus (emtricitabine or lamivudine) 3

Duration:

• Complete 28-day course regardless of exposure severity 3
• Provide full 28-day prescription at initial assessment 3

Baseline Testing Before PEP:

• Rapid HIV test or laboratory-based antigen/antibody combination test on exposed worker 3
• Do NOT delay first PEP dose for test results 3

HCV Post-Exposure Management

Critical Limitation:

• No post-exposure prophylaxis exists for HCV 1
• Immune globulin is NOT effective for HCV prevention 1

Monitoring Protocol:

• Test exposed worker for anti-HCV antibody and ALT at baseline 1
• Repeat anti-HCV and ALT testing at 4-6 months post-exposure 1
• Early detection allows for treatment of acute HCV infection if transmission occurs 1

Source Patient Evaluation

Immediate Assessment:

• Test known source patients for HBsAg, anti-HCV, and HIV antibody using rapid testing when available 1
• Do NOT test discarded needles or syringes for virus contamination 1
• If source unknown, assess epidemiologic likelihood of exposure based on clinical setting 1

HIV-Positive Source Considerations:

• Obtain viral load, CD4+ count, and antiretroviral therapy history if available 1
• Consider drug resistance patterns when selecting PEP regimen 1
• Do NOT delay PEP initiation while gathering this information 1

Follow-Up Testing Schedule

HIV Monitoring:

• Test at 6 weeks, 12 weeks, and 6 months post-exposure 1
• Extended follow-up to 12 months may be considered for certain high-risk exposures 1

HCV Monitoring:

• Anti-HCV antibody and ALT at 4-6 months 1

Clinical Surveillance:

• Test immediately if acute retroviral syndrome symptoms develop regardless of timeline 1
• Monitor for PEP side effects with baseline and every 2-week laboratory testing 1

Situations Requiring Expert Consultation

Contact PEPline (1-888-448-4911) for:

• Delayed exposure report beyond 24-36 hours 1, 3
• Unknown source (needle in sharps container) 1, 3
• Pregnancy in exposed worker 1, 3
• Known or suspected antiretroviral resistance in source virus 1, 3
• Significant PEP toxicity requiring regimen modification 1

Common Pitfalls to Avoid

Documentation Failures:

• Under-reporting remains a major problem, with 25-90% of sharps injuries going unreported 2
• Only 45% of injured healthcare workers pursue appropriate follow-up 4
• Many reported injuries never appear in occupational health databases 5

Clinical Errors:

• Do NOT wait for source HIV test confirmation before starting PEP 3
• Do NOT assume low risk based on clinical setting alone 1
• Do NOT discontinue PEP prematurely due to manageable side effects like nausea 1
• Do NOT test sharp instruments directly for bloodborne pathogens 1

Prevention Emphasis:

• Nurses sustain the highest proportion of sharps injuries (52.4%), followed by cleaners (22.3%) 6
• Operating rooms, inpatient units, and emergency departments are highest-risk locations 6
• Hollow-bore needles cause 46.5% of injuries 4, 7
• Recapping used needles accounts for 30% of injuries and should be avoided 2