What is the best next step for post-exposure prophylaxis (PEP) after a phlebotomist is stuck with a needle used on a patient with a history of syphilis, hypertension, and end-stage renal disease, but no known HIV status?

Post-Exposure Prophylaxis After Occupational Needlestick Injury

Start PEP immediately and perform a rapid HIV test on the source patient simultaneously—do not delay PEP initiation while awaiting test results. 1

Immediate Management Algorithm

Step 1: Initiate PEP Without Delay

• Begin PEP within 1-2 hours of the needlestick injury, as efficacy decreases significantly after 24-36 hours and is unlikely to be effective beyond 72 hours. 1
• The phlebotomist's exposure involves blood (highest risk body fluid) via percutaneous injury, which carries approximately 0.3-0.36% transmission risk per exposure—this warrants immediate prophylaxis. 2, 3
• Do not wait for the source patient's HIV test results before starting the first PEP dose. 1

Step 2: Concurrent Source Patient Testing

• Perform a rapid HIV antibody or fourth-generation antigen-antibody test on the source patient immediately while PEP is being initiated. 1
• A fourth-generation test is preferred because it can detect recent infection several weeks earlier than standard antibody tests. 1
• If the rapid test is negative and the source has no clinical signs of acute HIV infection, PEP can be discontinued. 1

Step 3: Risk Assessment of Source Patient

The source patient has multiple risk factors that increase the likelihood of HIV exposure:

• End-stage renal disease patients have higher HIV prevalence due to historical blood product exposures and dialysis-related transmission risks. 1
• History of syphilis indicates prior sexual exposure risk, as syphilis and HIV share transmission routes. 1
• Unknown HIV status with risk factors mandates presumptive PEP initiation. 1

Recommended PEP Regimen

Preferred Three-Drug Regimen

• Bictegravir/emtricitabine/tenofovir alafenamide (single tablet once daily) for 28 days. 3, 4
• Alternative: Dolutegravir 50mg once daily PLUS emtricitabine/tenofovir alafenamide for 28 days. 3, 4

Special Consideration for This Case

• Given the source patient's end-stage renal disease, if tenofovir is used, tenofovir alafenamide (TAF) is strongly preferred over tenofovir disoproxil fumarate (TDF) due to better renal safety profile. 1, 3
• Assess the phlebotomist's baseline renal function before initiating any tenofovir-based regimen. 3

Why Option A is Correct and Others Are Wrong

Option B (Defer PEP) is dangerous and contradicts all guidelines:

• The absence of documented HIV history does not mean the patient is HIV-negative. 1
• Unknown HIV status with risk factors (syphilis, ESRD) requires presumptive treatment. 1
• Delaying PEP beyond 72 hours renders it ineffective. 1

Option C (Test first, then start PEP) violates the fundamental timing principle:

• "Initiating PEP should not be delayed pending HIV test results" is explicitly stated in CDC guidelines. 1
• Even a rapid test takes 15-30 minutes, and every hour of delay reduces PEP efficacy. 1
• If testing reveals the source is HIV-negative, PEP can simply be discontinued. 1

Option D (HIV RNA testing) is inappropriate for initial management:

• HIV RNA testing is not recommended for routine source patient evaluation in occupational exposures. 1
• RNA testing takes longer to result than rapid antibody tests and would delay decision-making. 1
• RNA testing is reserved for detecting acute HIV infection when antibody tests are negative but clinical suspicion is high. 1

Follow-Up Protocol

Phlebotomist Testing Schedule

• Baseline: Rapid HIV test before starting PEP (do not delay first dose for results). 1
• 4-6 weeks post-exposure: HIV antigen-antibody combination test. 3, 4
• 12 weeks post-exposure: Final HIV testing. 3, 4

Monitoring for PEP Toxicity

• Complete blood count and renal/hepatic function tests at baseline and 2 weeks after starting PEP. 1
• Common side effects include nausea and gastrointestinal symptoms, which can be managed with antiemetics to improve adherence. 2

Critical Pitfalls to Avoid

• Never delay PEP initiation to "gather more information"—the 72-hour window is absolute, and optimal efficacy requires starting within hours. 1
• Do not stop PEP prematurely if the source tests HIV-negative on initial testing but had recent high-risk exposures within 3-6 months (window period concern). 1
• Complete the full 28-day course unless the source is definitively confirmed HIV-negative with no recent risk exposures. 1, 3
• Do not use a two-drug regimen for this exposure—three drugs are preferred for occupational exposures involving blood. 1