What to do after a needlestick injury with potential exposure to HIV (Human Immunodeficiency Virus) from a patient's blood?

Immediate Post-Needlestick HIV Exposure Management

Start HIV post-exposure prophylaxis (PEP) immediately—ideally within the first hour and absolutely within 72 hours—using a 28-day course of combination antiretroviral therapy, even before confirming the patient's HIV status. 1, 2

Immediate Actions (First 15 Minutes)

• Wash the exposure site thoroughly with soap and water immediately—do not squeeze or apply pressure to increase bleeding 3, 1
• Report the incident to your supervisor immediately and document the exposure details including date, time, type of device, and extent of injury 3, 1
• Seek emergency medical evaluation within 1 hour to initiate PEP—the sooner you start, the more effective it is, with effectiveness dropping dramatically after 72 hours 2, 4

Risk Context You Should Understand

The actual risk of HIV transmission from a percutaneous needlestick with HIV-infected blood is approximately 0.3-0.36% (3-4 per 1,000 exposures), but PEP reduces this risk by approximately 81% when started promptly 1, 2. Your risk is higher because this was a hollow-bore needle that had been in the patient's vein with visible blood 2. For comparison, hepatitis B risk without prophylaxis can exceed 30%, and hepatitis C risk is about 1.8% 1.

Testing Protocol

Source Patient Testing (Obtain ASAP)

• HIV antibody test (rapid testing preferred to expedite PEP decisions) 1
• Hepatitis B surface antigen (HBsAg) 3, 1
• Hepatitis C antibody (anti-HCV) 3, 1

Your Baseline Testing (Before First PEP Dose)

• HIV antibody or antigen/antibody combination test—but do not delay the first PEP dose waiting for results 1, 2
• Hepatitis B serology and document your vaccination history 3, 1
• Hepatitis C antibody (anti-HCV) 1
• Pregnancy test if you are a woman of childbearing age 1
• Complete blood count and renal/hepatic function tests (baseline for PEP monitoring) 1

Your Follow-Up Testing Schedule

• HIV testing at 6 weeks, 3 months, and 6 months post-exposure 1
• Hepatitis C testing (anti-HCV and ALT) at 4-6 months, with optional HCV RNA at 4-6 weeks for earlier diagnosis 1
• Monitoring for PEP drug toxicity every 2 weeks while on medication 1

PEP Regimen

Preferred Antiretroviral Combinations

• Bictegravir/emtricitabine/tenofovir alafenamide (single tablet once daily), OR 2
• Dolutegravir plus (tenofovir alafenamide or tenofovir disoproxil fumarate) plus (emtricitabine or lamivudine) 2
• Complete the full 28-day course—stopping early eliminates protection 2

Managing Side Effects

• Common side effects include nausea and gastrointestinal symptoms—use antiemetics or anti-diarrheal agents to maintain adherence 2
• Report severe symptoms immediately to your healthcare provider 2

Hepatitis B Management

Your management depends on your vaccination status:

• If you are unvaccinated or incompletely vaccinated and the source is HBsAg-positive: receive hepatitis B immune globulin (HBIG) immediately and start the hepatitis B vaccine series 3, 1
• If you were previously vaccinated and responded (documented anti-HBs): no treatment needed 3, 1
• If your response to vaccination is unknown: test for anti-HBsAg now and manage based on results 3

Hepatitis C Management

There is no post-exposure prophylaxis for hepatitis C—early identification through testing is the primary approach 1. If the source is HCV-positive, you need close monitoring with HCV RNA at 4-6 weeks and anti-HCV/ALT at 4-6 months 1.

Critical Pitfalls to Avoid

• Do not delay PEP beyond 72 hours—effectiveness drops dramatically, and ideally you should start within 1 hour 2, 4
• Do not attempt to test the discarded needle or IV cap for HIV—this is unreliable and not recommended by the CDC 1
• Do not stop PEP prematurely even if the source tests HIV-negative later—complete the full 28-day course once started 2
• Do not fail to return for follow-up testing—ensure a system is in place to track your scheduled tests 1
• Do not assume low risk means no action—the consequences of HIV infection far outweigh the manageable risks of PEP medications 2

Counseling and Precautions During Follow-Up

• Use barrier protection during sexual activity for 6 months post-exposure 1
• Do not donate blood, plasma, organs, tissue, or semen during the follow-up period 1
• Seek immediate medical evaluation for any acute illness (fever, rash, myalgia, fatigue) during follow-up, as these may indicate acute retroviral syndrome 1