What is the recommended treatment and management for a non-vaccinated individual with no known immune system compromise, following post-exposure to blood-borne pathogens, including hepatitis B (HBV), hepatitis C (HCV), and Human Immunodeficiency Virus (HIV)?

Post-Exposure Management for Blood-Borne Pathogens

For a non-vaccinated individual exposed to blood-borne pathogens, immediately wash the exposure site with soap and water, initiate hepatitis B post-exposure prophylaxis with both HBIG and hepatitis B vaccine, start HIV post-exposure prophylaxis within 72 hours if indicated based on source testing, and monitor for hepatitis C infection without prophylaxis. 1

Immediate Care at Exposure Site

First action within minutes of exposure:

• Wash wounds and skin thoroughly with soap and water 1
• Flush mucous membranes with water if mucous membrane exposure occurred 1
• Do not squeeze or manipulate the wound excessively 1

Risk Assessment and Source Evaluation

Determine exposure risk by evaluating:

• Type of fluid involved (blood, visibly bloody fluid, other potentially infectious fluid, or concentrated virus) 1
• Type of exposure (percutaneous injury carries 0.3% HIV risk, 1.8% HCV risk, and 6-30% HBV risk in unvaccinated individuals) 2
• Mucous membrane or non-intact skin exposure 1

Test the source patient immediately:

• Obtain rapid testing for HBsAg, anti-HCV, and HIV antibody 1
• Use rapid HIV testing when available to expedite decision-making 1
• Critical pitfall: Do not waste time testing discarded needles or syringes for virus contamination—this is not recommended 1

Hepatitis B Post-Exposure Prophylaxis

For unvaccinated individuals exposed to HBsAg-positive or unknown source:

• Administer hepatitis B immune globulin (HBIG) as soon as possible 1
• Initiate hepatitis B vaccine series simultaneously 1
• Both HBIG and vaccine should be available for timely administration 1
• Test for anti-HBs response 1-2 months after the last vaccine dose 1
• Important caveat: Anti-HBs response cannot be accurately assessed if HBIG was received in the previous 3-4 months 1

HIV Post-Exposure Prophylaxis

Initiate HIV PEP within 72 hours (ideally within 24 hours) for high-risk exposures: 3

• Time is critical: PEP effectiveness decreases significantly after 72 hours, and the window for effective prophylaxis closes rapidly 3
• Basic regimen historically included Zidovudine (ZDV) 600 mg daily in divided doses plus Lamivudine (3TC) 150 mg twice daily 1
• Complete the full 28-day course if started 3
• Evaluate the exposed person within 72 hours after exposure and monitor for drug toxicity for at least 2 weeks 1
• Monitor periodically for adverse effects through baseline and follow-up testing every 2 weeks 1

HIV testing schedule:

• Baseline testing immediately before starting PEP 3, 4
• Follow-up at 6 weeks, 3 months, and 6 months post-exposure 1, 3
• Critical understanding: 95% of infected individuals will test positive by 6 weeks, but definitive exclusion requires 6-month testing 3, 4
• Test immediately if symptoms of acute retroviral syndrome develop (occurs in 81% of seroconverters at median 25 days) 3, 4
• Common pitfall: A negative test at 2-3 weeks does not exclude HIV infection—do not skip follow-up testing even if asymptomatic 3

Hepatitis C Management

No post-exposure prophylaxis is recommended for HCV exposure: 1, 5

• Perform baseline testing for anti-HCV and alanine aminotransferase (ALT) 1
• Follow-up testing for anti-HCV and ALT at 4-6 months after exposure 1
• Perform HCV RNA testing at 4-6 weeks if earlier diagnosis is desired 1
• Confirm repeatedly reactive anti-HCV enzyme immunoassays with supplemental tests 1
• Important context: Despite availability of direct-acting antivirals, prophylactic use is not supported due to low transmission risk (1.8%), lack of clinical trial data, and poor cost-effectiveness 5, 2

Counseling and Precautions During Follow-Up

Advise the exposed person to:

• Seek immediate medical evaluation for any acute illness during the follow-up period 1
• Use precautions to prevent secondary transmission during the 6-month follow-up period 1
• Understand that the actual risk of HIV transmission from needle stick is only 0.3-0.36% (3-4 per 1,000 exposures) 3

Special Considerations for Non-Vaccinated Status

For individuals with no prior HBV vaccination:

• This represents the highest risk scenario for HBV transmission (6-30% risk vs. <1% in vaccinated individuals) 2
• Both passive immunization (HBIG) and active immunization (vaccine series) are essential 1
• Complete the full vaccine series even after HBIG administration 1
• Key point: HBV vaccination should have been completed prior to any occupational exposure risk, but post-exposure vaccination still provides protection 6