What is the plan of care for a patient who received a tattoo with dirty needles in a prison setting, potentially exposing them to bloodborne pathogens such as Human Immunodeficiency Virus (HIV), Hepatitis B (HBV), and Hepatitis C (HCV)?

Management of Prison Tattoo from Dirty Needles

Treat this as a percutaneous bloodborne pathogen exposure and immediately test for HIV, HBV, and HCV, with consideration for post-exposure prophylaxis based on the patient's baseline serology and vaccination status. 1

Immediate Assessment and Testing

Baseline Serologic Testing

• Test immediately for HIV antibody, HBV surface antigen (HBsAg), HBV surface antibody (anti-HBs), HBV core antibody (anti-HBc), and HCV antibody 1
• Document the patient's hepatitis B vaccination history, as this determines the need for post-exposure prophylaxis 1
• Recognize that prison tattooing represents a high-risk exposure due to shared needles, reused ink, and the high prevalence of bloodborne infections in incarcerated populations (16-41% HCV prevalence, elevated HBV rates) 1, 2, 3

Risk Stratification

• Prison tattoos carry significantly higher transmission risk than professional tattoos, with studies showing 2.0-3.6 times increased odds of HCV infection when tattoos are applied in prison settings versus professional parlors 4
• Among prisoners who received tattoos in prison, 27% reported needle sharing and 42% reported ink reuse 2
• One study of injection drug users showed increased risk for both HBV and HCV among those tattooed in prison, though evidence is mixed 1

Post-Exposure Prophylaxis Protocol

For Hepatitis B Exposure

If the patient is unvaccinated or has unknown vaccination status:

• Initiate hepatitis B vaccine series immediately (first dose within 24 hours if possible) 1
• Consider hepatitis B immune globulin (HBIG) if the source is known to be HBsAg-positive or if high-risk exposure occurred 1
• Complete the 3-dose vaccine series at 0,1, and 6 months 1

If the patient is vaccinated:

• Check anti-HBs titer; if protective (≥10 mIU/mL), no further action needed 1
• If non-protective or unknown response, give booster dose and consider HBIG if source is HBsAg-positive 1

For HIV Exposure

Assess need for HIV post-exposure prophylaxis (PEP):

• PEP should be initiated within 72 hours (ideally within 2 hours) if the exposure is deemed high-risk 1
• Given the high HIV prevalence in prison populations and the percutaneous nature of tattooing with potentially contaminated equipment, consider PEP initiation while awaiting baseline results 1
• Standard PEP regimen: tenofovir disoproxil fumarate/emtricitabine plus raltegravir or dolutegravir for 28 days 5, 6
• Before initiating tenofovir-based PEP, test for chronic HBV infection, as discontinuation can cause severe acute exacerbations of hepatitis B 5, 6

For Hepatitis C Exposure

• No post-exposure prophylaxis is available for HCV 1
• Baseline HCV antibody testing, then repeat at 3 and 6 months post-exposure 1
• If HCV antibody becomes positive, obtain HCV RNA to confirm active infection and refer for treatment evaluation 1

Follow-Up Testing Schedule

HIV Follow-Up

• Repeat HIV testing at 6 weeks, 3 months, and 6 months post-exposure 1
• If PEP was initiated, monitor for medication side effects and ensure completion of the 28-day course 5, 6

Hepatitis B Follow-Up

• If unvaccinated and vaccine series initiated, check anti-HBs titer 1-2 months after completing the series 1
• Monitor liver function tests at baseline and 3 months if concern for acute infection 1
• Patients coinfected with HIV and HBV who discontinue anti-HBV therapy require close monitoring for at least several months, as severe acute exacerbations can occur 5, 6

Hepatitis C Follow-Up

• Repeat HCV antibody at 3 and 6 months 1
• If seroconversion occurs, obtain HCV RNA and liver function tests 1
• Early treatment of acute HCV infection has high cure rates, so prompt referral to hepatology or infectious disease is critical 1

Local Wound Care

Tattoo Site Management

• Clean the tattoo site with soap and water 7
• Monitor for signs of local infection (erythema, warmth, purulent drainage, abscess formation) 7
• If signs of infection develop, consider both typical pyogenic bacteria (Staphylococcus aureus, Streptococcus pyogenes) and atypical pathogens including nontuberculous mycobacteria (NTM), which can be introduced through contaminated water in ink 7
• Standard empiric antibiotics for tattoo-associated infections include coverage for MRSA (trimethoprim-sulfamethoxazole, doxycycline, or clindamycin) 7
• If infection fails to respond to standard antibiotics within 48-72 hours, strongly consider NTM infection and switch to combination therapy with trimethoprim-sulfamethoxazole plus ciprofloxacin 7

Critical Pitfalls to Avoid

• Do not delay PEP initiation while waiting for source testing—the 72-hour window is critical for HIV PEP efficacy 1
• Do not assume the tattoo exposure is low-risk—prison tattooing has documented high rates of equipment sharing and bloodborne pathogen transmission 2, 3, 8, 4
• Do not start tenofovir-based PEP without first testing for HBV—abrupt discontinuation in HBV-infected patients can cause severe hepatic decompensation 5, 6
• Do not dismiss persistent tattoo site infections as simple bacterial infections—NTM infections require prolonged combination antibiotic therapy (minimum 4 weeks) and will not respond to standard antibiotics 7
• Do not forget to counsel the patient on transmission prevention during the follow-up period, including safer sex practices and avoiding blood donation 1