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Accidental, unexpected, unwanted exposure to biological material from a person potentially infected by the Human Immunodeficiency Virus (HIV), Hepatitis B virus (HBV) or hepatitis C virus (HCV) may lead to infection of the exposed person through a puncture, a lesion of the skin or mucous membranes of the mouth, eyes, vagina or rectum (HGA 2016, SPNS 2015, GeSIDA 2015).
Exposure can be occupational, OE (in the field of work, generally sanitary) by means of punctures or splashes and non-occupational, NOE, (punctures, bites, sexual contact without protection or due to protection failure, sexual assaults).
This article does not deal with the exposure of infants to the breastmilk of an HIV+ mother.
INFECTING FLUIDS AND TISSUES (Carrion 2018, CDC 2016, Goldschmidt 2016, HGA 2016, SPNS 2015, GeSIDA 2015, Ford 2015, WHO 2014, Azkune 2011, Chin 2010, McCarthy 2002):
The fluids that can infect are: blood, semen, vaginal secretions, breastmilk, cerebrospinal, pleural, peritoneal, pericardial, amniotic and synovial fluids and tissues, organs, cell cultures and laboratory virus concentrates. The following are not considered infectious: sweat, saliva, sputum, vomit, nasal mucus, tears, urine, or faeces, unless they have visible blood
RISK OF INFECTION AND INDICATIONS OF POST-EXPOSURE PROPHYLAXIS (PEP) (Tan 2018, HGA 2016, SPNS 2015, GeSIDA 2015, Azkune 2011, Chin 2010):
In OE there is 0.3% (0.2-0.5%) risk of HIV transmission, 1.8% (0-7%) of HCV and 6 to 30% of HBV transmission.
If the exposure was to blood with high viral load, it is necessary to use PEP. With a high viral load (<40 copies/mL), individually assess the PEP. With exposure to liquids which are not considered infectious, do not use PEP.
The most frequent NOE is sexual intercourse without protection or with protection failure (condoms). The contact status is not usually known. There is greater risk in case of rape with bleeding, if the contact does not receive ART and its viral load is greater than 1,500 copies/ml: PEP indicated.
PEP not indicated after kissing, scratching and punctures from discarded needles.
ACTIONS AFTER EXPOSURE (HGA 2016, SPNS 2015, GeSIDA 2015, WHO 2014):
Immediately wash with water and soap or saline solution, let blood flow and disinfect.
ANALYTICS:
Contact-source analytic: HBsAg, HCV Ag, HIV and viral load (VL-HIV-1) and type of antiretroviral treatment (ART). The results should be known in 2 hours.
Analytics of exposed persons: anti-HIV, anti-HCV and anti-HBV (Anti-HBs, Anti-HBc, HBsAg), blood count, renal and hepatic function, state of HB and tetanus vaccination.
In addition, in sexual assaults: pregnancy, gonorrhea, syphilis, chlamydia, HSV, HPV and trichomoniasis tests.
PEP of HBV, HCV, TETANUS AND SEXUAL ASSAULT (Tan 2018, HGA 2016, SPNS 2015, GeSIDA 2015, Ford 2015, WHO 2014):
If the exposed person is not HB vaccinated or has an anti-HBs titre <10 mUI/ml, vaccinate and administer anti-HBV gammaglobulin in the first 72 hours. HCV does not have an effective prophylaxis, the situation must be monitored.
Evaluate in wounds and punctures, vaccinate against tetanus.
PEP of sexual assaults: include antibiotic guidelines: Ceftriaxone + Metronidazole + Azithromycin or Doxycycline or Cefixime.
HIV PEP (Muller 2018, Carrion 2018, Tan 2018, WHO 2016, CDC 2016, Goldschmidt 2016, HGA 2016, SPNS 2015, GeSIDA 2015, WHO 2014, Azkune 2011, Chin 2010):
If PEP is indicated, start it immediately and, if necessary, withdraw it later. Start PEP within 24 hours and not beyond 72 hours.
Daily for 28 days: [Tenofovir (TDF) / Emtricitabine (FTC)] + Raltegravir (RAL). In renal failure (HGA 2016) substitute TDF / FTC for Zidovudine (ZDV) + Lamivudine (3TC)
Alternative to RAL: co-formulated combination of Ritonavir (r) with Darunavir (DRV), Atazanavir (ATV) or Lopinavir (LPV).
Infants older than 1 month and children: ZDV + 3TC + Ral or LPV/r. The 3TC can be replaced by Emtricitabine (FTC).
Clinical and analytical follow-up at 1.5, 3 and 6 months is recommended.
BREASTFEEDING:
Breastfeeding mothers exposed to HBV or HCV or sexually transmitted diseases can continue to breastfeed (HGA 2016). HBV and HCV are not transmitted through breastmilk. The necessary treatments are compatible with breastfeeding (CDC 2016).
If a breastfeeding mother who has been exposed to HIV has been classified as low risk and does not need PEP, she can continue to breastfeed.
If the exposure was classified as high risk, the mother should be informed that PEP is very effective in preventing infection, but does not involve zero risk: there has been occasional failures with various explanations (Muller 2018, CDC 2016, MSE 2015 , GeSIDA 2015, Beckmann 2014, Roland 2005) and that the medication used in PEP is compatible with breastfeeding.
Breastfeeding does not contraindicate PEP, but the risks and benefits of continuing breastfeeding should be discussed with the mother (WHO 2014).
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