DETERMINING THE NEED FOR HIV POST EXPOSURE PROPHYLAXIS (P.E.P.
)
AFTER AN OCCUPATIONAL EXPOSURE
STEP 1: DETERMINE THE EXPOSURE CODE (E.C.)
Is the source material blood, bloody fluid, other potentially infectious material (O.P.I.M:
semen, vaginal secretions, CSF, synovial, pleural, peritoneal, pericardial or amniotic fluids or
tissue), or an instrument contaminated with one of these substances?
YES NO
O. P. I. M. * Blood or No P.E.P. Needed
Bloody Fluid
WHAT TYPE OF EXPOSURE HAS OCCURRED?
Mucous Membrane or Skin Intact Skin Only + Percutaneous
Integrity Compromised** Exposure
Volume No P.E.P Needed Severity
Small Large Less Severe More Severe
(e.g., few drops, (e.g., several drops, major blood (e.g., solid bore needle, (e.g., large bore hollow
short duration) splash &/or longer duration [i.e., superficial scratch) needle, deep puncture,
several minutes or > ]) visible blood on device
used in source pt’s
artery or vein)++
E.C. 1 E.C. 2 E.C. 3 E.C. 4
*Exposure to OPIM must be evaluated on a case by case basis. In general, these body substances are
considered low risk for transmission in health care settings. Any unprotected contact to HIV in a research
laboratory or production facility is considered an occupational exposure that requires clinical evaluation to
determine need for PEP.
**Skin integrity is considered compromised if there is evidence of chapped skin, dermatitis, abrasion or open
wound.
+Contact with intact skin is not normally considered a risk for HIV transmission. However, if the exposure was to
blood & the circumstances suggests a higher volume exposure (e.g., an extensive area of skin was exposed or
there was prolonged contact with blood), the risk for HIB transmission should be considered.
++The combination of these severity factors (e.g., large bore hollow needle and deep puncture) contribute to an
elevated risk for transmission if the source person is HIB positive.
STEP 2: DETERMINE THE HIV STATUS CODE
(HIV S.C.)
What is the HIV status of the exposure source?
HIV Negative ^ HIV Positive ^^ Status Unknown Source Unknown
No P.E.P Needed
Lower Titer Exposure Higher Titer Exposure
(e.g., asymptomatic & high (e.g., advanced AIDS, primary
CD4 count ^^^) HIV infection, high or
increasing viral load or low
CD4 count ^^^)
HIV SC 1 HIV SC 2 HIV SC Unknown
^ A source is considered negative for HIV infection if there is laboratory documentation of a negative HIV antibody, HIV polymerase chain reaction
(PCR), or HIV p24 antigen test result from a specimen collected at or near the time of the exposure and there is no clinical evidence of recent
retroviral-like illness.
^^ A source is considered infected with HIV (HIV positive) if there has been a positive laboratory result for HIV antibody, HIV PCR, or HIV p24
antigen or physician-diagnosed AIDS.
^^^ Examples are used as surrogates to estimate the HIV titer in an exposure source for the purposes of considering PEP regimens & do not
reflect all clinical situations that may be observed. Although a high HIV titer (HIV SC2) in an exposure from a source with a low HIV titer also
must be considered.
STEP 3: DETERMINE P.E.P. RECOMMENDATION
EC HIV SC P.E.P. RECOMMMENDATION:
P.E.P. may not be warranted. Exposure type dose not pose a known risk for HIV
1 1
transmission. Whether the risk for drug toxicity outweighs the benefit of PEP should be decided
by the exposed employee & the treating clinician.
Consider basic regimen. Exposure type poses a negligible risk for HIV transmission. A high
1 2
HIV titer in the source may justify consideration of PEP. Whether the risk for drug toxicity
outweighs the benefit of PEP should be decided by the exposed employee & the treating
clinician.
Recommend basic regimen Most HIV exposures are in this category; no increased risk for
2 1 HIV transmission has been observed but use of PEP is appropriate.
Recommend expanded regimen . Exposure type represents an increased HIV transmission
2 2
risk.
Recommend expanded regimen Exposure type represents an increased HIV transmission
3 1 or 2
risk.
If the source or, in the case of an unknown source the setting where the exposure
Unknown occurred, suggests a possible risk for HIV exposure and the E.C. is 2 or 3, consider P.E.P.
basic regimen.
Basic Regimen: 4 weeks Truvada (Tenovir & Emtricitabine) 1 po daily. Truvada is better tolerated than Combivir, it is 1 st choice
unless known renal disease. Alternative is Combivir (Zidovudine (AZT) 300mg) and ( Lamivudine (Epivir) 150mg) 1 po BID
Expanded Regimen: Basic regimen PLUS, Kaletra 200/50 (Lopinavir 200 mg and Ritinavir 50 mg) 2 tablets po BID
{ updated 9/09}