Put More oPEP in Your Step: The Impact of Occupational Post-Exposure Prophylaxis
Pharmacists should be aware of workplace hazards involving sharps and, if necessary, initiate oPEP.
Health care workers are frequently exposed to needles, and despite numerous safety protocols, approximately 385,000 needle stick and other sharps-related injuries still occur annually in US hospitals.1
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Sharps-related injuries have decreased since the 1990s due to the increased focus on sharps safety protocols. Devices with sharps injury protection (SIP), such as retractable or sheathed needles, have also been introduced. However, various factors can still impact the safety of employees handling needles. The Needlestick Safety and Prevention Act of 2000 mandated the use of SIP devices to mitigate injuries; nevertheless, accidents still happen, especially when safety mechanisms are not activated immediately in busy health care settings.2,3
In high-stress, chaotic environments, health care workers can be easily distracted by their colleagues, patients, or surroundings. Such interruptions have been associated with incidence of clinical errors.4 Additionally, some health care settings have adopted a culture of patient safety that prioritizes patient care. This can prompt employees to compromise their own safety by taking shortcuts to meet the facility’s standard of care. Patient safety culture can cause more job-related stress by increasing the likelihood of employee injuries and diminishing the overall quality of care provided to patients.5 Employees must be aware of the potential life-changing consequences of not following safe work practices.
Occupational Exposure
Health care workers can be exposed to potentially infectious body fluids via different points of entry such as the bloodstream, mucous membranes, or skin that is not intact. Potentially infectious body fluids include blood and cerebrospinal, synovial, pleural, peritoneal, pericardial, and amniotic fluids. Body fluids such as feces, nasal secretions, saliva, vomit, and urine are not considered potentially infectious, unless they contain visible blood.6
Individuals who handle needles are at risk of exposure to bloodborne pathogens including, but not limited to, hepatitis B virus (HBV), hepatitis C virus (HCV), and human immunodeficiency virus (HIV), although the risk of occupational HIV transmission via percutaneous injury is low (less than 1%).6-8
“Occupational exposure” refers to a work-related injury that exposes a health care professional to blood or body fluids that might contain HIV. This is considered a medical emergency with specific protocols to follow. In the case of exposure to a needle that has been used by an individual with a confirmed or unknown diagnosis of HIV, occupational post-exposure prophylaxis (oPEP) is given to the exposed health care worker to prevent HIV infection.6
Post-Exposure Protocols
If exposed to potentially infectious body fluid, health care workers should immediately follow 3 pertinent steps:
- Depending on the site of injury, employees must wash the area with soap and water; flush the nostrils, mouth, or skin with water; or irrigate the eye(s) with sterile water or saline.
- Report the incidence to a supervisor.
- Seek medical treatment immediately.9
Despite this universal protocol, it is estimated that about half of sharps injuries are not reported.3 If left unreported, it is difficult to understand the prevalence and magnitude of needlestick injuries in the health care setting.
Additionally, if medical attention is not obtained, employees may unknowingly contract a bloodborne pathogen, which can lead to further complications. In this circumstance, timing is critical. oPEP is most effective in preventing HIV when given within 72 hours of exposure. After 72 hours, the benefits of oPEP are unclear.6
oPEP is not indicated for everyone who experiences a needlestick injury. Therefore, seeking immediate medical attention is necessary for determining if oPEP is required. When the source of exposure is unknown (eg, needle from a sharps disposal container), initiation of oPEP is decided on a case-by-case basis. The severity of exposure and epidemiologic likelihood of HIV exposure should be evaluated. However, when the source patient is known, this patient should undergo rapid HIV testing. Rapid testing can produce results within 30 minutes. This promotes timely decision-making regarding the initiation of oPEP for the exposed health care worker. If rapid testing is not available, but other HIV testing is, then initiation of oPEP should not be delayed while waiting for results.6
If the source patient refuses to be tested or is determined to have positive results for HIV, then oPEP should be taken for the full 28-day duration. If the source patient’s results come back as negative for HIV after prophylaxis is initiated, then oPEP can be discontinued.6
Drug Therapy
There is 1 preferred regimen for oPEP, which includes emtricitabine (FTC; Emtriva; Gilead Sciences) and tenofovir disoproxil fumarate (TDF; Truvada; Gilead Sciences) and raltegravir (Isentress; Merck).6
FTC-TDF is a combination of 2 HIV-1 nucleoside reverse transcriptase inhibitors (NRTIs). FTC is a nucleoside analog of cytidine and TDF is an acyclic nucleoside phosphate diester analog of adenosine monophosphate. Both act by competitively inhibiting the activity of HIV-1 reverse transcriptase, preventing the virus from converting RNA into DNA and incorporating into the host’s cells. This causes chain termination in the viral DNA to stop the replication of any virus that may have entered the body. Each tablet contains 200 mg of FTC and 300 mg of TDF. Pharmacists should provide counseling regarding the most common adverse effects (AEs)—which include headache (7%) and abdominal pain (4%)—in individuals taking FTC-TDF for prophylaxis. FTC-TDF has special dosing considerations (Table 1) for individuals with renal impairment due to the TDF component.10
Raltegravir is an integrase inhibitor (INSTI) that inhibits the catalytic activity of HIV-1 integrase. This prevents the insertion of unintegrated linear HIV-1 DNA into the host cell so the HIV-1 provirus cannot form. Each tablet contains 400 mg of raltegravir. Exposed health care workers will take 1 tablet by mouth twice daily. The most common AEs that individuals experience include insomnia (4%), headache (4%), and nausea (3%). Individuals are at risk for elevated creatine kinase, which can result in myopathy or rhabdomyolysis.11
Health care workers indicated for oPEP who are pregnant or breastfeeding can take both FTC-TDF and raltegravir without risk for complications or major birth defects. However, it is recommended that people living with HIV should not breastfeed their infants to avoid the risk of postnatal transmission of HIV. Therefore, health care workers with unknown HIV status should avoid breastfeeding until they are confirmed to be negative for HIV.10,11
There are alternative regimens available for individuals who cannot tolerate or are contraindicated to the preferred regimen (Table 2).6
Additionally, health care employees should be informed of possible drug toxicities that may present as a rash or hypersensitivity reaction that could mimic acute HIV seroconversion. Therefore, these individuals require careful monitoring. Prior to starting oPEP, health care workers should undergo HIV testing for seroconversion after exposure. Follow-up HIV testing should be done at 6 weeks, 12 weeks, and 6 months after exposure. A fourth-generation HIV antigen (Ag)/antibody (Ab) immunoassay allows for earlier detection of HIV infection. Persons living with HIV are highly infectious during acute stages, so early detection is very important to prevent further spread of the infection.6,12,13
The Role of the Pharmacist
Pharmacists play a key role in promoting adherence to oPEP and preventing needlestick injuries from occurring in the future.
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Medication adherence is very important for individuals receiving oPEP. The goal of all antiretroviral therapy is for the HIV virus to remain undetected. Nonadherence in patients living with HIV is associated with detectable HIV RNA levels.14 In individuals taking antiretroviral therapy for prophylaxis, the effectiveness of preventing HIV is highly dependent on adherence. Effectiveness is greater than 80% if they are adherent.15
Completing the full 28-day regimen as prescribed can be difficult for health care professionals due to AEs of FTC-TDF and raltegravir. Pharmacists can recommend prescribing anti-emetics as an adjunct to oPEP to help improve adherence.6Pharmacists should also counsel on the importance of adherence and encourage reaching out if individuals are experiencing AEs. This allows pharmacists to recommend nonpharmacologic or pharmacologic options to relieve symptoms or discomfort.
Additionally, the difference in once-daily dosing for FTC-TDF and twice-daily dosing for raltegravir may be confusing for some and act as a barrier to adherence.16 Pharmacists can suggest the use of a pill box or setting alarms while counseling individuals on the different dosing schedule to promote adherence.
Pharmacists should also advise exposed health care workers to use precautions such as avoiding blood or tissue donations and using barrier contraception to prevent secondary transmission, especially during the first 6 to 12 weeks after exposure.6
When engaging with exposed health care workers, pharmacists should be mindful of the stigma and fear surrounding a potential diagnosis of infection. It is important to display empathy and use person-first language in counseling sessions. Bringing positivity to the conversation can give exposed individuals a sense of hope in a time of uncertainty.
In the health care setting, pharmacists can prevent future needlestick injuries from occurring in the workplace by reinforcing safety measures to colleagues. This includes using devices with safety features, avoiding recapping needles, disposing needles in a conveniently placed sharps container immediately after use, and reviewing the protocol to become familiar with appropriate steps in the case of a needlestick injury.9
Conclusion
In the health care setting, needlestick and other sharps-related injuries are a serious occurrence. Health care professionals should be aware of the preventive safety measures put in place to avoid injuries. However, in the case of an accident and suspected exposure to HIV, employees can start a 28-day oPEP regimen. Adherence to the regimen and attending follow-up appointments is the key to successful prophylaxis. Pharmacists have a major role in providing education to exposed health care employees to promote adherence to medications and workplace protocols.
