Evaluation of non-sexual, non-needlestick, non-occupational HIV post-exposure prophylaxis cases

Potential exposures to HIV outside of the workplace are a common reason for individuals to seek medical care for non-occupational HIV post-exposure prophylaxis (nPEP). Published guidelines from public health agencies recommend standardized diagnostic testing, follow-up, and initiating a 4-week course of antiretroviral (ARV) medications for higher risk HIV exposures if patients present within 72 h [1–4]. The vast majority of exposures are sexual, followed by needle exposures [5]. Here, we evaluate the clinical presentation, management decisions, and outcomes of non-sexual, non-needlestick exposures from a large nPEP cohort. The current retrospective cohort study took place in a dedicated HIV Prevention Clinic at the Toronto General Hospital (Toronto, Ontario) between January 2013 and August 2015. Research Ethics Board approval was obtained from the University Health Network. All cases were referred from one of three affiliated emergency departments. Based on standardized clinical algorithms, patients presenting to affiliated emergency departments for potential HIV exposures received baseline screening investigations and a 3–6 day ‘starter pack’ of a three-drug nPEP regimen. The patient was then contacted by the HIV Prevention Clinic prior to completing the starter pack and was evaluated by an HIV specialist. Exclusion criteria included sexual and needlestick exposures of all varieties, and all other nPEP cases were included. Standardized data were collected from identified charts and included the type of exposure, risk of HIV transmission (as deemed by the HIV specialist), nPEP use, and adherence to follow-up appointments. Of the 255 cases referred to the HIV Prevention Clinic, 15 (5.9%) were non-sexual, non-needlestick, non-occupational exposures. Of the 15 cases, five (33.3%) were women and 10 (66.7%) were men, with an age range of 21–48 years (mean 33.1 years). The exposure in nine (60%) cases was blood on skin that was either not intact or perceived to be not intact at the time of exposure. Five (33.3%) cases involved bite wounds, and one (6.7%) involved exposure of a mucous membrane to sputum that was possibly contaminated with blood. Table 1 summarizes these exposures. Of the nine cases involving exposure to blood on non-intact skin, seven involved minor skin defects or abrasions and were determined to have a negligible HIV transmission risk. In four cases, nPEP was prescribed for a 28-day course, often at the request of the patient. In one case, nPEP was discontinued when the source patient tested negative. nPEP was discontinued in one case as the patient was off ARVs for 5 days prior to presentation in clinic. One patient had nPEP discontinued at their clinic appointment due to the negligible risk of transmission and side effects from the regimen. Two cases were determined to be non-exposures as the patients’ skin was intact, and nPEP was not continued in the HIV Prevention Clinic.Table 1: Clinical presentation, management and follow-up of non-sexual, non-needlestick, non-occupational HIV post-exposure prophylaxis cases.The few cases of non-sexual, non-needlestick exposures were generally characterized as having a negligible risk of HIV transmission as determined by patient history and physical exam. However, management of some of these cases is complicated by uncertainty regarding the accuracy of the patient's history and whether all potential exposures were being described by the patient. These challenges in addition to patient preference played a role in the six cases in which nPEP was prescribed or continued. No HIV seroconversions were detected during the course of follow-up for each patient. A prior study evaluating changes to the initial nPEP regimens between the emergency department and outpatient clinic demonstrated that regimens were changed in roughly 20% of cases [6]. In our study, nPEP was discontinued in five (41.7%) of the 12 cases in which nPEP was initiated by the emergency department physician after a reevaluation of the risk of exposure in clinic. This process of nPEP initiation by the emergency department physician, followed by a reassessment of the exposure in a specialized out-patient setting a few days later allows for a valuable second appraisal of the risk of transmission and permits for discontinuation or modification of the regimen, providing better stewardship of ARV agents and a patient-centered approach to care. The circumstances described by the patients described above varied substantially and were often quite unique. Determining if a true HIV exposure occurred and estimating transmission risks remain within the clinician's judgment is solely based on the limited history and physical examination. Indeed, nPEP was often continued as the clinician's judgment was that the history was unreliable and the benefit of 28 days of nPEP outweighed the risk of withholding treatment. Non-sexual, non-needlestick, non-occupational exposures to HIV represent a minority of cases for those presenting for nPEP care. Although many of these cases likely represent a negligible or non-exposure, care for these individuals is complicated by limited history and little data to determine actual risk of HIV transmission. Acknowledgements Conflicts of interest There are no conflicts of interest.

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