Last reviewed: March 2026
Contents
MDM Templates
Near-Zero Risk Exposure
Patient presents for evaluation of occupational exposure. The mechanism involved *** with exposure to ***. Exposure was limited to contact with intact skin / non-infectious body fluid (saliva, urine, sweat, tears, or uncontaminated feces), or involved a sharp that had not been in contact with infectious body fluid, or involved a sharp that did not penetrate skin.
This exposure carries near-zero risk for HIV, Hepatitis B, and Hepatitis C transmission. Given the negligible risk, source patient testing and baseline labs on the exposed patient are not indicated. PEP was offered and the patient declined given the risk assessment.
Plan: Wound care as appropriate. No labs or PEP indicated for this risk level.
Disposition: Discharge with return precautions for any acute illness symptoms. PCP follow-up within 48 hours. Occupational health referral for documentation.
Clinically Meaningful Exposure
Patient presents for evaluation of occupational exposure. The mechanism involved *** with exposure to ***. This represents a clinically meaningful exposure: penetrating injury with an object that had been in contact with blood or potentially infectious body fluid, OR mucosal splash (eyes, mouth, nose) or non-intact skin exposure to blood or potentially infectious body fluid.
Given the meaningful transmission risk, PEP initiation, baseline labs, and source patient testing are indicated. Time is critical — PEP is most effective when initiated within 1-2 hours and should not be delayed for source results.
Plan: PEP initiated immediately — tenofovir-emtricitabine (Truvada) 1 tab PO daily + dolutegravir (Tivicay) 50 mg PO daily x 28 days. Baseline labs on exposed patient: rapid HIV, hepatic function panel, pregnancy test. Source patient: rapid HIV, Hepatitis C antibody and RNA, Hepatitis B surface antigen.
Disposition: Discharge with follow-up with occupational health and PCP within 72 hours for drug toxicity monitoring, counseling, and follow-up testing at 6 weeks, 12 weeks, and 6 months.
Clinical Education
Risk Assessment Framework
Near-zero risk (PEP generally NOT indicated):[1]
Contact with non-infectious body fluids (saliva, sputum, urine, vomitus, sweat, tears, feces without visible blood). Exposure to a sharp not in contact with blood. Sharps that did not penetrate skin.
Clinically meaningful (PEP indicated):[1]
Percutaneous injury (needlestick, scalpel) with blood or infectious body fluid contact. Mucosal splash to eyes, mouth, nose. Non-intact skin exposure to blood or infectious body fluids.
Highest risk exposures: Deep percutaneous injury, large-bore hollow needle, device visibly contaminated with blood, needle used in artery or vein, source patient with high viral load or AIDS. Transmission risk per percutaneous needlestick with HIV-positive source is approximately 0.3%.[1]
PEP Regimen
Current preferred PEP regimen (2024 USPHS update): Tenofovir disoproxil fumarate/emtricitabine (TDF/FTC, Truvada) 1 tab PO daily + dolutegravir (DTG) 50 mg PO daily x 28 days. This replaced the older raltegravir-based regimen due to better tolerability and once-daily dosing.[2]
Timing is critical: Initiate as soon as possible, ideally within 1-2 hours. PEP is likely ineffective after 72 hours. Do NOT delay PEP for source patient results — start immediately and adjust based on results.
Side effects to counsel about: Nausea, fatigue, headache (common, usually mild). Renal monitoring needed with tenofovir. Drug interactions with dolutegravir are minimal compared to older PIs.
Source Patient Testing
Source patient testing: Rapid HIV, Hepatitis B surface antigen, Hepatitis C antibody and RNA. Results guide whether PEP should be continued (if source is negative for all, PEP can be stopped). If the source patient refuses testing or is unable to consent, California law permits a rapid HIV test on an available blood sample in the context of a clinically meaningful exposure.[1]
Unknown source: If the source patient is unknown (e.g., needlestick from discarded sharps), PEP is generally recommended and continued for the full 28 days unless the clinical context makes HIV exposure extremely unlikely.
Hepatitis B Considerations
Check the exposed patient’s Hepatitis B vaccination status and antibody titer. If unvaccinated or non-responder (anti-HBs 10), no additional treatment needed.[3]
Hepatitis C Considerations
There is no PEP for Hepatitis C. Management relies on early detection and treatment. If the source is HCV positive, the exposed patient should be tested for HCV RNA at 4-6 weeks (earliest time for seroconversion) and HCV antibody at 4-6 months. If the patient seroconverts, direct-acting antiviral therapy achieves >95% cure rates and should be initiated promptly.[4]
References
- Kuhar DT et al. Updated USPHS Guidelines for the Management of Occupational Exposures to HIV. Infect Control Hosp Epidemiol. 2013;34(9):875-892. PubMed
- Mayer KH et al. Antiretroviral Post-Exposure Prophylaxis After Sexual, Injection-Drug, or Occupational Exposure — 2024 Update. MMWR Recomm Rep. 2024. CDC
- Schillie S et al. Prevention of Hepatitis B Virus Infection in the United States: ACIP Recommendations. MMWR Recomm Rep. 2018;67(1):1-31. PubMed
- Ghany MG et al. Hepatitis C Guidance 2023 Update: AASLD-IDSA Recommendations for Testing, Managing, and Treating Hepatitis C Virus Infection. Hepatology. 2023;77(2):632-660. PubMed
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