There is a risk of HIV, HCV and HBV transmission in occupational exposure and it differs depending on the fluid the professional has been exposed to. For HIV, prospective studies performed in healthcare workers have estimated that the average risk of transmission after a percutaneous exposure to blood is 0.3% (CI 95%: 0.2–0.5%). The risk of transmission after exposure to other fluids or tissues has not been quantified, but it is probably considerably lower than that of contact with blood.

The average incidence of seroconversion after a percutaneous exposure to a positive HCV source is 1.8% (range: 0–7%).

Accidental infection by HBV constitutes a well-established occupational risk for healthcare professionals if they are not vaccinated against this virus. The risk for unvaccinated workers to acquire an HBV infection in a percutaneous accident depends on the marker levels of the person from which the blood or corporal fluid comes from. Studies performed in healthcare workers with percutaneous exposure to HVB-contaminated blood show that the risk of transmission is lower than 30% if the source patient is HBs Ag positive and HBe Ag positive and lower than 6% if he/she is HBe Ag negative.

Post-exposure prophylaxis is a biomedical prevention strategy.1 Without a doubt, the best way of preventing occupational transmission is avoiding exposure. To this end, each institution should foster resource allocation to:

• (a)

  Teach and train workers in universal precautions. Including vaccination against HBV (Article 8 of the Royal Decree 664/1997 about protection of workers against risks related to exposure to biological agents at work) and the appropriate management of residues, which should be followed in every risk situation of contact with potentially contaminated liquids like blood or other fluid or tissue contaminated with blood, semen, vaginal discharge, cerebrospinal, synovial, pleural, peritoneal, pericardial or amniotic fluid.

• (b)

  Have the necessary materials available to act as a barrier (gloves, masks, white coats and protective glasses), as well as containers for disposable potentially contaminated material and security equipment (set up in various Autonomous Communities through transposition of the Council Directive 2010/32/EU of 10 May 2010 implementing the Framework Agreement on prevention from sharp injuries in the hospital and healthcare sector).

• (c)

  Guarantee counselling and 24-h assistance with access to serological diagnosis, preferably in less than 2h and always before 72h for HIV and as soon as possible and always before 96h for HBV and HCV (see algorithms of action).

• (d)

  Facilitate the access to medication in necessary cases within established time limits.

• (e)

  Establish the appropriate monitoring protocols.

• (f)

  Have professionals available working in attention and monitoring of occupational exposure (OE) cases (Labour Risk Prevention Services, Infection Units and Emergency Rooms).

• (g)

  Establish centralized notification rules to create a registry through Labour Risk Prevention Services (LRPS) and assess the efficacy of the interventions.

The worker must receive urgent assistance, for which he/she will immediately go to the labour health service during working hours and to the emergency services outside working hours, where he/she will be given a report explaining the assistance received, including injuries suffered. They must inform the immediate superior so that he/she can fill the accident report, which will be sent to a mutual insurance company, independently of being treated at the labour health service or the emergency room.

For skin wounds (punctures, cuts) and spatters to damaged skin, it is recommended to:

• (a)

  wash with water and soap;

• (b)

  let blood flow;

• (c)

  disinfect the wound with an antiseptic (povidone-iodine, chlorhexidine gluconate);

• (d)

  cover with a waterproof bandage.

For spatters to mucosa (connective tissue, etc.) it is recommended to wash with abundant water or physiological saline.

Caustic agents must never be applied. It is not recommended to “press”, because it induces hyperaemia, which may increase the risk to acquire the infection.

The risk of transmission after an OE depends on multiple factors like serological state of the worker, type of exposure, quantity of the virus existing in the inoculum and virological state of the source, as well as time elapsed since exposure.

Various studies prove that exposure to large viral loads is associated to a higher risk of transmission of the infection. Therefore, in periods of high viraemia, like acute infection stages or advanced stages of the disease, if the source is not receiving ART the risk of transmission is higher.

On the other hand, exposure to corporal fluids of patients with HIV infection and undetectable viral load does not completely eliminate the risk of transmission. However, it makes it very improbable, being essential to monitor and assess the PEP.

HIV shares transmission routes with HBV and HCV. Therefore, the assessment of the situation should be performed considering both types of hepatitis. HCV is not transmitted effectively through occupational exposure, as it has been previously said, the average seroconversion incidence after a contact with an HIV positive patient's blood is 1.8% and transmission through mucous membranes is very rare. HBV, as it has been discussed before, is frequently transmitted if the exposed worker is not vaccinated.

Assessment of the risk exposure is the same as for HIV regarding the way and type of exposure. It is essential to assess appropriately the presence of infection in the source patient. If the serological state is unknown, a blood drawn should be performed to make a serology under previous request of informed consent and be able to access the results in the shortest time. Systematic determination of HBV or HCV viral load is not necessary. It is only advised in case that the patient is in advanced immunosuppression state or has other diseases associated with the possibility of a false negative result of the serology. If the patient does not give its consent for the performance of serological determinations, being this unknown or impossible to be performed, the source should be considered as infected.

Moreover, the sensitivity of the exposed worker should be assessed, determining the serology of HCV, of HBV if he/she is not vaccinated and of anti-HBs if he is vaccinated and this was unknown before or he/she is immunosuppressed. The worker is considered susceptible of HBV infection when he/she is not vaccinated and, when vaccinated, he/she presents antiHBs <10mIU/ml.

There is no effective prophylaxis against HCV, because viral kinetics shows that there must be a previous established infection so that the treatment can be effective. Therefore, monitoring of these patients is important, to be able to diagnose a possible HCV acute infection as soon as possible, in which case the treatment can be more efficient.

Table 2 shows the protocol for action and PEP against HBV.

Recommendations

Exposure to HBV and/or HCV

• (1)

  In the case of HBV, the actions and PEP depend on the situation of the source patient as well as of the exposed person (strong recommendation, moderate quality evidence).

• (2)

  If the vaccination guideline against HBV is correct, monitoring should not be performed, except for possible legal implications. In these cases, a serological study against HBV should be performed at the start and at 6 months (strong recommendation, low quality evidence).

• (3)

  In the case of HCV, there is no effective PEP, so an early diagnosis of a possible acute infection of the exposed person should be guaranteed to be able to treat him/her as soon as possible (strong recommendation, very low quality evidence).

Risk and basic fundamentals of non-occupational percutaneous transmission are similar to those of occupational transmission, except for the frequent difficulty to identify the source of exposure that characterizes (NOE). Therefore, this section will focus on sexual transmission.

Non-occupational exposure (NOE) is defined as the accidental contact by sexual or percutaneous means to blood and/or other potentially HIV infected biological fluids outside the occupational or perinatal field.

HIV transmission can only take place by exposure to potentially infecting fluids. The highest risk of transmission is through blood or fluids containing visible blood. Semen, vaginal discharge, cerebrospinal, pleural, pericardial, peritoneal and amniotic fluids, and human milk are also considered potentially infecting. Urine, faeces, saliva, vomit, nasal discharge, tears, sweat and sputum are not considered infecting as long as they do not contain visible blood.

The probability of HIV transmission will basically depend on the type of exposure, the source person's state, the amount of virus in the inoculum and the exposed individual.

Taking all these factors into account, different risk degrees can be established. These risk degrees can be modified by the aforementioned concurrent factors. When referring to sexual relations, these are considered as potential risk when a condom has not been used or has been used inappropriately. The type of exposure is described from the exposed point of view.

• 1.

  Considerable risk, if the following three conditions are met:

  • •

    exposure of anus, vagina, eyes, mouth or other mucosa membranes, damaged skin or percutaneous contact;

  • •

    with potentially infecting fluids;

  • •

    and an HIV positive source.

  In these cases it is recommended that the person exposed receive NOPEP

• 2.

  Risk to be assessed individually, if the following three conditions are met:

  • •

    exposure of anus, vagina, eyes, mouth or other mucosa membranes, damaged skin or percutaneous contact;

  • •

    with potentially infecting fluids;

  • •

    and a source with unknown HIV state.

    The probability of getting an HIV infection when the source's state is unknown, can be estimated by multiplying the probability of the person being positive and the probability of transmission.

    As it has been said, in NOE it is not always possible to know if the source of exposure has an HIV infection. This is the reason why NOPEP is recommended if the source has a high probability of being infected by HIV:

    • 1.

      men who have sex with men (MSM),

    • 2.

      intravenous drug user (IDU),

    • 3.

      sex worker,

    • 4.

      sex offender,

    • 5.

      background of ingress in correctional facilities or

    • 6.

      an individual coming from a country with an HIV prevalence higher than 1% (Haiti, Bahamas, Jamaica, Belize, Trinity and Tobago, Estonia, Russia, Thailand and Sub-Saharan Africa).

• 3.

  Negligible risk:

  • •

    Any type of exposure to fluids not considered potentially infecting, independently of the source's state relating HIV.

  • •

    Any type of exposure with any type of fluid if the source is HIV negative.

  • •

    In these cases it is not recommended to perform NOPEP.

• 4.

  No considerable risk:

  • •

    Kisses.

  • •

    Bite without interruption.

  • •

    Superficial scratch with a sharp object, including needles abandoned on the street.

  • •

    Infecting fluids on undamaged skin (0%).

  • •

    In these exposures it is not recommended to perform NOPEP.

Assessment of risk of non-occupational percutaneous exposure is similar to that of occupational exposure, except for the frequent difficulty to identify the exposure source that characterizes NOE. Moreover, the risk of transmission of HBV and HCV by sexual means should be considered in NOE.

Regarding HBV, it is important to know the source's state and the state of immunity of the exposed subject and vaccinate or use anti-HBV gamma globulin when necessary. In patients non-immunized against HBV or who do not know their immunological state, the decision to vaccinate should not be postponed until receiving the anti-HBs serology (Table 2).

More frequently, cases of HCV transmission after sexual intercourse are described, especially in MSM. Moreover, there is no effective prophylaxis against HCV, because viral kinetics shows that for the treatment to be efficient, there should be an established infection. Therefore, monitoring of these patients is so important to be able to diagnose a possible acute HCV infection as soon as possible, in which case the treatment can be more efficient.

Recommendations

• (1)

  In the case of HBV, actions depend on the situation of the source patient as well as of the exposed person (strong recommendation, moderate quality evidence).

• (2)

  If HBV vaccination guideline is appropriate, monitoring should not be performed, except for possible legal implications. In these cases, a serological study against HBV should be performed at the beginning and at 6 months (strong recommendation, low quality evidence).

• (3)

  Regarding HCV, currently there is no effective PEP measure, so recommendations should be aimed at an early diagnosis of a possible acute infection of the person exposed, to be able to treat him/her as soon as possible (strong recommendation, low quality evidence).

After exposure by sexual means, the possibility of transmission of other STI (like syphilis, gonococcus and chlamydia) should be considered. This depends on the prevalence in the community, the type of exposure, the existence of a traumatism and the number of source people.

Recommendations

• (1)

  After an exposition by sexual means, apart from HIV, other STI should be called off, performing the appropriate diagnosis proceedings (strong recommendation, high quality evidence).

• (2)

  In the case of sexual abuse, it is recommended to start a triple empirical therapy (ceftriaxone plus metronidazole plus azithromycin plus doxycycline) (strong recommendation, moderate quality evidence).

PEP guidelines of choice consist on the combination of two nucleosides/nucleotides reverse transcriptase inhibitors (NRTI) associated to a third ARVD of a different family.

Due to their better tolerance and once-a-day administration, the two preferential NRTI are co-formulated (1 pill a day) tenofovir/emtricitabine (TDF/FTC). As an alternative, co-formulated (1 pill two times a day) zidovudine/lamivudine (ZDV/3TC) can be used if you do not want to use TDF (e.g., for people with kidney disease). The use of abacavir is not recommended due to the risk of hypersensitivity to said drug, because it is not possible to have available HLA-B*5701 in the person exposed at the beginning of PEP.

As third drug a protease inhibitor enhanced with ritonavir (PI/r) or an integrase inhibitor (IN) can be used, because the probability of exposure to a virus resistant to these ARVD is very low. Among different PI/r available, just as in antiretroviral treatment guides, the preferential ones are darunavir/ritonavir (DRV/r, 800/100mg a day) or atazanavir/ritonavir (ATV/r 300/100mg a day) and as an alternative lopinavir/ritonavir (LPV/r 2 pills two times a day). As IN it is recommended to use raltegravir (RAL, 1 pill two times a day) due to its good tolerance, scarce drug interactions and larger experience. With other IN, like elvitegravir/cobicistat (EVG/COBI) and dolutegravir (DTG) there is not enough experience, so currently they should only be used as alternative drugs. Regarding the use of PI/r or RAL, the newest guides about PEP prefer RAL to enhance adherence and tolerance as well as due to its scarce risk of interactions, although it should be administered two times a day.

Generally, it is not recommended in preferential guidelines the use of first generation non-nucleosides reverse transcriptase inhibitors (NNRTI), efavirenz (EFV) and nevirapine (NVP), as third drug, due to its side effects and higher risk of primary resistances. Due to its better tolerance, rilpivirine (RPV) and etravirine (ETR) could be an alternative. A recent study has shown good results with RPV, but there is no experience with ETR in PEP.

When the source patient of the exposure has known or suspected resistances (previous virological failures) to one or more ARVD of the preferential guidelines recommended in PEP or in case the exposed person has possible contraindications to the use of some of them, it is recommended to consult an expert in HIV infection to select the most appropriate guideline in these cases, without this being a delay in the start of PEP (the recommended guideline can begin and the expert review and adjust it as soon as possible, preferably before 24–72h).

Recommendations

• (1)

  It is recommended to use TDF/FTC with RAL as a preferential guideline, in both occupational and non-occupational PEP (strong recommendation, moderate quality evidence).

• (2)

  As alternative guidelines TDF/FTC can be used with DRV/r, ATV/r, DTG, EVG/COBI or RPV, in both occupational and non-occupational PEP (weak recommendation, low quality evidence).

Even though the optimum length of PEP is unknown, based on the results of studies with animal models and occupational transmissions, a 28-day guideline is recommended.

Recommendations

• (1)

  A 28-day guideline is recommended for PEP (strong recommendation, low quality evidence).

• (2)

  A reassessment of adherence and toxicities is recommended in 72h after beginning PEP (strong recommendation, low quality evidence).

Once beginning PEP, a reassessment of the patient within 72h after exposure is recommended. Currently, new data about it can be obtained, as well as clarifying risks and benefits, modifying and adjusting the PEP guideline, guaranteeing an appropriate adherence and managing symptoms associated to side effects. Later on, clinical controls at least every 2 weeks are recommended until completing the PEP guideline.

Monitoring will be the same in OPEP and NOPEP. However, in the case of exposures by sexual means an early detection of other STI should be performed (syphilis, gonococcus, chlamydia).

ART toxicity is a very important problem that conditions the adherence to it. To this we have to add the existence of possible drug interactions derived from the previous or concomitant administration of other drugs that may reduce the benefit of PEP or increase the possibility of side effects.

If a toxicity or side effect that can limit the success of PEP is observed, modification of the guideline or use of other treatments that minimize these side effects should be assessed (e.g. antiemetics).

When selecting PEP, there are different guides and webpages in which you can look up the main side effects of ARVD employed and the risk of interactions.

It is recommended that the professional assess in the PEP prescription visit the need of giving psychological support depending on the level of anxiety and worries the patient has. If the anxiety level is high, there is a risk that the transmission of information is useless because the emotional state of the patient can make it more difficult for the patient to comprehend the instructions to follow, with a fundamental effect of a worse adherence to the treatment. If we confront a sexual abuse situation it is essential to refer the patient to the mental health centre of reference and monitor the adherence properly, because it has been shown to be inadequate in the context of sexual abuse.

Regarding occupational PEP, the professional should give all the necessary information to resolve doubts. Even though it is not usual, if anxiety or distress is very high and it may interfere with his/her work activities, it will be necessary to refer the patients to mental health specialists.

Regarding children and adolescents, the professional should assess the need to refer to the corresponding mental health team depending on anxiety and worries the family or child presents. The referral of the family to an entity that treats these topics and that has qualified professionals available can also be considered. In the case of proven sexual abuse, referral for psychological intervention by professionals specialized in this field will be essential. In the case of adolescents, it is important that the professional uses during interviews a close language and style, aimed at creating a climate of confidence and closeness that facilitates the obtaining of true information.

Except for adolescents, who can receive an identical guideline as adults, children should receive a guideline adjusted to this age, taking into account the approval state of ARVD for paediatric age recommended in adults’ PEP, as well as the availability of suspension for children who cannot swallow pills or capsules.

In case the child is not properly vaccinated or he/she is vaccinated but presents negative serology (anti-HBs), vaccination and immunoglobulin specifically against HBV intramuscular is recommended, if possible during the first 72h.

Recommendations

• 1.

  The same diagnosis system should be followed as for adults (strong recommendation, low quality evidence).

• 2.

  If it is indicated, a 28-day length of PEP treatment is recommended, preferably within the first 6h after exposure, and always within the first 72h (strong recommendation, low quality evidence).

• 3.

  PEP in adolescents (>12 years old) can be performed following an identic guideline as for adults (strong recommendation, low quality evidence).

• 4.

  PEP in children younger than 12 years old should consist on emtricitabine (FTC)+zidovudine (AZT)+lopinavir enhanced with ritonavir (LPV/r). In children who cannot swallow pills, these drugs will be administered in paediatric suspension (strong recommendation, low quality evidence).