OSHA: Occupational Exposure to Bloodborne Pathogens

Transmission of and subsequent infection with HBV after occupational exposure to HBV is common. The risk of developing serologic evidence of HBV infection after an occupational, percutaneous exposure is 37% to 62%, and the risk of developing clinical hepatitis is 22%-31% (Shenoy & Weber, 2021; Weber, 2022). A splash contact can transmit hepatitis B to a mucous membrane (Schillie et al., 2018). There are no reported incidents of transmission of HBV through intact skin (Chilaka et al., 2020).

Transmission of and infection with HCV after percutaneous exposure is uncommon (Egro et al., 2017; Weber, 2022). The CDC has estimated that the incidence of HCV seroconversion (the production of antibodies to a specific pathogen) after an  HCV exposure is 0% to 7%, with an average of 0.7% (Weber, 2022). Egro et al. (2017) examined data from 13 years of HCW occupational exposure to HCV-contaminated body fluids. The authors reported that the estimated risk of HCV infection from percutaneous exposure to anti-HCV-positive blood was 0.2%. There were 458 mucocutaneous exposures, and no HCW developed an infection (Egro et al., 2017).

The risk of HIV transmission after a needlestick or a sharps injury where the object was contaminated with blood from someone who has an HIV infection is approximately 0.23%. The risk of HIV transmission after a mucous membrane exposure to blood from someone who has an HIV infection is approximately 0.09% (Fauci et al., 2022). These estimates assume that the exposed HCW does not receive antiretroviral therapy within 24 hours after the exposure (Fauci et al., 2022; Shenoy & Weber, 2021). Transmission of HIV through non-intact skin has occurred, but the level of risk for this type of exposure is unknown (Fauci et al., 2022). There are currently no reported incidents of transmission of HIV through intact skin (Chilaka et al., 2020; Fauci et al., 2022).

The risk of transmission of and infection with HBV, HCV, or HIV to HCWs depends on the HBV vaccination status of the employee, how common these viruses are in the patient population, the viral load of the source, and how the exposure occurred (Weber, 2022; Zachary, 2023). Transmission and infection are more likely to occur and the risk is increased if the patient has a high viral load; if the needlestick was from a hollow bore needle; if the needle had been in an artery or a vein; if the injury is deep; if there was visible blood on the needle/instrument, or if a large volume of blood was involved (Fauci et al., 2022; Weber, 2022; Zachary, 2023).

Situations that increase the risk of a needlestick injury include, but are not limited to:

• Recapping (Canadian Centre for Occupational Safety and Health [CCOSH], 2024; CDC, 2021; CDC, 2019; Ibrahim et al., 2024).
• Improper disposal (Canadian Centre for Occupational Safety and Health [CCOSH], 2024; Ibrahim et al., 2024).
• Accessing an IV line (Canadian Centre for Occupational Safety and Health [CCOSH], 2024).
• Needle insertion or removal (Canadian Centre for Occupational Safety and Health [CCOSH], 2024).
• Using disposable syringes (Weber, 2022).
• Restraining a patient (CDC, 2019).
• Passing a sharp to another HCW (Canadian Centre for Occupational Safety and Health [CCOSH], 2024).
• Transferring a body fluid between containers (CDC, 2021).
• Suturing (Weber, 2022).
• Work environment, e.g., distraction/lack of concentration, frequency of exposure to needles and/or sharps, long hours, poor staffing, time pressure, and job-related stress (Ibrahim et al., 2024; Weber, 2022).

Standard 1910.1030 states that employers must offer hepatitis B vaccination to at-risk employees at no cost (OSHA, n.d.). Employees are exempt if they have been vaccinated, if antibody testing shows that they are immune, or if the vaccine is contraindicated (OSHA, n.d.).

Hepatitis B vaccination is effective. Approximately 95% of vaccinated, immunocompetent adults are seroprotected (Mironova & Ghany, 2024; Nikolopoulou et al., 2023).

There are no hepatitis C and HIV vaccines.

Engineering controls are devices, equipment, and procedures that help reduce the risk of exposure to bloodborne pathogens (OSHA, n.d.). Examples of engineering controls mentioned in Standard 1910.1030 are disposal containers for needles and sharps, needleless systems for self-sheathing needles, and sharps with built-in injury protection (OSHA, n.d.). Example: Sharps with engineered sharps injury protections means that a non-needle sharp or a needle device used for withdrawing body fluids, accessing a vein or artery, or administering medications or other fluids has a built-in safety feature or mechanism that effectively reduces the risk of an exposure incident (OSHA, n.d.).

The OSHA Bloodborne Pathogens standard recommends using Universal Precautions. Universal Precautions were the original CDC infection guidelines for preventing exposure to and transmission of bloodborne pathogens. Standard precautions, which were developed later, were added to and expanded to universal precautions. Standard Precautions are used by all healthcare facilities today.

Standard Precautions include:

• Hand hygiene
• Respiratory hygiene and cough etiquette
• Use of personal protective equipment (PPE)
• Safe injection practices

Hand hygiene has been identified as the most important method of preventing and reducing the transmission of pathogens from one patient to another and from an infected site on a patient to a clean site on the same patient (Anderson, 2025; Gammon & Hunt, 2020). Unfortunately, HCW compliance with hand hygiene protocols is often sub-optimal (Hoffmann et al., 2020). Poor compliance is a source of iatrogenic infections (Kovacs-Litman et al., 2021). The OSHA Bloodborne Pathogens standard states that employers must provide handwashing equipment and facilities (OSHA, n.d.), and employees must know when and how to wash their hands (OSHA, n.d.).

Hand hygiene can be done with an alcohol-based hand sanitizer or soap and water (CDC, 2024a). Alcohol-based hand sanitizers are preferred because they are (CDC, 2024a):

1. More effective at killing microorganisms on the hands than soap
2. Simpler to use
3. Are less likely than soap and water to dry or irritate the skin

An alcohol-based hand sanitizer should be used in these situations (CDC, 2024a):

• Immediately before and immediately after touching a patient
• Immediately before performing an aseptic procedure or before handling an invasive device or a piece of invasive equipment
• Immediately after taking off the gloves
• After touching anything in the patient's immediate environment
• After you have contacted blood, body fluids, or a contaminated surface
• Before touching a clean part of the patient, after you have been working or touching a contaminated or soiled part

To properly use an alcohol-based hand sanitizer (CDC, 2024a):

• Put the recommended amount on your hands
• Rub your hands together, covering every part of your hands and fingers until they are dry; this usually requires about 20 seconds
• Pay particular attention to the thumbs, between the fingers, and the fingertips; these areas are often missed

Soap and water should be used in these situations (CDC, 2024a):

• When your hands are visibly soiled
• When you are providing direct care for someone who has or could have infectious diarrhea
• Before eating and after using the restroom
• During the care of patients with suspected or confirmed infection during outbreaks of C. difficile or norovirus

To properly wash your hands with soap and water:

• Wet your hands
• Apply the recommended amount of soap and then rub your hands together, covering every part of your hands and fingers
• Do this for 15 to 20 seconds
• Rinse your hands and fingers
• Use a paper towel to dry them
• Use the towel to turn the faucet handle to the off position
• Discard the towel

The recommended 15 to 20 seconds is a guideline only, and the CDC notes that the length of time is less important than ensuring you clean all areas of your hands (CDC, 2024a).

The World Health Organization (WHO) Save Lives: Clean Your Hands program has a simple way to remember when to use hand hygiene.

Respiratory hygiene and cough etiquette were added to Standard Precautions in 2003 in response to the severe acute respiratory syndrome (SARS) outbreak (Siegel et al., 2007).

Viruses like the coronaviruses SARS-CoV-2003 and SARS-CoV-2 and the influenza virus are transmitted by infected droplets that are spread when someone coughs, sneezes, talks, and to a lesser degree, by airborne transmission (CDC, 2024b; Gandi, 2025). Respiratory hygiene and cough etiquette can help prevent the transmission of viruses that cause respiratory infections, and this infection control technique includes the following measures (CDC, 2024c):

• Post signs that inform people to cover their mouths and noses with tissues when they cough or sneeze.
• The facility should provide tissues.
• The tissue should be discarded after it has been used. The facility should provide a no-touch receptacle for discarding used tissues.
• Wash your hands with an alcohol-based hand sanitizer or soap and water after touching your mouth or nose.
• Alcohol-based hand sanitizer or soap and water should be provided.
• After contact with respiratory secretions or contaminated materials and objects, clean your hands with an alcohol-based sanitizer or soap and water.
• Offer a mask to anyone who is coughing or sneezing.
• Practice social distancing.
• The facility should clean frequently touched surfaces, including countertops, handrails, doorknobs, and chairs/ chair arms.

Personal protective equipment is designed to prevent direct contact and/or inhalation transmission of pathogens. Personal protective equipment includes eye shields, face shields, foot/shoe covers, gloves, goggles, gowns, head covers, and respirators. Employers must provide employees with the PPE they need to protect themselves and provide training on how to use PPE (OSHA, n.d.).

Choose the PPE to use by assessing a situation and determining what you may be exposed to and how you may be exposed. Healthcare facilities must train employees in the proper use of PPE, but healthcare professionals must use their judgment to decide what PPE they need. For example, the OSHA Bloodborne Pathogens Standard states, “Masks in combination with eye protection devices, such as goggles or glasses with solid side shields, or chin-length face shields, shall be worn whenever splashes, spray, spatter, or droplets of blood or other potentially infectious materials may be generated and eye, nose, or mouth contamination can be reasonably anticipated (OSHA, n.d.)." PPE must be donned and removed correctly to protect patients and HCWs.

It is important to note that handwashing and the proper use of gloves are effective infection control techniques. However, healthcare workers often do not follow handwashing recommendations (Hoffmann et al., 2020; Moore et al., 2021. Gloves are a necessary part of infection control (Anderson, 2025). However, gloves can tear and be penetrated (Zhang et al., 2021). Using gloves does not eliminate the need for hand hygiene (Anderson, 2025). Likewise, hand hygiene does not eliminate the need for gloves (Anderson, 2025). Gloves should be changed when they are damaged, when you move from a contaminated body site to a clean body site, and when the gloves are bloody, dirty, or contaminated by body fluids (Anderson, 2025).

Safe injection practices, also called injection safety, are practices and techniques that:

• Prevent the transmission of bloodborne pathogens to patients and healthcare workers when IV catheters, IV equipment, needles, and sharps are used
•  Prevent unsafe disposal of potentially harmful medical waste

A good rule to remember is One Needle, One Syringe, Only One Time!(CDC, 2024d)

Safe injection practices were added to Standard Precautions after four large outbreaks of HBV and HCV infection occurred in patients who had been treated in ambulatory care centers (an endoscopy clinic, a hematology/oncology clinic, a pain clinic, and a private physician's office) (CDC, 2024e). The outbreaks were caused by these specific failures to use safe injection practices (CDC, 2024e). These unsafe practices included the reinsertion of used needles into a multiple-dose vial or a container of a solution, using a single needle/syringe to give IV medication to multiple patients, and preparing medications in the same place where used needles/syringes were dismantled.

The specific techniques of safe injection practices are listed below (CDC, 2024e). They can be usefully separated into six basic categories:

1. Aseptic technique
2. Correct and safe use of syringes and needles
3. Correct and safe use of IV cannulas, IV solution bags and bottles, and IV tubing
4. Correct and safe use of medication vials
5. Infection control practices for lumbar puncture procedures
6. Proper disposal of hazardous waste

• Always use aseptic technique when using IV catheters, IV delivery systems, or needles.
• Do not administer medications from a syringe to multiple patients, even if the needle or cannula on the syringe is changed.
• IV catheters, infusion sets, bags, medications, solutions, needles, syringes, and cannulas are sterile, single-use items that should never be reused for another patient.
• A cannula, a needle, or a syringe that has been used to enter or connect to an IV tubing, an IV administration set, or an IV bag should be considered contaminated and should not be reused.
• Single-dose medication vials should be used whenever possible.
• Do not use a single-dose ampule or vial to give medications to multiple patients; do not combine the leftover contents of single-dose ampules or vials.
• Use a sterile cannula, needle, or syringe to enter a multiple-dose vial.
• Do not leave a multi-dose vial in the immediate area where patient care is delivered, and store multi-dose vials as per the manufacturer's instructions.
• Do not use bags or bottles of intravenous solution as a common supply source for multiple patients.
• Infection control practices for special lumbar puncture procedures include wearing a surgical mask when placing a catheter or injecting material into the spinal canal or subdural space, e.g., during myelograms, lumbar puncture, and spinal or epidural anesthesia.
• Needles and sharps should be discarded into a sharps container.
• Wash hands before and after giving an injection. 

The OSHA Bloodborne Pathogens Standard recommendations for the safe use of needles and sharps are listed below:

• Contaminated needles and other contaminated sharps shall not be bent, recapped, or removed unless the employer can demonstrate that no alternative is feasible or that a specific medical or dental procedure requires such action.
• Bending, recapping, or needle removal must be done using a mechanical or one-handed technique.
• Shearing or breaking contaminated needles is prohibited.
• Contaminated reusable sharps shall be placed in appropriate containers immediately or as soon as possible after use until properly reprocessed.
• These containers shall be color-coded or labeled, leakproof on the bottom and the sides, and puncture-resistant (OSHA, n.d.).

After a needlestick or a sharps injury, immediately wash the wound with soap and water (Weber, 2022; Zachary, 2023). If there has been an ocular, mucous membrane, or non-intact skin exposure, flush the area with water (Weber, 2022; Zachary, 2023). Small wounds that involve HIV exposure can be cleaned with an alcohol-based hand wash (Zachary, 2023). Alcohol has been shown to kill HBV and HCV (Zachary, 2023). Topical antiseptics can be applied to a wound that involves HBV or HCV exposure, but there is no evidence that they are effective at preventing transmission (Weber, 2022). Do not inject anything into the area, do not apply bleach, and do not waste time squeezing the wound to try and express blood or fluid from the wound (Weber, 2022; Zachary, 2023).

The OSHA Bloodborne Pathogens Standard defines exposure as specific eye, mouth, other mucous membranes, non-intact skin, or parenteral contact with blood or other potentially infectious materials that results from performing an employee's duties.

Employees should report exposure to blood and body fluids, a needlestick injury, or a sharps injury immediately, or as soon as possible(National Institute for Occupational Safety and Health [NIOSH], 2024; National Clinician Consultation Center, 2021). The importance of immediately reporting an exposure cannot be overstated! If an HCW is exposed to HIV, post-exposure prophylaxis (PEP) MUST be started as soon as possible and preferably within 1 to 2 hours after the exposure (Zachary, 2023).

The treatment for an HBV exposure or a possible HBV exposure will depend on the HBV status of the source and the employee's HBV immune status (Schillie et al., 2018; Weber, 2022). There are multiple scenarios.

1. The employee has evidence of a prior HBV infection. No treatment is needed, even if the source has a positive HBsAg (hepatitis B surface antigen) test (Schillie et al., 2018; Weber, 2022).
2. The employee has completed the HBV vaccination series, and they have an adequate response. An adequate response is an HBsAb (hepatitis B surface antibody) level ≥ 10 mIU/mL; in this case, no treatment is needed even if the source has a positive HBsAg test (Schillie et al., 2018; Weber, 2022).
3. The source patient has a positive HBsAg test or the HBsAg status can’t be determined, and the employee has completed HBV vaccination, but they are a non-responder, i.e., the HBsAb level is < 10 mIU/mL. In this situation, the employee should be given two doses of hepatitis B immune globulin (HBIG) (National Clinician Consultation Center, 2021; Weber, 2022). The first HBIG dose should be given as soon as possible (National Clinician Consultation Center, 2021). The second dose should be given 28-30 days later (UpToDate Online, n.d.). Depending on the HBV vaccine series the employee received, they may need to be revaccinated (National Clinician Consultation Center, 2021). Six months after the exposure, the employee should have HBsAg and HBsAb testing done (Weber, 2022).
4. The source patient’s HBsAg is negative. The employee should be vaccinated, and no other treatment is needed (Weber, 2022). One month after the vaccination, the employee should have HBsAb testing done (Hibberd, 2025).
5. For employees who have not completed the HBV vaccination series, the HBsAg status of the source should be determined, but the employee's HBsAb should not be measured. An HBsAb level > 10 mIU/mL does not indicate immunity (Weber, 2022). If the HBsAg of the source is positive or if it cannot be determined, the employee should be given one dose of HBIG and complete the vaccination series, and if unvaccinated, be given the complete vaccination series (Weber, 2022).

An employee exposed to an HBsAg-positive source or a source whose HBsAg status is unknown should not donate blood, organs, plasma, semen, or tissues during the six-month follow-up period (Schille et al., 2018; Weber,2022). Sexual practices do not need to be changed, becoming pregnant is not contraindicated, and breastfeeding can be continued (Schillie et al., 2018). Also, the employee can continue their normal work responsibilities (Schillie et al., 2018).

There is no HCV vaccine. Direct-acting antivirals (DAA) are highly effective for treating acute and chronic HCV infections. However, there is no evidence that DAA treatment is an effective prophylactic (Weber, 2022), and DAA treatment is not recommended or approved for acute occupational exposure to HCV (CDC, 2024f; Moorman et al., 2020; National Clinician Consultation Center, 2021; Weber, 2022). The source should have an HCV RNA test and an HCV antibody test done (National Clinician Consultation Center, 2021; Weber, 2022). Testing should be done as soon as possible, preferably within 48 hours of exposure (Weber, 2022).

If the antibody test is positive, the exposed employee should have an HCV antibody test and an HCV RNA test (Weber, 2022). Testing should be done as soon as possible, preferably within 48 hours of the exposure (Weber, 2022).

If the source does not have HCV RNA, no further testing of the source or the employee needs to be done (National Clinician Consultation Center, 2021). If the source has a positive HCV RNA test and/or a positive HCV antibody test, they should be referred for evaluation and (possible) treatment (National Clinician Consultation Center, 2021).

An employee who has been exposed to a source whose HCV tests, either one, were positive or whose HCV status cannot be determined should be evaluated three to six weeks after the exposure (National Clinician Consultation Center, 2021). If the HCV RNA is positive at that time, the employee should be referred to a specialist for care (National Clinician Consultation Center, 2021).

If the HCV RNA at that time is negative, the employee should return in four to six months for HCV antibody testing. If the test is negative, further testing is unnecessary; if it is positive, refer the employee to a specialist for care (National Clinician Consultation Center, 2021). If an exposed employee has signs/symptoms of a viral illness within the six-month follow-up period, they should contact a healthcare provider (National Clinician Consultation Center, 2021).

Occupational exposure to HIV should be treated as a medical emergency (Fauci et al., 2022). There is no HIV vaccine. The source should have a rapid HIV antibody-antigen test done. If an acute HIV infection is suspected to be present or the source has an increased risk of HIV infection in the previous four weeks, HIV RNA should be measured (Zachary, 2023). The exposed employee should have a rapid HIV antibody-antigen test or an HIV antibody test (National Clinician Consultation Center, 2021; Zachary, 2023), HCV testing, and, depending on the employee’s immunization status, HBV testing (National Clinician Consultation Center, 2021). The antigen-antibody test is preferred because it detects an infection sooner than the antibody test (Zachary, 2023).

The result of a rapid combined HIV antigen-antibody test will typically be available within 30 minutes (Cachay, 2025). These tests are very sensitive and specific. A negative test should be considered definitive unless the source may have an acute HIV infection (National Clinician Consultation Center, 2021; Zachary, 2023). A positive rapid antibody-antigen test should be considered a true positive, and the use of PEP should be considered(National Clinician Consultation Center, 2021). A confirmatory test to determine the accuracy of the rapid test should be done, and if that test is negative, PEP, if it was started, can be discontinued (Zachary, 2023).

There is a lag between an initial, acute HIV infection and the production of detectable HIV antibodies (National Clinician Consultation Center, 2021; Kuhar et al., 2013; Zachary, 2023). This lag, referred to as a window period, is concerning, but in the United States, no cases of occupational HIV transmission during the window period have been detected (Kuhar et al., 2013; National Clinician Consultation Center, 2021). If the source could have an acute HIV infection or if in the previous 1 to 2 months the source engaged in high-risk behaviors, an HIV RNA PCR test (aka a viral load test), should be done to see if the source is in the window period and to determine if PEP is needed (National Clinician Consultation Center, 2021).

Post-exposure prophylaxis should be given:

• If the source is known to be HIV positive
• While waiting for the results of the source's HIV tests, especially if the source has a high risk of having an HIV infection, and
• If the source's HIV status cannot be determined and if a high-risk needlestick or sharps injury occurred (Zachary, 2023)

Post-exposure prophylaxis with anti-retroviral drugs should be started as soon as possible, preferably within one to two hours post-exposure (National Clinical Consultation Center, 2021; Kuhar et al., 2013; Zachary, 2023). Do not wait for test results unless the results will be available within 1 to 2 hours (National Clinician Consultation Center, 2021). Delaying the use of PEP is likely to diminish its effectiveness (Kuhar et al, 2013). Authoritative sources recommend that PEP should not be given ˃ 72 hours post-exposure (National Clinician Consultation Center, 2021; Zachary, 2023). However, this recommendation is based on drug testing in animals (National Clinician Consultation Center, 2021; Zachary, 2023), and treatment at > 72 hours post-exposure can be considered (National Clinician Consultation Center, 2021; Zachary, 2023). Zachary (2023) wrote, “For most healthcare professionals, we do not initiate PEP if more than 72 hours have elapsed after the initial exposure. However, we do offer PEP after a longer interval to patients with a very high-risk exposure (e.g., sharps injuries from a needle that was in an artery or vein of an HIV-infected source patient)”. For such healthcare professionals, The United States Public Health Service suggests that PEP can be offered up to one week after the exposure.” 

It is recommended that clinicians get a consultation if they intend to prescribe PEP > 72 hours post-exposure (National Clinician Consultation Center, 2021). Call the National Clinician Consultation Center at 1-888-448-4911 for advice about this situation.

If the source's rapid HIV test is negative, the employee can discontinue using the PEP (National Clinician Consultation Center, 2021).

Worldwide, recommendations for PEP protocols vary considerably (Maisano et al., 2025). The recommended PEP drug regimens are described below (CDC, 2025; National Clinician Consultation Center, 2021). 

CDC PEP Regimen 1: This is the preferred regimen for healthy adults and adolescents

• Emtricitabine 200 mg and tenofovir disoproxil fumarate 300 mg (Combination tablet), one tablet once a day, plus
• Raltegravir, 400 mg, one tablet twice a day or
• Dolutegravir, 50 mg, one tablet once a day

CDC PEP Regimen 2: An alternative regimen for healthy adults and adolescents

• Emtricitabine 200 mg and tenofovir disoproxil fumarate 300 mg (Combination tablet), one tablet once a day, plus
• Darunavir, 800 mg, one tablet once a day and
• Ritonavir, 100 mg, one tablet once a day

National Clinician Consultation Center PEP Regimen 

• Emtricitabine 200 mg and tenofovir disoproxil fumarate 300 mg (Combination tablet), one tablet once a day, plus
• Raltegravir 400 mg, one tablet twice a day, or
• Dolutegravir, 50 mg, one tablet once a day

Serum BUN and creatinine, a CBC (complete blood count), and hepatic function tests (LFTs) should be done before starting PEP (CDC, 2025; National Clinician Consultation Center, 2021).

The duration of treatment is 28 days, and these drug regimens are safe and well tolerated(CDC, 2025; National Clinician Consultation Center, 2021). Common adverse effects include diarrhea, fatigue, insomnia, nausea, stomach upset, and vomiting. They are usually self-limiting, and the CDC notes that “... the benefits of HIV prevention outweigh any other risks posed by the medications” (CDC, 2025).

Tenofovir disoproxil fumarate can be nephrotoxic. Its use should be avoided in patients with an eGFR < 60 mL/min/1.73 m²(Zachary, 2023), and an alternative should be used.

Abacavir sulfate should not be used in any PEP regimen (CDC, 2025). It has been linked to potentially fatal hypersensitivity reactions. These are more likely to occur in people with the HLA-B*57:01 allele (Mounzer et al., 2019), and because PEP must be started as soon as possible, there is no time for genetic testing (CDC, 2025).

The risk of vertical HIV transmission is high (National Clinician Consultation Center, 2021; Whiteley, 2019), and perinatal transmission can occur, as well (National Clinician Consultation Center, 2021; Whiteley, 2019). For a pregnant patient, the benefits of anti-retroviral therapy are much higher than the known risks (Abrams, 2024), and the PEP drugs are effective (Hughes & Cu-Uvin, 2021; Rogers & Roberts, 2020). Using PEP during the first trimester does not appear to cause congenital disabilities (Abrams, 2024; National Clinician Consultation Center, 2021), and the prevalence of congenital abnormalities in pregnant women who are taking antiretroviral therapy is equivalent to the prevalence of congenital abnormalities in the United States (Abrams, 2024). The toxic effects of PEP drugs do not appear to be amplified or changed by pregnancy.

All pregnant patients who are beginning PEP with antiretrovirals should be entered into the Antiretroviral Pregnancy Registry. This is a database that collects information on the outcomes of pregnancies in which anti-retroviral drugs were used, regardless of the HIV status. Clinicians can reach the Antiretroviral Pregnancy Registry at 1-800-258-4263 or on their website.

The PEP regimens that are recommended for treating pregnant patients are like the ones used for non-pregnant patients (Zachary, 2023).

The National Clinician Consultation Center recommends either of these two PEP regimens (National Clinician Consultation Center, 2021). The duration of the treatment is 28 days Zachary, 2023).

• Emtricitabine 200 mg and tenofovir disoproxil fumarate 300 mg (combination product) 1 tablet once a day, plus
• Raltegravir 400 mg, 1 tablet twice a day, or
• Dolutegravir 50 mg, 1 tablet once a day
• Zidovudine 300 mg and lamivudine 150 mg (Combination product) 1 tablet twice a day, plus
• Darunavir 800 mg, 1 tablet once a day, boosted with ritonavir 100 mg, 1 tablet once a day, or
• Atazanavir 300 mg, 1 tablet once a day, boosted with ritonavir 100 mg, 1 tablet once daily

Breastfeeding is not contraindicated for women taking PEP (National Clinical Consultation Center, 2021). However, a lactating mother and a breastfed infant may have a risk for HIV transmission, and the information on the PEP drugs and breastfeeding is limited (National Clinician Consultation Center, 2021). Two helpful information sources on breastfeeding and antiretrovirals are:

1. LactMed®, a website maintained by the National Institutes of Health. Visit Source, and
2. Clinical Info. HIVgov. This website is maintained by the U.S. Department of Health and Human Services and has updated information on HIV, breastfeeding, and antiretrovirals. Visit Source.

If PEP is continued, the patient should be reminded of the need to adhere to the treatment regimen, they should see their provider if they have signs and symptoms of an infection, and they should be asked about and examined for the presence of drug side effects (Zachary, 2023). Non-adherence to PEP is common. Liu et al. reported a 58.4% non-adherence rate (This included healthcare workers and patients who needed PEP for other reasons), and non-adherence reduces HIV suppression (Altice et al., 2019). Most drug side effects of HIV PEP are mild and well tolerated. Patients taking tenofovir disoproxil fumarate should have BUN, creatinine, and LFTs monitored for kidney function(National Clinician Consultation Center, 2021).

Patients taking zidovudine should have their CBC and LFTs monitored (National Clinician Consultation Center, 2021; Zachary, 2023).

If the source is HIV positive, the patient should have HIV testing in 6 weeks and 3 months (National Clinician Consultation Center, 2021). If the HCW develops an HCV infection and the source is HIV and HCV positive, the HCW should have HIV testing done in 12 months (National Clinician Consultation Center, 2021; Zachary, 2023). This recommendation is made because one case was reported in which an HCW had delayed HIV seroconversion after developing HIV infection and HCV infection from a single needlestick injury (Zachary, 2023). (Note: The recommendations for post-exposure HIV testing can differ, depending on the PEP drugs that are used and the source (Zachary, 2023). The recommendations of the National Clinician Consultation Center are in basic agreement with other available recommendations.