Sharps injury with a high-risk source in a district hospital
A 24-year-old nurse in a district hospital sustains a hollow-bore needlestick while recapping a needle after drawing blood from a patient admitted with fever and jaundice. The patient's rapid HIV test is reactive; a venous blood sample for HIV ELISA has been sent and results are expected in 48 hours. The nurse's own HIV status is unknown, and she has never received hepatitis B vaccination. The exposure occurred 40 minutes ago. The hospital's antiretroviral starter kit contains tenofovir/lamivudine plus dolutegravir. The nurse is 10 weeks pregnant and is worried about the fetus. The infection control nurse is off duty and the on-call physician must decide on immediate management.
1. What should be done in the first hour, and how should the decision about post-exposure prophylaxis be framed given that the source's confirmatory result is pending?
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Immediate steps are simultaneous, not sequential:
- First aid - wash the puncture site with soap and water; do not squeeze, scrub with caustic agents, or inject anything. Report and document the exposure in the exposure register.
- Baseline testing - draw the nurse's blood for HIV, HBV (HBsAg, anti-HBs, anti-HBc), HCV, and save serum. Pregnancy status is already known.
- Source risk assessment - a reactive rapid test plus fever and jaundice makes this a high-risk source; do not wait for ELISA to start PEP. Rapid tests have a low false-positive rate in high-prevalence settings but confirmation is still required for the source's own care.
- Start PEP now - guidelines direct initiation within hours (ideally <2–4 h, no later than 72 h). Tenofovir/lamivudine/dolutegravir is a recommended first-line regimen and is considered compatible with pregnancy; the risk of untreated HIV transmission outweighs fetal concerns. Do not delay for the ELISA.
- Hepatitis B - an unvaccinated exposed person needs hepatitis B immunoglobulin plus the first vaccine dose within 24 h, at a separate site.
- Review at 48 h - if the source ELISA is negative, PEP can be stopped; if positive, complete 28 days with follow-up HIV testing at baseline, 6 weeks, 3 months and 6 months. The judgement point is that PEP is started on risk, not on a pending laboratory result.
2. The nurse asks whether she can keep working on the ward and whether her pregnancy changes the PEP regimen. How do you answer?
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Work restriction: she does not need to be removed from patient care. Standard precautions apply; she should avoid invasive exposure-prone procedures only if she becomes HIV-positive and her viral load is not suppressed, which is a later occupational-health determination, not an immediate one. Confidentiality must be maintained - the exposure is recorded in a restricted register, not in the general ward notes. Pregnancy and regimen: dolutegravir is now widely used in pregnancy and is preferred over older options in many national guidelines; tenofovir/lamivudine is also acceptable. Do not substitute a less effective regimen out of fetal concern. Emphasise adherence, explain common early side effects (nausea, headache), and arrange obstetric review plus baseline renal and liver function. If she develops severe symptoms, she should be reviewed rather than stopping silently. Counselling: discuss the 28-day course, the follow-up schedule, the small residual risk even with PEP, and the need for condom use until the 6-month test is negative. Document that she was counselled and consented.