Needlestick injury from a source patient with HIV and treated HCV
A 29-year-old dental hygienist sustains a deep needlestick injury to the left index finger while recapping a local anaesthetic needle after treating a patient. The needle penetrated the glove and drew blood. The patient is a 41-year-old man with a history of hepatitis C treated 5 years ago with sustained virological response, and he is known to have HIV with a viral load of 1,200 copies/mL; his antiretroviral regimen is unknown. The hygienist received a complete hepatitis B vaccination series as a student but has never had a post-vaccination titre checked. She is 10 weeks pregnant and is visibly anxious. The clinic has a sharps injury protocol but the source patient has already left. The exposure occurred 20 minutes ago.
1. What immediate first aid and reporting steps should be taken, and why?
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Wash the wound with soap and running water for at least 15 minutes; do not scrub, suck, or apply bleach or caustic agents, because these can damage tissue and increase viral entry. Encourage bleeding gently but do not squeeze. Report the injury immediately to the occupational health or infection control lead and complete a sharps injury form. Identify the source patient through the clinic record; the patient has left, so the clinic must contact him for consent to test. Take baseline blood from the hygienist for HIV, HBV, and HCV, with consent, and save serum. The 20-minute interval matters because HIV PEP is most effective when started within 2 hours. Document the device, depth, glove use, and source status. Arrange urgent occupational health review; do not wait for source results to start risk assessment.
2. Assess the transmission risk and outline HIV, HBV, and HCV post-exposure prophylaxis, including pregnancy considerations.
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The injury is a deep needlestick with visible blood, so it is a higher-risk exposure. HIV risk is increased by the source's detectable viral load of 1,200 copies/mL; PEP should start within 2 hours and no later than 72 hours, using a 28-day three-drug regimen such as tenofovir disoproxil fumarate/emtricitabine plus dolutegravir or raltegravir. These agents are considered compatible with pregnancy, but she should be managed jointly with an HIV physician and obstetrician. For HBV, check her anti-HBs titre; if it is below 10 IU/L or unknown, give hepatitis B immunoglobulin and a vaccine booster. For HCV, there is no PEP; test HCV RNA at 4–6 weeks and 12 weeks, and if acute infection is confirmed, treat with direct-acting antivirals. Baseline and follow-up testing should include HIV, HBV, and HCV, with counselling and confidentiality.
3. How would you communicate with the hygienist and the source patient, and what follow-up would you arrange?
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Explain the risk in plain language without minimizing it, and reassure her that PEP is effective when started promptly. Obtain her consent for baseline testing and explain the 28-day HIV regimen, expected side effects, and the need for adherence. For the source patient, contact him confidentially, explain the exposure and the reason for testing, and obtain consent; do not disclose the hygienist's identity. If he refuses, follow local public health policy and document the refusal. Arrange follow-up at 2 weeks, 6 weeks, 3 months, and 6 months for HIV and HCV, and at 3 months for HBV if indicated. Offer psychological support and discuss pregnancy follow-up. Review the clinic's recapping policy and move to a sharps-safe device; the injury was preventable.