ABBREVIATIONS. HIV, human immunodeficiency virus; USPHS, US Public Health Service; PEP, postexposure prophylaxis; CDC, Centers for Disease Control and Prevention; CI, confidence interval; AIDS, acquired immunodeficiency syndrome; PI, protease inhibitor; NRTI, nucleoside analog reverse transcriptase inhibitor; PCR, polymerase chain reaction; ZDV, zidovudine.
Exposure to human immunodeficiency virus (HIV) can occur in a number of situations unique to or more common among children and adolescents. Guidelines for prophylaxis after exposure to HIV in occupational and nonoccupational (eg, sexual, needle-sharing) settings have been published by the US Public Health Service (USPHS), (1-3) but they do not directly address nonoccupational HIV exposures unique to children (such as accidental exposure to human milk from a woman infected with HIV or a puncture wound from a discarded needle on a playground), and they do not provide antiretroviral drug information relevant to postexposure prophylaxis (PEP) in children.
This clinical report provides a review of the literature focused on issues of HIV exposure uniquely related to children and adolescents and gives recommendations for PEP in the following situations: injury from discarded needles, bite wounds, sexual exposure, and inadvertent exposure to human milk from an HIV-infected woman. In each setting, the risk of HIV transmission is directly related to the probability that the exposure source has HIV infection and that transmission of a sufficient amount of infectious virus occurred in a manner that could result in infection in the recipient. Because no studies have directly measured the effectiveness of PEP in decreasing the risk of HIV transmission in nonoccupational settings or after mucosal exposure, the potential benefit of PEP in modifying transmission risk is extrapolated from data regarding HIV pathogenesis in animals, from information about PEP for needlestick injuries in occupational settings, and from studies of vertical transmission of HIV.
Type of Source Material
Not all body fluids from persons with HIV infection are equally infectious (Table 1). Blood and fluids contaminated with blood from persons with HIV infection should be assumed to contain HIV and are associated with the highest risk of HIV transmission. Semen or vaginal secretions, cerebrospinal fluid, synovial fluid, pleural fluid, peritoneal fluid, pericardial fluid, amniotic fluid, human milk, and unfixed tissue from persons with HIV infection also may contain HIV and should be considered infectious. However, exposure to these "other potentially infectious materials" (1) is associated with a lower risk of HIV transmission. Blood-free saliva, urine, feces (including diarrhea), and vomitus are highly unlikely to transmit HIV.
Volume of Source Material
Exposure to a large volume of infectious material carries a greater risk of HIV transmission than does exposure to a smaller volume. For example, in studies of health care professionals with percutaneous exposure to blood from persons with HIV infection (Table 2), (4) injuries with large-gauge, hollow-bore needles were 14 times as likely to result in HIV transmission as were injuries with smaller-gauge, hollow needles; solid suture needles; or solid objects (such as a scalpel; Table 2). (4) Risk is also greater after exposure to a needle on which blood is visible, com