Occupational Exposure & Needlestick PEP Pathway

One pathway for a needlestick, covering HIV, HBV and HCV together · v1.5
How to use this tool: Enter the exposure details and the status of both source and recipient. The tool assesses risk for HIV, hepatitis B and hepatitis C together, and returns a single post-exposure prophylaxis plan with the baseline tests due. This is written for occupational exposure in a healthcare worker. Sexual and other non-occupational exposure follows a different pathway and is not covered here.

1. Exposure Details

2. Source Patient Serology

If the source is unknown, a needle found in the laundry for instance, select Unknown in those fields. Do not delay PEP while waiting for laboratory results when the exposure is high-risk.

3. Exposed Person (HCW) Status

Pathophysiology & Clinical Pearls

1. Mnemonic for Immediate First Aid: "WASH"

  • W - Wash the area thoroughly with soap and flowing water.
  • A - Avoid squeezing or milking the wound. Do NOT apply bleach or caustic agents.
  • S - Source testing. Draw blood from the source patient for HBsAg, HIV and Anti-HCV immediately.
  • H - HIV PEP & HBIG evaluation, inside the 72-hour window.
Clinical Caution, the Squeeze: The instinct after a needlestick is to squeeze the finger and bleed it out, and it is the wrong one. Squeezing creates intermittent negative pressure in the capillary bed, which acts as a vacuum and draws viral particles deeper into the tissue. Alcohol and bleach cause tissue necrosis, and the micro-tears left behind are themselves a route of entry. Wash gently with soap and water, and use nothing else.

2. Pathophysiology: Why HBIG + Vaccine?

In a high-risk exposure (Unvaccinated HCW + Positive Source), the Hepatitis B vaccine alone is too slow, because the virus replicates before active immunity develops. Both are given, one to cover the gap and one to close it:

  • HBIG (Hepatitis B Immune Globulin): Provides immediate, passive neutralising antibodies that bind to the HBsAg on the viral envelope, preventing hepatocyte entry. This protection fades in a few weeks.
  • HBV Vaccine: Initiates the endogenous T-cell and memory B-cell response for long-term active immunity.
  • Administration Rule: If giving both, they MUST be administered in different limbs (e.g., Left Deltoid and Right Deltoid). If given in the same site, the passive HBIG antibodies will bind to and neutralise the vaccine antigen, rendering the vaccine useless.

3. Illness Script: The "Rule of 3s" for Needlestick Risk

When counselling a colleague after a hollow-bore needlestick from a positive source, these are the baseline transmission probabilities without treatment.

Pathogen Untreated Transmission Risk Post-Exposure Efficacy
Hepatitis B (HBV) ~30% (Highest Risk) HBIG + Vax is >95% effective if given within 24-72 hours (HBIG viable up to 7 days).
Hepatitis C (HCV) ~3% No active PEP available. Monitor HCV RNA; treat with Direct-Acting Antivirals (DAAs) if infection occurs (Cure rate >95%).
HIV ~0.3% Triple-therapy ART PEP for 28 days reduces risk by >80% if started within 72 hours.

4. NACO Guidance: HIV PEP Regimen

The National AIDS Control Organisation (NACO) standard for adult PEP is a 28-day course of a three-drug regimen. The preferred regimen is Tenofovir (TDF) 300mg + Lamivudine (3TC) 300mg + Dolutegravir (DTG) 50mg once daily.

  • Pregnancy: NACO and WHO both strongly recommend Dolutegravir-based regimens for pregnant women. The neural tube defect risk suspected earlier was found to be statistically insignificant.
  • Renal Impairment: Tenofovir Disoproxil Fumarate (TDF) is nephrotoxic. If eGFR is < 50 mL/min, TDF must be dose-adjusted or substituted with Zidovudine (AZT) or Abacavir (ABC) per specialist advice.
Abbreviations: ABC (Abacavir) · Ag/Ab (Antigen/Antibody) · ALT (Alanine Aminotransferase) · anti-HBs (Antibody to Hepatitis B Surface Antigen) · anti-HCV (Hepatitis C Antibody) · ART (Antiretroviral Therapy) · ARV (Antiretroviral) · AZT (Zidovudine) · DAAs (Direct-Acting Antivirals) · DTG (Dolutegravir) · eGFR (Estimated Glomerular Filtration Rate) · HBIG (Hepatitis B Immunoglobulin) · HBsAg (Hepatitis B Surface Antigen) · HBV (Hepatitis B Virus) · HCV (Hepatitis C Virus) · HCW (Healthcare Worker) · HIV (Human Immunodeficiency Virus) · IM (Intramuscular) · NACO (National AIDS Control Organisation) · PEP (Post-Exposure Prophylaxis) · RNA (Ribonucleic Acid) · STAT (Immediately, Latin Statim) · TDF (Tenofovir Disoproxil Fumarate) · Vax (Vaccine) · WASH (Wash, Avoid Squeezing, Source Testing, HIV PEP and HBIG) · WHO (World Health Organization) · 3TC (Lamivudine)
Algorithm References & Evidence Base
  1. National AIDS Control Organisation (NACO), Ministry of Health and Family Welfare, Government of India. National Guidelines for HIV Care and Treatment. 2021.
  2. World Health Organization. WHO updated recommendations on HIV clinical management: recommendations for a public health approach. Geneva: WHO; 7 January 2026. [NACO remains the operative source for Indian practice.]
  3. Schillie S, Vellozzi C, Reingold A, et al. Prevention of Hepatitis B Virus Infection in the United States: Recommendations of the ACIP. MMWR Recomm Rep. 2018;67(1):1-31.
  4. Weng MK, Doshani M, Khan MA, et al. Universal Hepatitis B Vaccination in Adults Aged 19-59 Years: Updated Recommendations of the ACIP, United States, 2022. MMWR Morb Mortal Wkly Rep. 2022;71(13):477-483. [Changes the baseline vaccination assumption underlying the HBV arm of this pathway. The 2018 PEP algorithm itself has not been withdrawn.]
  5. Kuhar DT, Henderson DK, Struble KA, et al. Updated US Public Health Service guidelines for the management of occupational exposures to human immunodeficiency virus and recommendations for postexposure prophylaxis. Infect Control Hosp Epidemiol. 2013;34(9):875-892.
  6. Singh A, Kumar H, Tandon N. Guidelines for vaccination in normal adults in India. J Assoc Physicians India. 2016;64(Suppl):S1-S5.
How to Cite This Tool

AMA Style:
Umakanth S. Occupational Exposure & Needlestick PEP Pathway. MEDiscuss. Published 2026. Accessed .

Vancouver Style:
Umakanth S. Occupational Exposure & Needlestick PEP Pathway [Internet]. MEDiscuss.org; 2026 [cited ]. Available from:

Disclaimer and scope
Disclaimer: This decision-support system is written for healthcare professionals. It does not substitute clinical judgment, and the treating physician retains absolute responsibility for every diagnostic, dosing and therapeutic decision. The algorithms are built on the evidence as it stands, and the evidence moves. Verify the output against your current institutional protocol, and against the patient in front of you.
© 2026 MEDiscuss.org. All rights reserved. This CDSS Module was designed and developed by Dr Shashikiran Umakanth from the published evidence. Provided free of charge for clinical use. Unauthorised reproduction or redistribution is strictly prohibited. Keep this system on your phone's home screen
Category Immunisation & ProphylaxisPathway
Specialties Internal Medicine, Infectious Diseases
Status Essential
Written and maintained by Dr Shashikiran Umakanth.
Last revised: 8 August 2026
Related Clinical Tools
First-Line ART SelectionAdult Immunisation GuideHIV Clinical Pathway Hub