October 21st, 2008

Back to School, Day 4: PEP and More PEP

After a lecture on HIV for Primary Care Providers in our course last week, the most controversial topic was, not surprisingly, the use of post-exposure prophylaxis (PEP) for both occupational and non-occupational exposures.  And today, after an entire lecture on PEP to a group of HIV providers in our AIDS course, again the subject drew numerous questions — and strong opinions — from the audience.

Since this is a relatively data-free zone, one turns to the guidelines for advice.  But not surprisingly, they offer tons of wiggle room for a clinician to do pretty much anything he or she wants in all but the most florid exposures or non-exposures.

(Can there be a florid non-exposure?)

So here’s a case we just posted on AIDS Clinical Care. (Drawn from real life, of course.)  Emergency room resident sticks herself with a needle while suturing a patient’s wound, a patient who’s HIV positive with an undetectable viral load on treatment. Oh, and the resident is pregnant.

To give PEP or not to give PEP?

7 Responses to “Back to School, Day 4: PEP and More PEP”

  1. Gabriella De Carli, MD says:

    1) There has never been an occupational case of HIV infection following an injury with a suture needle. The amount of blood on solid needles is negligible and it has never been sufficient to transmit the infection. The percutaneous rate of 0.3% we estimated in our 22-year surveillance of the risk of HIV infection following occupational exposures in the Studio Italiano Rischio Occupazionale da HIV (SIROH) is related to hollow-bore, blood-filled needles, apart from one case following a cut with a scalpel in which the HCW’s finger was in direct contact with the blood of the patient. Moreover, approximately 50% of the material on the needle will remain on the surgical glove. 2) The source patient’s viral load is undetectable. 3) When giving PEP, remember that severe (requiring hospitalization) adverse effects occur in 0.7% of cases. In conclusion, my advice to thisw HCW, that I gave and give in similar cases, would be that PEP is not indicated, regardless of whether the HCW is pregnant or not.

  2. Todd Ellerin, MD says:

    In response to Dr. De Carli’s comments, I agree that there has not been a documented report of HIV transmission after injury with a suture needle, but that does not mean the risk of transmission is zero– absence of evidence does not necessarily mean evidence of absence. As you mentioned, there have been reports of transmission following scalpel injuries. There have also been reports of HIV-infected health care providers where clear occupational exposure have not been documented but one could imagine underreporting in some instances. With that said, I agree that to observe her off antivirals seems very reasonable since the serious adverse effects of antivirals (while small) could be greater than benefit given the very low risk of transmission in this case. In keeping with CDC guidelines, I would follow this patient for at least 6 months after exposure with periodic HIV antibody testing. If the skin had remained completely intact without abrasion then I would conclude that there was zero risk for HIV transmission and would not consider antiviral PEP. I would be curious to know whether Dr. De Carli would perform periodic HIV antibody testing in this case?

  3. Peter Mariuz says:

    There has never been a case of an occupational transmission of HIV to a surgeon by a finger stick using a suture needle in the United States,(that we know of), over 20 years into the HIV epidemic and who knows how many thousands of similar finger sticks. Surely this, coupled with the patients undetectable viral load, make transmission of HIV virtually zero. So long story short not offering PEP would also be correct.

  4. T Tsai, MD says:

    I had to present to our surgery colleagues earlier this year regarding HIV and as it concerns surgeons. As Dr. Mariuz stated, there are no reported cases of HIV transmission via solid needle in the population of surgeons that we know of. I found interesting during my presentation how many surgeons still do not double glove. I wonder if the double vs single gloving question would change the answer of anyone regarding this case. I also wonder why one would follow guidelines in this case and give two drugs vs three. We already know what the patient is on, why not use a similar regimen like combivir/boosted reyataz. My feeling would be, if giving PEP…”GIVE IT” i.e. three drugs. If not, then observe.

  5. Paul Sax says:

    >>I also wonder why one would follow guidelines in this case and give two drugs vs three.

    The “scientific” argument is that 2 drugs are better tolerated than 3, and hence adherence is going to be better as well.

    But I tend to agree that if you’re going to give PEP, you might as well go the whole way to 3 drugs. I use the 2 drug approach for those who don’t need PEP at all, but are simply too anxious not to take something.

  6. Mehdi says:

    If after suture incident to fingure (double glove case) the resident starts on Combivir and the HIV tests (antibodies) for the patient, being treated by the resident, turns out to be negative,. how long should the resident continue the drug or should he/she stop immdiately

  7. Paul Sax says:

    >>how long should the resident continue the drug or should he/she stop immdiately.

    If the source patient tests negative, Combivir can be stopped! This is one of the great (but underutilized) settings for rapid HIV testing …

    Only exception to this rule is if the source patient might have acute HIV — a rare event, and one that generally would be evident clinically if one is thinking of it.

HIV Information: Author Paul Sax, M.D.

Paul E. Sax, MD

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Infectious Diseases

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