Bridging the Gap: Conference Record [Abstract book, International Conference on AIDS (12th: 1998: Geneva, Switzerland)]

12th World AIDS Conference

Abstracts 33175-33178 627

penetration during the assault, presence of blood or tissue damage, ejaculation
or patient request and presentation within 72 hours of assault. Survivors are
tested for HIV antibodies at baseline (within 7 days of assault), and at 4, 12 and
24 weeks. HAART PSEP consists of 2 NRTI's and a potent protease inhibitor
(nelfinavir or indinavir) self administered for 4 weeks.
Results: A retrospective review of 35 medical records of sexual assault survivors seen following July 1997 and meeting protocol criteria was conducted.
Patient characteristics were as follows:- (age range 4-42 years of age, 7 below 19 years of age):Gender: - 2 males, 33 females (1 female was known HIV
positive on HAART). 6 (18%) of the survivors, were placed on HIV prophylaxis
[2 (100%) males, 4 (12%) females including one female below 19 years of age,
all not pregnant]. All 6 patients given HAART prophylaxis had been penetrated
(vaginally, rectally and/or orally) yet had no remarkable genital or physical findings
on examination. All had been seen by a multi disciplinary team of nurses, social
workers, counselors, patient advocates, physicians and rape crisis volunteers and
except for one male, all had had NYPD intervention. HIV prophylaxis consisted of
triple combination therapy with a potent protease inhibitor except for one female
patient (below 19 years of age) who received 2 NRTI's. Two of the 4 female rape
survivors on prophylaxis knew the perpetrator and none were menstruating. Of
33 patients not on prophylaxis, 12 (36%) had multiple penetrations with unknown
presence of ejaculate; 6 (18%) had both penetration and known ejaculation, 2
(6%) had penetration, known ejaculation and were menstruating and 1 survivor
had penetration by a completely unknown perpetrator. The 6 survivors who have
been treated with HAART for 4 weeks have received baseline HIV antibody
testing and counseling and are being followed prospectively. None to date have
seroconverted.
Conclusion: Following sexual assault, PSEP with HAART can be implemented
in an outpatient hospital based setting through a coordinated effort between ER
providers, HIV specialists, rape crisis counselors, nurses, social workers and
patient advocates. The efficacy of PSEP in this setting is unknown but is being
evaluated.
S33175 Combination post-exposure prophylaxis (PEP):
A prospective study of HIV-exposed health care workers
(HCW)
Julie L. Gerberding 2, Rita Fahrner2, S.E. Beekman3, L. Nelson4,
J.L. Perlman2, D.K. Henderson4. 1EPI - Center SFGH Bldg. 100 Room 301 1001
Potrero Ave. San Francisco, CA 94110, 2University of California at San
Francisco San Francisco, CA; 3University of Iowa College of Medicine Iowa City,
IA; 4 National Institutes of Health Bethesda, MD, USA
Background: PEP for occupational HIV exposures is now a standard of care, but
safety and adherence with the new combination PEP regimens is not established.
Methods: Prospective multicenter open label trial of PEP (ZDV + 3TC ~
indinavir) for occupational HIV exposures, beginning 3/96.
Results: By 1/15/98, 127 HCW (14 NIH, 113 SFGH) elected PEP. 50 (40%)
HCW had HIV+ source patients (SP) and were eligible to continue and 4 (3%)
had untested SP presumed HIV+. Of 50 HIV+ exposures, 31% SP had early HIV,
10% had symptomatic infection and 55% had AIDS; 4% HCW had lab exposures
to tissue/HIV cultures. Most HCW (35%) had no CDC exposure risk factors (RF)
for occupational HIV; 33% had 1 RF, 26% had 2 RF, and 6% had 3 RF. No HCW
had all 4 RF.

Results: Between August 1996 and February 1998, 23 persons were referred
following an occupational exposure, and 8 following a significant sexual exposure.
Of the occupational exposures, 19 were needlestick and 4 were splash injuries;
14 were among medical staff, 5 in nurses, 2 in phlebotomists and 2 in ancillary
staff. The HIV status of the source patient was known in 15 (65%) of cases.
Five were classified as high, 14 as medium and 5 as low risk exposures, and 3
(60%), 8 (57%) and 2 (22%) respectively received PEP, within a median of 1 hour
following exposure (range 15 mins-4 days). Eight (61%) completed the treatment
course. The reasons for premature discontinuation after a median of 4.5 days
were nausea in 1 and because the risk of infection was in retrospect considered
to be low in 4. Only 5/23 individuals attended for further serological follow-up. Of
the 8 sexual exposures, all received PEP at presentation after a median delay of
4.5 days following exposure (range 6 hours-9 days). Only 3 were known to have
completed therapy, and 5 failed to attend for any further follow-up.
Conclusions: There is a high uptake of PEP following occupational and sexual
exposures, although a significant proportion discontinue prophylaxis after the
initial 3-5 day starter pack. The poor rate of attendance for follow-up highlights
the need for improved liason with occupational health departments, and better
staff and patient education. There were no major adverse effects among those
who completed the 1 month course.
33177 Follow-up of health care workers (HCWs) and prophylaxis
after an occupational exposure to HIV: A no show
Pierre Robillard, E. Roy, M. Pineault. Montreal Public Health Department 75 Port
- Royal East Room 240 Montreal, Canada
Background: Recommendations for HCWs follow up and prophylaxis after an
HIV exposure have been issued by different international and national bodies.
This study describes the type of follow up and prophylaxis HCWs received in a
sample of Quebec acute care hospitals (ACHs).
Methods: A surveillance network for blood and body fluid (BBF) exposures
was implemented in 20 ACHs throughout the province of Quebec, Canada. Data
on BBF exposures were collected by employee health services (EHS) through
a standardized questionnaire and a software provided to network members and
are transferred twice a year for analysis. Data presented here are from 10 ACHs
participating to the network for at least 6 months in the period ranging from
05/01/95 to 09/30/97.
Results: 2380 significant BBF exposures (needlestick 72.9%, cut 8.9%, scratch
3.5%, bite 1.2%, mucous membrane 9.9% and non intact skin 3.1 %) were reported
to the network. Nurses sustained 61.5% of exposures, physicians 9.2%, nursing
aides 5.8% and lab technicians 5.2%. 1890 (79.4%) of BBF exposures were to
identified source patients and only 1401 (74.1%) were tested for HIV; 87 (6.2%)
of these patients were infected. Of the 87 HCWs exposed to an HIV-infected
source, only 42 (48.3%) had a baseline anti-HIV test. Only 27.5% of those due for
a 6-week test had it, 31.9% for the 3-month test and 22.7% for the 6-month test.
19 HCWs (21.8%) took post-exposure prophylaxis an average 3.75 hours after
exposure (range: 0.25-53). 6.1% of HCWs with no seroconversion risk factor
took prophylaxis, 35.7% with 1 risk factor, 55.6% with 2 risk factors and 100%
with 3 risk factors, X2 for trend = 19.3, p - 0.001. PEP regimens did not respect
CDC June 1996 recommendations: 1 HCW received AZT monotherapy in Sept.
1996 and only 1 case should have received tripletherapy but 7 did.
There is a big gap between recommendations and what really happens in
Quebec ACHs. There appears to be a selection process in the testing of source
patients. Testing of HCWs is far from being optimal and triple therapy for PEP,
instead of being the exception, became the standard of practice and this may
have tremendous consequences in terms of side effects and compliance.
33178 Antiretroviral prophylaxis of occupationally exposed
health care workers at two large urban medical centers
Mark Russi, Martha Buitrago, J. Perlotto, D. Van Rhijn, E. Nash, G. Friedland,
M. Rigsby, W. Hierholzer. Yale University Occupational Medicine 135 College ST
New Haven, CT 06510, USA
Issue: In response to the Provisional US Public Health Service Recommendations
for Chemoprophylaxis after Occupational Exposure to HIV, medical practitioners
frequently prescribe drugs with significant side effects to healthcare workers
exposed to source patients whose HIV status is unknown.
Project: We report the one-year experience of two urban medical centers
following implementation of the US Public Health Service Recommendations.
Protocols were put into place June 7, 1996, for the employee health clinics and
emergency departments to provide 24-hour immediate evaluation of bloodborne
pathogen exposures.
Results: A total of 450 bloodborne pathogen evaluations were carried out
over a one-year period from an at-risk population of approximately 9500 health
care workers. Forty-nine individuals (11%) elected to receive a two-or three-drug
regimen, (zidovudine + lamivudine +/- indinavir) of whom 33 (67%) took medications less than 96 hours. Reasons for discontinuing included source patient
HIV negativity by ELISA (85%), gastrointestinal side effects (9%), and personal

decision after counseling (6%). Of the 16 individuals treated longer than 4 days,
only 9 (56%) completed the recommended 4-week regimen. Gastrointestinal side
effects and headache were the most commonly cited reasons for discontinuation.
Of 49 individuals who elected to begin antiretroviral prophylaxis, only 8 (16%)
were exposed to subsequently confirmed HIV-positive source patients, and of
those only three elected to take the full 4-week course of medications. Of the
5 who did not complete a 4-week regimen, three (60%) discontinued due to

ZDV (200 mgtid) + 3TC (150 mgbid)
ZDV + 3TC + IDV (800 mgtid)
DDI (200 mgbid) + D4T (40 mgbid)

Compl. D/C D/C
28d. early w/sx early-other
23 (64%) 9 (25%) 4 (9%)
10 (63%) 6 (37%) 0
2(100%) 0 0

Total
n = 54
36 (66%)
16(30%)
2 (04%)

"2 HCW also had laboratory toxicity (f LFTs): 1 was on isoniazid prophylaxis (PEP d/c'd on day
10), 1 was developing acute HCV infection (PEP d/c'd on day 23). The latter HCW developed
HIV antibody 12 months later. The majority of HCW electing PEP had no CDC-designated
RF for HIV seroconversion. 65% of HCW taking PEP completed 28 days. Only 30% of HCW
stopped PEP early due to symptoms (mainly nausea/headache).
Conclusions: Current combination PEP regimens are better tolerated than
previous regimens using monotherapy with high dose ZDV. PEP failures occur,
and may be associated with co-transfer of HCV. HIV-exposed HCW who acquire
HCV should be tested for IRV longer than 6 mos to exclude late seroconversion.
247* / 33176 Post-exposure prophylaxis for occupational and
sexual exposures to HIV: experience in a London
hospital
Phillippa Easterbrook, D. Hawkins, F. Boag, A. Pearce, H. Vaile, C. Richardson.
Chelsea and Westmonister Hospital, London, UK
Objectives: To describe our clinical experience following the introduction of a
post-exposure prophylaxis (PEP) policy for occupational exposures to HIV in
August 1996.
Design: Retrospective review of medical records.
Methods: All staff who had a definite or probable occupational exposure to
HIV were referred by the Occupational Health Dept. for further assessment.
Exposures were graded using a severity index into high, medium and low risk.
Self-referrals following a sexual exposure were evaluated on a case-by case
basis. The recommended PEP regimen was zidovudine, 3TC and indinavir for 1
month.