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

628 Abstracts 33179-33182

12th World AIDS Conference

gastrointestinal side effects, and two due to personal decision. There were no
seroconversions.
Lessons Learned: We conclude that in hospitals with relatively low prevalences of HIV-positive patients, most health care workers who initiate antiretroviral
prophylactic regimens will have been exposed to HIV-negative sources. Rapid
ascertainment of source patient HIV status permits the majority of such prophylactic regimens to be limited to 4 or fewer days of treatment. Among health care
workers exposed to known HIV + patients, gastrointestinal side effects are a
common reason for discontinuing medications prematurely.
251* /33179 Post-exposure prophylaxis: Community
controversies in San Francisco
Valerie Rose Kegebein, J.D. Bamberger, M.H. Katz, T.J. Coates2. 1San
Francisco Dept. of Public Health 25 Van Ness #500 San Francisco CA; 2Univ.
Calif. Ctr. for AIDS Prev. Studies San Francisco CA, USA
Issues: Recent studies have indicated that post exposure prophylaxis (PEP)
following occupational, percutaneous exposures and its use during pregnancy,
may be an effective method for the prevention of HIV transmission. However,
its effectiveness for sexual exposures is unknown. Unlike conventional behaviorally-based prevention interventions for which numerous studies have predicted
safe and effective outcomes, PEP is a biomedical as well as behavioral intervention with unproven outcomes, potential toxicities and the fear among prevention
advocates of an increase in risk behavior among those at highest risk for HIV
infection.
Project: In an unprecedented move, the San Francisco (SF) Department of
Public Health, in collaboration with SF General Hospital and the University of
California, became the first health department in the US to offer access to medication, in-depth counseling, and antibody testing to individuals who experienced
a significant non-occupational exposure to HIV (sexual or needle sharing), at two
clinics in SF. The project, which began in Oct. 1997, is both a feasibility study
and a free service which is promoted though local and state hotlines, community
agencies and the internet.
Results: Prior to the opening of the PEP clinics, efforts to educate HIV prevention providers and the media about the risks and benefits of this service were
undertaken. Initially, there was a vociferous negative response by community
groups about societal disinhibition and the erosion of established prevention
messages, contrasted with resistance by HIV activists to any exclusion criteria
established by research protocols. Print, radio and television media reported PEP
as a "morning after pill" rather than as a complicated, untried intervention, thereby
amplifying concerns.
Lessons Learned: A sound media plan, with focused, timely press releases,
coordinated with key stakeholders can prevent inflammatory and inaccurate press
coverage. Continuous education of community providers which describes the potential benefits and known harms of PEP is critical. The San Francisco PEP
experience will be extremely useful for others that attempt to integrate biomedical
prevention interventions into more traditional prevention efforts.
33180 1Risk behaviors reported by newly infected men who have
sex with men (MSM): Implication for prevention
intervention
Susan Buchbinder, D. Donnell2, S. Self2, K. Mayer3, M. Gross4, M. Marmor5,
C. Celum1. Suite 500, 25 Van Ness Avenue, San Francisco, CA; 1Seattle HIVNet
Site; 2FHCRC-HIVNet Statistical Center, Seattle, WA; 3Memorial
Hospital/NEBHS, Pawtucket, RI; 4ABT Associates Inc., Bethesda, MD; 5New
York University Medical Center, New York, NY USA
Backgroud: A comprehensive understanding of the risk behaviors associated
with HIV seroconversion is critical to designing and testing prevention interventions. To avoid sampling biases that occur in studying clinic-based cohorts of
newly identified seroconverters, we evaluated detailed, calendar-based retrospective interviews of newly seroconverting MSM recruited from a prospective
cohort study.
Methods: Men were recruited from the HIVNET Vaccine Preparedness Study,
an 18-month study of 3257 MSM enrolled in 6 US cities. Risk assessments and
HIV testing and counseling occurred semiannually. Newly infected men underwent a calendar-based interview of all risk activities from 3 months prior to their
last negative test through their first positive test.
Results: Of 79 seroconverters (SC), only 4 (5%) reported being in a monogamous serodiscordant relationship. Of 77 SC with available data, ranked according
to their highest level risk activity (mutually exclusive):

quire infrequent interventions (e.g. post-exposure chemoprophylaxis for URA w/
+ or U) could potentially benefit more than 1/3 of seroconverting MSM.
33181 Efficacy of an out-of-house post-exposure prophylaxis
team for occupational exposures to blood-borne
pathogens
Michael Wong1, P.M. Allen2, J. Kaatz3, C. Weir-Wiggins3, J. Zeh3
F.J. Tortotrella2. 1MCV Hospital, PO Box 980019, Richmond, VA 23219; 2 VCU
Employee Health, Richmond, VA; 3VCU HIV/AIDS Center, Richmond, VA, USA
Issue: In order to initiation of therapy within 1-2 hours following occupational
exposure of healthcare workers (HCWs) to blood or body fluids, of exposure, a
unique call system was designed for a university-based medical center.
Setting: The Medical College of Virginia Hospitals is an 800 bed tertiary care
hospital in Richmond, Virginia. It serves an area with an AIDS rate of 32.5/100,000
population.
Program: A Post-exposure prophylaxis (PEP) Call team is available 24 hours
for off-site personnel, and after hours for the hospital. Risk assessments, recommendations and counseling are made by phone. Medications are provided by
pharmacy services. Exposures occurring during regular work hours are reported
directly to Employee Health. The PEP Team consists of trained nurses and
mid-level practitioners with Infectious Diseases trained physician back up. The
program was implemented 1 Jul 97.
Results: Since the program started, there were 171 reported occupational
exposures to blood or body fluids (mean, 28.5 exposures/month), with 45 (26%)
reported via the PEP Team. Exposures were: percutaneous (PC) n = 35; mucus
membrane (MM) or eyes 11; skin 7, and 43 were unknown status (2 percutaneous exposures were to needles from an unknown source). Occupations were:
22 nurses, 5 staff attendings, 11 residents, 3 aides, 2 housekeepers, and 1
laboratory personnel. Gloves were worn in 91% of PC but facewear was 33%.
Exposures occurred on: wards 38%, ICU 29%, ER 20%, OR 6% and Clinics
6%. PEP for potential HIV exposure was offered to 78% of the exposures: 31%
refused medication; 57% received 2 medications (zdv, 3TC); and 11% received
3 medications (zdv, 3TC + IDV). Medications were continued for 4 weeks for
4 healthcare workers (HCWs) without side effects. Source testing revealed 0
HBSAg+, 1 HIV+, and 4 HCV+. No seroconversions to HIV, HBV, or HCV have
occurred. Most HCWs were HBSAb+.
Conclusions: The PEP Team is a very effective means of performing risk
assessment for occupational exposures to blood and body-fluids. Nursing personnel continue to have the highest proportion of exposures, whit the majority
occurring on general wards. Interestingly, although Richmond is in a high HIV
endemic region, nearly 1/3rd refused HIV PEP medications, and appropriate PPE
was worn only while handling sharps.
33182 Zidovudine and combination antiretroviral post exposure
prophylaxis
Vincenzo Puro1, Ippolito Giuseppe1. 1Centro Riferomento AIDS-IRCCS "Lazzaro
Spallanzani" via Portuense, 292 00149, Roma; and Regisco Italiano Profilassi
Antiretrovirale; Studio Italiano Rischio Occupazionale HIV (SIROH), Italy
Objective: To evaluate toxicity of antiretroviral post-exposure prophylaxis (PEP)
in Italy.
Methods: A national protocol of zidovudine (ZDV) post-exposure prophylaxis
(Z-PEP) has been instituted in 1990 and updated in 1996 towards Combination
Antiretroviral PEP (C-PEP).
Results: Up to December 1997, 789 individuals were treated with Z-PEP and
65 treated with C-PEP. In the Z-PEP group 1 health care worker seroconverted
despite of Z-PEP after conjunctival blood contamination; mean duration of treatment was 22 days; 51% individuals reported at least one adverse effects, and 18%
discontinued PEP because of side effects (mean 7 days); nausea was reported
in 299 cases, hb 7.7 g/dl in 1 case, hb 9.5-11 g/dl in 11; <1000 neutrophyls/mmc
in 2, ALT 3 times the upper normal level in 7.
C-PEP group included ZDV in 64 cases, 3tc in 57, ddl in 5, d4T in 2, ddC in 1,
indinavir (IDV) in 29, and saquinavir (SQV) in 1. Mean duration of treatment was
20 days; 14/20 who were in the 2-drug C-PEP and 18/29 in the 3-drug C-PEP
reported at least one constitutional adverse effect, 3 and 7 discontinued C-PEP
before 4 weeks because of side effects (mean 8 days), respectively. Nausea was
reported in 18 cases. No hematological side effects were observed in the 2-drug
C-PEP. In 11/28 persons in 3-drug C-PEP was observed an increase of ALT level
in 3, indirect bilirubinemia in 8, tryglicerides in 1.
Conclusions: C-PEP short-term toxicity seems to be more frequent than
Z-PEP, althought no significant differences are observed in the lenght of tretment
despite of side effects. In different PEP regimens adverse effects seem to be
mild, and reversible. No unusual side effects were observed. Further studies are
needed to assess the risk of long-term sequelae. (Supported by Italian Ministry
of Health - I.S.S., AIDS project)

Injection drug use
Unprotected receptive anal sex (URA) w/HIV positive partner (+)
Unprotected receptive anal sex w/unknown serostatus partner (U)
Unprotected insertive anal sex w/ + or U
Protected receptive anal sex w/ + or U
Other (protected insertive anal, unprotected oral, fisting, other)

4 (5%)
16 (21%)
33 (43%)
7 (9%)
12 (16%)
5 (6%)

Infrequent risk (-:2 weeks at risk) occurred in 64% SC reporting URA w/ + and 56% reporting
URA w/ + or U.
Conclusions: Prevention strategies and study enrollment should target MSM
with multiple partners including U partners; monogamous serodiscordant couples
were rare in this high risk cohort of MSM. While URA is reported by most men,
other lower risk activities, under-recognition of condom failure, or underreporting
was associated with approximately 1/3 of seroconversions. Strategies which re