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

630 Abstracts 33188-33192

12th World AIDS Conference

delivery took place within 24h and among these 40.2% within 2h. 189 (34%) of
the reported exposures did not fulfill the criteria for PEP.
Conclusion: The training program and the establishment of the reference
services allowed a prompt counseling and drug delivery. The surveillance system
is efficient considering a large number of reports without the use of antiretroviral
drugs. Also, this system has been a useful planning tool to target the most
important aspects for the HIV occupational exposure prevention.
33188 Post HIV exposure prophylaxis: Who may benefit?
Philippe Sudre1, G. Schockmel2, C. Fagard3, L. Perrin2, B. Hirschell2. 1DMI
HUG, Rue Micheli du Crest, Geneva; 2University Hospital Geneva, Switzerland;
3Hopital D'Annecy, Annecy, France
Background: Post-exposure prophylaxis (PEP) is effective after professional
exposure to HIV and is increasingly used after inadvertent sexual or parenteral
non-professional exposure. Current guidelines recommend PEP if (1) the patient
consulted within 72 hours after potential exposure, (2) the potential source is
known to be HIV infected, and (3) the exposure is unlikely to be repetitive. We
determined how frequently these conditions were met in patients with recent HIV
infection.
Methods: Patients with primary HIV infection (PHI) in 1996-97 were interviewed to determine the precise circumstances of HIV exposure. We assessed
the likelihood that infection could have been prevented by PEP.
Results: In 42 PHI patients infection occurred by homosexual contacts (23),
heterosexual contacts (16) and intravenous drug use (1). The patients first sought
medical advice at the time of symptomatic PHI and not in the days following
exposure. Only 1 of 42 patients had been aware of his source partner being HIV
infected (his wife). Five more patients were married or in a stable (>2 months)
heterosexual relationship with an infected partner but had not been aware of their
partner's infection. All homosexual patients who were in a stable relationship to
a partner were infected through sexual contacts outside of the relationship. The
universal cause underlying infection was repeated risk behaviour except for the
5 patients living in a stable heterosexual relationship with partners who became
infected outside the relationship.
Conclusions: Among 42 patients diagnosed with PHI, only 1 (2%) might have
fulfilled the criteria for receiving PEP. Since patients with symptomatic PHI are
more likely to contact health care providers than other recently infected patients,
PEP is unlikely to substantially contribute to the prevention of new community
acquired HIV infections.
33189 Post-exposure prophylaxis and sexual HIV transmission
between husband and wife
L.U.C Perrin1, Jean-Francois Balavoine2, G.A. Schockmel1, L. Kaiser1,
S. Yerly1, B. Hirschel1, L. Perrin1. Laboratory of Virology, University Hospital
CH-1211, Geneva 14; 2 Rue Agasse 45 CH-1208, Geneva, Switzerland
Background: Only few data are available concerning the indication, timing,
composition and efficacy of post-exposure prophylaxis (PEP) with antiretroviral
drugs.
Methods: Highly sensitive assays for integrated proviral DNA in peripheral
blood mononuclear cells (PBMC) (lower detection limit: 2 copies/106 PBMC) and
HIV-1 RNA in plasma (3 copies/ml) were used, and the viral reverse transcriptase
gene sequenced in both partners.
Results: A 45 year old man presented with symptomatic primary HIV-1 infection (viremia > 106 HIV RNA copies/ml) 25 days after a sexual relationship with
a female prostitute in Ethiopia. During the 8 days preceding diagnosis he had
repeated sexual intercourse with his wife, then the couple used condoms. The
man received HAART (IDV, 3TC, ZDV) and 10 days later his wife was started
on the same regimen as PEP. At that time, his wife had no antibodies to HIV-1/2
and no detectable viremia (detection limit: 3 copies/ml). She stopped PEP after
1 month but 3 weeks later presented with positive viremia of 14,000 copies/ml.
Retrospective analysis by highly sensitive assays of the wife's plasma revealed
the intermittent presence of both HIV-1 RNA (approx. 3 copies/ml) and integrated
proviral DNA (2-4 copies/106 PBMC) during PEP and demonstrated that the circulating virus of both patients presented complete reverse transcriptase sequence
homology and harboured no resistance mutations. Both patients had a rapid
decrease of viremia after initiation of antiviral therapy and a rapid reconstitution
of CD4 and CD8 T cell levels.
Conclusions: In the present case, PEP (IDV, 3TC, ZDV) started 10-18 days
after sexual exposure, despite absence of antibodies to HIV-1/2 and undetectable
viremia (-3 copies/ml), failed to prevent HIV infection. Highly sensitive assays
for HIV RNA and DNA might help to determine the duration and timing of
post-exposure prophylaxis in high-risk patients.
33190 Sharps injuries and HIV: Experience with a rapid
response system
Irving Salit, P. Chantler, A. Tseng, J. Conly, S. Walmsley, D. Fletcher. The

Toronto Hospital, Eaton G-216, 200 Elizabeth Street, Toronto, M5G 2C4, Canada
Issue: A standardized, rapidly accessible management plan is required to treat
persons exposed to HIV in the workplace.
Project: In October 1996, we developed a hospital-based rapid response
protocol for possible occupational exposures to HIV. A 24-hour/day telephone
hotline, which was well advertised, was set up to give concise, easily understood

information and directions to employees. The hospital emergency rooms have a
3-day supply of antiretroviral medication (AZT, 3TC indinavir) for urgent therapy.
Ongoing support is provided by a nurse and an infectious disease physician.
Results: From October 1996 to January 1998, we have assessed 30 possible sharps-related exposures to HIV. After counselling, 5 persons chose to not
take treatment; 8 persons started chemoprophylaxis but discontinued when the
source patient's results were negative. Rapid HIV testing helped to reduce the
duration of treatment. The remaining 17 persons planned to take 1 month of
chemoprophylaxis: 9 of 17 persons completed the medications. Eight did not
complete therapy: 5 stopped treatment due to side effects and 3 stopped after
being assessed to have a low risk. One healthcare worker tested positive for HIV
during the baseline testing. Side effects were experienced by all persons who
were on the medications: these included nausea, vomiting, headaches, diarrhea,
and insomnia. None of the subjects seroconverted to HIV.
Lessons Learned: A Rapid Response System for HIV-related sharps injuries
was useful in providing immediate information, availability of antiretrovirals and
longer term follow up. Chemoprophylaxis was poorly tolerated and was often
discontinued.
33191 Pharmaceutical costs associated with managing a
population-based HIV accidental exposure program
Alaistair McLeod, M.V. O'Shaughnessy, B. Yip, N. Gataric, R.S. Hogg,
J.S.G. Montaner, M.T. Schechter. BC Centre for Excellence in HIV/AIDS,
613-1081 Burrard St., Vancouver, BC, Canada
Objective: To estimate the pharmaceutical costs in 1997 associated with managing a population-based HIV accidental exposure program in British Columbia
(BC).
Methods: In BC prophylaxis for accidental exposures to HIV are distributed to
free of charge to eligible individuals according to specific guidelines. In 01/96 therapeutic guidelines for prophylaxis of accidental exposures to HIV were expanded
to include ZDV and ddC in combination for 28 days for massive, definite or probable exposures. Five-day starter kits were provided to all Hospital Emergencies
and eligible community health clinics to ensure universal access to treatment. In
06/96 an evaluation component was added and guidelines were updated in 02/97
to include ZDV/3TC and triple therapy in certain situations. All dollar figures are
in 1997 US dollars figures assuming a rate of exchange of $1.40 Canadian.
Results: From 01/97 to 12/97, a total of 543 BC workers sought treatment
for accidental HIV exposure in BC. Of the 291 exposures where occupation was
known, 98 (34%) were in nurses, 58 (20%) police officers, prison and security
guards, or paramedics, 21 (7%) physicians or medical students, and 29 (10%)
janitors, housekeepers, or sanitation workers. From 01/97 to 12/97 expenditures
on accidental exposure prophylaxis totaled $122,105 for five day starter kits
and $177,654 for the remaining 23-day antiretroviral drug supply. The total cost
of $299,760 in 1997 represents a 63% increase in pharmaceutical costs over
1996. The average drug cost per person treated has dropped slightly to $552
as compared to $582 in 1996 but the number of people we served increased by
72%.
Conclusion: Our data indicate that pharmaceutical expenditures on accidental
exposure prophylaxis have increased by over 63% in 1997. The average pharmaceutical cost per person was $552 and does not take into account other direct
and indirect costs associated with this population-based program. The total pharmaceutical costs associated with this program are high, because of the number of
people seeking prophylaxis and the increasing use of triple combination therapy
regimens.
248*/33192 French physicians experiences and attitudes about
non-occupational post-exposure prophylaxis (PEP)
Anne Laporte, F. Lamontagne, J. Saint-Maurice, F. Lot. RNSP 14 Rue Du Val
D'Osne, 94415 Saint-Maurice, Cedex, France
Objectives: To evaluate the number and the type of requests for PEP in the
context of non occupational exposure to HIV and the attitudes and prescriptions of physicians, from July 1996 to June 1997, before the issue of French
recommendations.
Methods: In July 1997, a questionnaire was sent to 1 604 physicians having
reported more than one AIDS case in the past 3 years, asking for 1) the number
of PEP requests (R) and number of PEP prescribed (P) in the last 12 months;
2) the description of the latest exposure with PEP prescription; 3) the attitude of
physicians regarding prescription towards 5 theoretical exposure situations.
Results: 722 (45%) physicians answered to the survey and 678 questionnaires
were available to be analysed.
1) Frequency of requests (R) and prescriptions (P): 26% of physicians had at
least one request. The total number of R was 390 and the total of P was 165 (P/R
= 42%). For sexual exposures, P/R = 104/278 = 37%. For parenteral exposures
(IDU), P/R = 19/32 = 59%. For other exposures (needle injuries in public places,
bites,...), P/R = 42/80 = 53%.
2) Description of the latest exposure with PEP prescription: 120 cases were

described. The 82 sexual exposures concerned a condom breakage for 70% of
cases and an unprotected intercourse for 30%. HIV status of partner was known
in 78% of sexual exposures and in 38% of other exposures.
3) Attitude of physicians towards prescription: 91% agreed with PEP when
partner's HIV infection was known, 34% if the partner had HIV infection risk
factors (HIV status unknown), 5% only if a condom breakage occurred with an
HIV+ partner, 6% whatever the exposure, 2% were against PEP in all cases.