HIV PEP: The sooner, the better

There's a disturbing report in the June issue of Infection Control and Hospital Epidemiology which details transmission of HIV to a healthcare worker following an occupational injury. The provider was placing a central line in a patient with AIDS and cryptococcal meningitis and was stuck with a 25 gauge needle used in the procedure. The patient was HAART-naive and the HCW was HIV negative at the time of the injury. The initial post-exposure prophylaxis (PEP) regimen (combivir + kaletra) provided to the HCW is a CDC-recommended regimen. This was changed to truvada + atazanavir (also CDC recommended) due to diarrhea on the 10th day after exposure. A total of 4 weeks of post-exposure prophylaxis was administered. Sixty days following exposure the HCW developed fever, fatigue and myalgias and was found to be infected with HIV.

Since the introduction of HAART PEP, HIV seroconversion in HCWs has nearly disappeared despite the large number of sharps injuries that occur. Importantly, the transmitted virus had no resistance to any of the antivirals used for prophylaxis. The only potential problem described in the report was that the first dose of PEP was administered 18 hours after the exposure occurred, and one is left to wonder if infection would have occurred if the first dose had been administered sooner. Our goal is to have the first PEP dose on board within one hour of exposure.

Photo: A Medical Resident's Journey