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Prophylaxis Against Possible Human Immunodeficiency Virus Exposure After Nonoccupational Needlestick Injuries or Sexual Assaults in Children and Adolescents
Franz E. Babl, MD, MPH;
Ellen R. Cooper, MD;
Beth Kastner, MPH;
Sigmund Kharasch, MD
Arch Pediatr Adolesc Med. 2001;155:680-682.
ABSTRACT
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Background Nonoccupational human immunodeficiency virus (HIV) postexposure prophylaxis
(PEP) for adults has been described, although the Centers for Disease Control
and Prevention, Atlanta, Ga, offer no specific recommendations. There is limited
information about its use in children and adolescents.
Objective To describe the current practices of physicians in pediatric infectious
disease (PID) and pediatric emergency medicine (PEM) departments regarding
nonoccupational HIV PEP for children and adolescents.
Design Survey.
Participants Directors of all PID and PEM departments with fellowship programs in
the United States and Canada between July and November 1998.
Main Outcome Measures General questions regarding HIV PEP and questions concerning 2 scenarios
(5-year-old with a needlestick injury and a 15-year-old after sexual assault).
Results The return rate was 67 (78%) of 86 for PID and 36 (75%) of 48 for PEM
physicians. Fewer than 20% of physicians reported institutional policies for
nonoccupational HIV PEP; 33% had ever initiated nonoccupational HIV PEP. In
both scenarios, PID physicians were more likely than PEM physicians to recommend
or offer HIV PEP in the first 24 hours after the incident (55 [83%] of 66
vs 20 [56%] of 36 for needlestick injuries [odds ratio, 4.0; 95% confidence
interval, 1.6-10.1] and 47 [72%] of 65 vs 16 [50%] of 32 for sexual assault
[odds ratio, 2.6; 95% confidence interval, 1.1-6.3]). Seven different antiretroviral
agents in single, dual, or triple drug regimens administered for 2 to 12 weeks
were suggested.
Conclusions Although few physicians reported institutional policies, and only one
third had ever initiated HIV PEP, many would offer or recommend HIV PEP for
children and adolescents within 24 hours after possible HIV exposure. A wide
variation of regimens have been suggested. There is a need for a national
consensus for nonoccupational HIV PEP.
INTRODUCTION
ACCIDENTAL needlestick injuries from discarded hypodermic needles in
children and sexual assaults in adolescents raise concerns about possible
human immunodeficiency virus (HIV) transmission for patients, parents, and
physicians. In the occupational setting, HIV postexposure prophylaxis (PEP)
is well established, and the Centers for Disease Control and Prevention (CDC),
Atlanta, Ga, have published recommendations for its management.1, 2
In the nonoccupational setting, HIV PEP has been used for adults exposed to
HIV through injection drug use or sexual contact.3, 4
However, there are no definitive recommendations for HIV PEP in the nonoccupational
setting by the CDC5 or by the Committee of
Infectious Diseases of the American Academy of Pediatrics.6
We have offered HIV PEP in our pediatric emergency medicine (PEM) department
for the past 3 years after accidental needlestick injuries from discarded
hypodermic needles and after sexual assault. We find HIV PEP to pose a considerable
management challenge.7 As no guidelines exist,
we attempted to determine the experience and opinions of physicians in PID
and PEM departments regarding the use of nonoccupational HIV PEP in children
and adolescents.
METHODS
Between July and November 1998 we mailed a questionnaire to the directors
of all PID and PEM departments with fellowship programs in the United States
and Canada as listed in the fellowship directories of the Pediatric Infectious
Disease Society of North America and the American Academy of Pediatrics. General
questions regarding management experience with nonoccupational needlestick
injuries, sexual assault, and HIV PEP use were followed by 2 case scenarios
that we find most frequently raise the question of HIV PEP in the PEM department.
The first scenario involves a 5-year-old boy with a needlestick injury from
a discarded hypodermic needle in a public park; the second, a 15-year-old
girl seen after sexual assault with vaginal penetration by an unknown assailant.
We compared answers from PID and PEM physicians using  2 analysis
and the Fisher exact test, as appropriate.
RESULTS
The questionnaire return rate was 67 (78%) of 86 for PID physicians
and 36 (75%) of 48 for PEM physicians. Not all physicians who responded answered
every question on the questionnaire. Data is given for those physicians who
responded to the question indicated. Only 10 (14%) of 66 PID physicians and
6 (17%) of 36 PEM physicians reported formal institutional policies for use
of nonoccupational HIV PEP. The PID physicians were more likely to have ever
recommended or initiated HIV PEP than PEM physicians (37 [57%] of 65 vs 7
[21%] of 34 for needlestick injuries [odds ratio {OR}, 5.1; 95% confidence
interval {CI}, 1.9-13.4], and 17 [27%] of 64 vs 5 [14%] of 36 for sexual assault
[OR, 2.2; 95% CI, 0.75-6.7]).
In both scenarios, PID physicians were more likely than PEM physicians
to recommend or offer HIV PEP in the first 24 hours after the incident (55
[83%] of 66 vs 20 [56%] of 36 for needlestick injuries [OR, 4.0; 95% CI, 1.6-10.1]
and 47 [72%] of 65 vs 16 [50%] of 32 for sexual assault [OR, 2.6; 95% CI,
1.1-6.3]) and between 25 and 72 hours after the incident (50 [78%] of 64 vs
18 [51%] of 35 for needlestick injuries [OR, 3.4; 95% CI, 1.4-8.2] and 41
[63%] of 65 vs 14 [44%] of 32 for sexual assault [OR, 2.2; 95% CI, 0.9-5.2]).
If more than 73 hours and less than 1 week had elapsed, both PID and PEM physicians
were less likely to recommend or offer HIV PEP (14 [22%] of 63 vs 8 [23%]
of 35 for needlestick [OR, 1.0; 95% CI, 0.4-2.6] and 12 [18%] of 65 vs 6 [21%]
of 29 for sexual assault [OR, 0.9; 95% CI, 0.3-2.6]), however, more than 1
week after the incident, some physicians would still recommend or offer it
(10 [16%] of 64 vs 4 [11%] of 35 for needlestick injuries [OR, 1.4; 95% CI,
0.4-5.0] and 5 [8%] of 65 vs 4 [14%] of 28 for sexual assault [OR, 0.5; 95%
CI, 0.1-2.0]).
A total of 7 different antiretroviral agents (zidovudine, lamivudine,
stavudine, indinavir, nelfinavir, saquinavir, and ritonavir) in single-, dual-,
or triple-drug combinations were suggested for both scenarios, with lengths
of therapy ranging from 2 to 12 weeks. Most PID physicians (42 [65%] of 65)
recommended 4 weeks of antiretroviral prophylaxis, and the most frequently
recommended drugs were zidovudine (50 [96%] of 52) and lamivudine (48 [92%]
of 52). Twenty-two (61%) of 36 PEM physicians would always consult an infectious
disease specialist if they were faced with HIV PEP issues as they were unsure
about appropriate drug regimens and length of therapy.
Baseline HIV testing in the PEM department after nonoccupational possible
HIV exposure would be undertaken by most PID and many PEM physicians (58 [88%]
of 66 vs 21 [58%] of 36 for needlestick injuries [OR, 5.1; 95% CI, 1.9-14.0]
and 60 [92%] of 65 vs 17 [47%] of 36 for sexual assault [OR, 13.4; 95% CI,
4.3-41.2]).
COMMENT
The results of this survey of PID and PEM physicians indicate that nonoccupational
needlestick injuries and sexual assault elicit a variety of management responses
regarding HIV PEP. Despite the lack of formal institutional policies or national
guidelines, most PEM and a greater number of PID physicians surveyed would
currently offer or recommend HIV PEP within 72 hours of possible HIV exposure.
The CDC recommendation to use HIV PEP after certain occupational HIV
exposures1, 2 is based on data
showing a reduction in HIV transmission by using antiretroviral drugs in animal
models of parenteral and mucosal exposure to retroviruses,8, 9, 10, 11
a case-control study of health care workers,12
and perinatal and postnatal HIV transmission studies.13, 14
The probability of transmission through a single episode of unprotected rectal
(0.1%-3%) or vaginal intercourse (0.1%-0.2%) with someone known to be infected
with HIV is similar in magnitude to that associated with percutaneous exposures
for health care workers (0.4%).3, 15, 16
Although HIV transmission after rape has been documented,17
the transmission risk with an assailant of unknown HIV status is difficult
to assess. To date no HIV transmission from a discarded hypodermic needle
in a nonoccupational setting has been documented,18
but viable virus has been recovered from hypodermic syringes maintained at
room temperature in excess of 4 weeks.19 While
HIV PEP has been used for adult patients after nonoccupational HIV exposure,3, 4 a recent CDC statement on the management
of nonoccupational exposures to HIV concluded that since no data exist regarding
the efficacy of PEP for nonoccupational exposures, recommendations for or
against its use cannot be made.5
Although our survey shows a variety of drug regimens and lengths of
treatment, most PID physicians would obtain HIV baseline testing in the emergency
department and use a 4-week regimen with 2 antiretroviral agents (in particular,
zidovudine and lamivudine) for patients who are seen within 72 hours of possible
exposure. We have also used this regimen for the past 3 years in roughly 30
children and adolescents. This regimen mirrors the occupational exposure guidelines
developed by the CDC for an exposure source with unknown HIV status.1, 2
The desire to potentially prevent a life-threatening disease with HIV
PEP conflicts with a lack of efficacy and safety data. Although a national
nonoccupational HIV postexposure prophylaxis registry has been established
by the CDC5 (patients can be enrolled by phone
[877-HIV-1PEP] or through the Internet [http://www.hivpepregistry.org]), it is unlikely that evidence-based guidelines for nonoccupational
HIV PEP will become available soon. Therefore, a national consensus panel
should develop preliminary recommendations for PID and PEM physicians in this
confusing and evolving area of medical care. In the meantime, management strategies
for HIV PEP, including issues such as HIV testing and follow-up arrangements,
should be coordinated and formalized within institutions.
AUTHOR INFORMATION
Accepted for publication January 10, 2001.
Presented in part at the Society of Pediatric Research Meeting, San
Francisco, Calif, May 1999, and at the Society of Academic Emergency Medicine,
Boston, Mass, June 1999.
From the Divisions of Pediatric Emergency Medicine (Drs Babl, Kastner,
and Kharasch) and Pediatric Infectious Diseases (Drs Babl and Cooper), Boston
University School of Medicine, Boston Medical Center, Boston, Mass.
Corresponding author and reprints: Franz E. Babl, MD, MPH, Division
of Pediatric Infectious Diseases, Finland 5, Boston Medical Center, 1 Boston
Medical Center Place, Boston, MA 02118 (e-mail: franz.babl{at}bmc.org).
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