Strategies Outlined to Prevent Nosocomial HIV Transmission

NEW YORK--All physicians, regardless of their specialty, mustbe prepared to treat HIV-infected patients, according to an expertfrom the Centers for Disease Control and Prevention. Althoughfears of nosocomial transmission of the virus are not unwarranted,much can be done to avoid it.

Harold W. Jaffe, MD, associate director for HIV/AIDS at the CDC'sNational Center for Infectious Diseases, Atlanta, said that therehas been a reported 0.3% infection rate from percutaneous injuries.Mucocutaneous exposure, resulting from splashes of infected fluidsto the mouth or eyes, were reported as 0.1%, and there have beenno documented cutaneous transmissions.

Dr. Jaffe spoke at a CME course on the management of the HIV-infectedpatient, cosponsored by the Center for Bio-Medical Communication,Inc. (Dumont, NJ) and AmFAR (American Foundation for AIDS Research).

He said that the principal risk factors for percutaneous transmissionare deep injury and visible blood on a needle, scalpel, or othersurgical instrument. The risk is greatest if the source patientis terminally ill, since individuals with end-stage HIV infectiontend to have a high viral load in their peripheral blood.

Dr. Jaffe said that the best approach is to employ universal precautionsto avoid exposure with all patients, assuming that the blood ofany patient could contain HIV or other blood-borne pathogens.

Many safety devices to decrease risk are newly available or indevelopment, he said. Among those currently available are a self-bluntingneedle for use with Vacu-tainer collection devices; a hinged recappingdevice; blunt surgical suture needles that can be used in some,but not all, procedures; and a self-sheathing device for butterflyneedles. He cautioned that some of these devices can be used withoutactivating the safety features.

Postexposure Prophylaxis

The issue of postexposure prophylaxis is still controversial.The US Public Health Service plans a review before determiningwhether to recommend post-exposure prophylaxis at all, and thedevel-opment of new antiviral agents has made the question morecomplex.

The earlier the intervention following inoculation, the greaterthe chance of prevention. The efficacy of prophylaxis dependsto a degree on what medication the source patient is receiving,since drug-resistant strains are increasing.

Zidovudine (AZT, Retrovir) significantly decreases risk of seroconversion,but is not 100% efficacious. Combining AZT with another reversetranscriptase inhibitor such as lamivudine (3TC) might be advisable,he said, since combination therapy is known to be more potent.The choice of drugs is influenced by whatever is known about donordrug resistance.

The other side of the coin--transmission of HIV from an infectedhealth-care worker to a patient--remains a concern, though Dr.Jaffe was quick to point out that there has, to date, been onlyone documented case.

CDC guidelines recommend that individuals who perform invasiveprocedures should voluntarily determine their HIV status, thenconsult with independent expert panels to decide whether theirpatient contact should be restricted.