Post-exposure prevention for HIV infection became a controversial issue last year after UCSF announced it would study the safety and feasibility of offering it to people following high-risk sexual or injection drug use exposure. Before the study, which is being conducted with the San Francisco Department of Public Health, began in January, only health care workers could access such treatment, known as post-exposure prophylaxis (PEP) -- counseling, testing and antiviral medication within 72 hours of exposure to HIV. Critics termed this study the "morning after" treatment, saying it would encourage people to take risks and undo the progress made by prevention efforts. (See sidebar below)

It may be too early to determine the results of offering PEP to the general population -- it has not been scientifically proven to prevent infection following sexual exposure to HIV -- but its effectiveness is well established among occupationally exposed health care workers. Since the mid-1980s, San Francisco General Hospital has been on the forefront of managing occupational exposure to HIV, and has shown that PEP has an 80 percent effectiveness in preventing infection from developing. In fact, only one in 300 occupational exposures to HIV results in infection.

Julie Gerberding, associate professor of medicine and director of the Epidemiology and Prevention Interventions (EPI) Center at SFGH, has been a leader in protecting health care workers from exposures since the beginning of the AIDS epidemic. She developed the Needlestick Hotline in 1988 to provide immediate treatment to exposed health care workers at SFGH. Last fall she was integral in launching the National Clinician's Post-Exposure Prophylaxis Hotline (PEPLine), which offers the most current information on treatment for occupational exposures. These hotlines have become models by which other hospitals shape their PEP programs.

"Initially, I think we were focusing on providing drug treatment and testing, but it became clear very soon after we initiated it that the major benefit from the hotline was probably the immediate triage and counseling," Gerberding said of the Needlestick Hotline. "The reporting of injuries almost doubled after we implemented the hotline." Soon after SFGH launched its hotline, it was made available to all health department workers. UCSF then initiated hotlines for its employees on Parnassus Heights and at the Veterans Affairs Medical Center. "I think UCSF was probably the first large medical institution to have hotlines for all of its affiliated hospitals," Gerberding said.

The system for workers at SFGH who fear they've been exposed to HIV is to call the Needlestick Hotline and get initial treatment and advice and, if they need to start drugs to prevent HIV infection, go to the pharmacy and get a starter packet after a clinician approves it. "There's no questions asked, no need to provide their name or any other information -- it's simply released anonymously by the pharmacy," Gerberding explained. Then they need to follow up in employee health services the next working day to have a face-to-face discussion about whether they should continue the drugs. An examination and blood test are also administered. "The thing that we try to initiate on the hotline is the counseling," Gerberding said. "Sometimes that's mostly what people need."

In the last ten years, the PEP drug treatment advice has changed significantly. At first, Gerberding says, hotline staffers would recommend as an antiviral treatment a high dose of AZT. Because of the varied combinations of antiretroviral drugs now being taken by people with HIV disease and the emergence of drug resistance, a much higher level of knowledge is required of the hotline workers to figure out which drugs to recommend to the potentially exposed health care worker.

"Now we're using very complicated drug regimens that are kind of tailor-made to the individual characteristics of each exposure," Gerberding said. "It's not like AZT where you have to know one drug. Now you have to know all 11 and all the complexities of how to prescribe them, how to monitor them, how to properly dose them and what the drug-drug interactions are." Whether or not the source patient is taking any antiviral drugs is crucial in evaluating which drugs to prescribe to the health care worker.

In response to this higher degree of complexity, the national PEPLine was created, which is staffed by expert clinicians at SFGH who give out advice to clinicians around the US who manage difficult occupational exposures.

"We are getting busy," Gerberding said of the service, which started in November. "Recently, the number of calls has gone up considerably, which tells us, I think, how complicated this situation really is for people." The project is a collaboration between the Needlestick Hotline and the National HIV Telephone Consultation Service or "Warm Line," which is run by Ron Goldschmidt, professor of family and community medicine and funded by Health Resources and Services Administration (HERSA).

Although PEP is effective in reducing HIV infection, efforts to prevent needlesticks and other occupational exposures to infections can be improved, Gerberding said. "There are still some worrisome areas," she said. "One area is the operating room where needles and sharps have to be used. There are a lot of people in a crowded space and it could be a very dangerous situation if there's not a lot of attention paid to safety. I think we're very fortunate here that Dr. Schecter, our chief of surgery, is so committed to safety and sets a very excellent standard of infection control. We have maybe some of the riskiest patients in the United States but we have some of the safest operating rooms in the United States." Emergency rooms, with their crowded quarters and chaotic pace, are the other area where needlesticks happen most often, Gerberding said.

"I think we've gone from a phase where we really looked at needle disposal issues and probably eliminated 30 percent of the problem right off the bat by dealing with that," said Gerberding of early prevention efforts. "We probably affected another 20 percent of the problem by implementing sharps safety programs and purchasing devices that are designed to be safe. The remaining problem is very difficult to address. Many of the injuries you see now are caused when people are using the sharp for the intended purpose. While they are sticking the patient for blood, for example, the patient moves and they get stuck, or while they are starting the IV, the patient has a seizure and they get stuck."

Up to four workers affiliated with SFGH have been infected with HIV through needlestick exposures, Gerberding said. But SFGH and UCSF have gone to great lengths to ensure that its students and clinicians are as knowledgeable as possible of safety precautions.

"There's no question that medical students are now better prepared but there's plenty of room for improvement," Gerberding said. "We're one of the few, if not the only, universities that have a mandated hands-on, all-day training for students in the new safety products we have so they're not confused by some newfangled device." Medical students as well as interns, when they arrive to start their residencies, go through an orientation about infection control, needle safety and hotlines and they have to get certified that they understand how safety devices work.

In the clinical setting, health care workers at SFGH use body substance precautions -- which are more far-reaching than universal precautions -- such as double-gloving or wearing face masks or protective garments when needed.

"Body substance precautions are designed to prevent contact with anything that might be potentially infectious," Gerberding said. "So any body fluid that may harbor a germ of any kind we take seriously, not just those from patients we know to be infected."

Although the risk of contracting HIV from skin or mucous membrane exposure is very low, the risk of becoming infected with other infectious diseases, such as Hepatitis B and C, is very real, Gerberding says.

"In this hospital the biggest hazard to workers is not HIV infection -- it's Hepatitis C infection," she said. "Thirty-three percent of our adult patients who've been sources of needle injuries have Hepatitis C and it's transmitted about ten times more readily than HIV and there's no prophylaxis for it."

On the flip side of prevention is protecting patients from contracting diseases from health care workers. Although the risk of doctors transmitting HIV to patients is, according to Gerberding, "infinitesimally small," there is a subset of certain surgical and dental pervasive procedures where there is a potential risk.

"Our policy does require that should an accident occur and the health care worker expose the patient, the health care worker has a moral and ethical duty to report it and we would manage the exposed patient with the same high standards that we manage the workers," Gerberding said.

And for HIV-positive health care workers who are concerned that they might expose a patient to HIV, a UCSF advisory group, chaired by Joel Palefsky, associate professor in residence, has devised a support system.

"It's a completely voluntary system for students, faculty and staff to contact qualified experts who can help them evaluate their risk, evaluate their career pathways, and get a supportive kind of interaction that addresses any concerns the person might have around the safety of the patient," Gerberding explained. "It's completely confidential. The hope is that it will be a safe place for people who want help to go without fear that they'll lose their job or their education. The vast, vast, vast majority of people don't want to do anything that would ever harm a patient. In many cases we can say 'no, you're not in a situation where you pose a risk to anyone, how can we help you feel confident and comfortable in work.' There's a lot more anxiety about things that don't need to be worried about."

Telephone Numbers:
PEPLine: 1-888-HIV-4911
The Warm Line: 1-800-933-3413

Websites:
The Epidemiology and Prevention Interventions Center

PEPNet:

by Paula Murphy

1st appeared 3/02/98

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