Needle-stick concerns
CMAJ 1997;156:1267
In response to: J.R. Sloan
Dr. Sloan raises a practical issue. Most guidelines call for initiation of antiretroviral therapy following percutaneous or mucous-membrane exposure to potentially infectious body fluids from persons known to be HIV-positive or who are at high risk for HIV infection. Potentially infectious fluids include blood and semen, and vaginal, cerebrospinal, synovial, pleural, peritoneal, pericardial or amniotic fluids. People at high risk for HIV infection include men who have sex with men, injection-drug users, people who received multiple blood transfusions between 1978 and November 1995 and sexual partners of the people in these risk groups.
When less is known about the patient, every effort should be made to counsel him or her about HIV and to obtain consent for HIV testing. When patients fully understand what is at stake for the health care worker, most will proceed with the test. A few days of antiretroviral therapy may then be prescribed for the injured worker, with a decision on further treatment made on receipt of the result.
Even if testing is not done, details about possible high-risk behaviour may be pursued during counselling. If such a history is unambiguously absent, postexposure prophylaxis may be legitimately deferred in most cases. Sloan correctly implies that when HIV status or risk status cannot be determined, judgement is more difficult, and health care workers have to rely on a knowledge of HIV prevalence in the patient population. Factors that should prompt consideration of therapy in these difficult cases include a patient population with a high prevalence of HIV infection -- patients seen at an inner-city emergency department, for example -- or a massive percutaneous exposure to a large volume of blood.
David M. Patrick, MD
Associate Director
Division of STD/AIDS Control
BC Centre for Disease Control
British Columbia Ministry of Health
Vancouver, BC
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