April 20, 2013
Paul E. Sax, M.D., is director of the HIV Program and Division of Infectious Diseases at Brigham and Women's Hospital in Boston.
From a colleague came this query:
We are being consulted by surgeons who are finding within blast victims tissues from other humans. We have been offering post-exposure prophylaxis. Have you folks developed any policies re PEP for explosion victims?
Welcome your thoughts,
Needless to say, the bombing victims are currently facing far greater challenges than exposure to blood-borne pathogens. But it's a very reasonable query and, as it turns out, there's an existing guideline that addresses the issue, published in MMWR in 2008.
Entitled "Recommendations for Postexposure Interventions to Prevent Infection with Hepatitis B Virus, Hepatitis C Virus, or Human Immunodeficiency Virus, and Tetanus in Persons Wounded During Bombings and Other Mass-Casualty Events" -- MMWR has a real knack for titles -- it's a valuable resource for a a very tricky clinical problem. It appropriately starts by stating that "Decisions regarding the administration of prophylaxis after a mass-casualty event are complex," then goes on to make the the following recommendations:
So in general, post-exposure prophylaxis for HIV is not recommended after bombings or other mass casualty events.
Still, the fine print does say it might be recommended in certain situations. One could imagine blast injuries in very high prevalence settings (Sub-Saharan Africa, certain urban areas in the USA) meeting this threshold.
Remember also that these were published in 2008, and at that time one major factor in the decision to withhold PEP was the toxicity of the intervention, which was zidovudine/lamivudine plus lopinavr/ritonavir. Today, with TDF/FTC and raltegravir the new standard of care, PEP is far better tolerated. (See here for the excellent New York PEP guidelines.)
So the bottom line? In grisly settings such as the one described in the above email -- tissue of other humans embedded into humans -- giving PEP is certainly defensible, guidelines notwithstanding.
Paul Sax is Clinical Director of Infectious Diseases at Brigham and Women's Hospital. His blog HIV and ID Observations is part of Journal Watch, where he is Editor-in-Chief of Journal Watch AIDS Clinical Care.