Papers

Surgeons' and occupational health departments' awareness of guidelines on post-exposure prophylaxis for staff exposed to HIV: telephone survey

S E Duff, senior house officer,  C K M Wong, registrar,  R E May, consultant. 

Department of Surgery, Frenchay Hospital, Frenchay, Bristol BS16 1LE

Correspondence to: Dr S E Duff, Department of Surgery, Winchester and Eastleigh Healthcare NHS Trust, Royal Hampshire County Hospital, Winchester SO22 5DG cduff68{at}aol.com

Surgeons face the occupational risk of parenteral transmission of infection, in particular with HIV, percutaneous exposure to which carries an estimated risk of transmission of 0.3%.^1-3 This risk may be reduced by antiretroviral prophylactic treatment.⁴ The UK Department of Health issued guidelines on post-exposure prophylaxis in June 1997.⁵ We assessed whether the guidelines had been implemented and whether surgeons were aware of them in the South and West health region.

	Methods and results

Top Methods and results Comment References

We conducted a telephone survey of all the occupational health departments and on-duty general surgical and orthopaedic registrar grade surgical trainees in the South and West region. Separate sets of questions were used for occupational health departments and surgical trainees (box).

Eleven occupational health departments were surveyed in September 1998. All the departments were aware of the Department of Health's guidelines, and all had either implemented a local policy (10) or nearly completed implementation (1). All local policies offered triple therapy 24 hours a day for healthcare workers occupationally exposed to HIV. Nineteen healthcare workers presented for consideration of post-exposure prophylaxis, of whom 3 declined treatment, 7 stopped the course early because of low risk of HIV infection in the source, and 9 completed the course.

Twenty six surgeons (13 orthopaedic, 13 general surgery) were surveyed in 13 hospitals. Only 8 surgeons knew of the Department of Health's guidelines on post-exposure prophylaxis; 10 were aware that local guidelines existed, but only 2 of these were familiar with the local recommendations. The time within which prophylaxis should be obtained was correctly stated as one hour by 10 surgeons; 9 surgeons thought that post-exposure prophylaxis should be obtained within 24 hours, 3 (12%) within 72 hours, and 4 did not know. Only 2 surgeons knew where to obtain post-exposure prophylaxis out of hours. No surgeons knew the correct estimated risk of seroconversion after a needlestick injury from an HIV positive patient. The incorrect responses were as low as 0.0025% and as high as 100%, although 13 estimated a <1% risk. The risk was estimated as <0.3% by 5 surgeons, 0.3% to <1% by 8, 1-5% by 7, 5-50% by 3, and 50-100% by 2; 1 surgeon did not hazard an estimate.

	Comment

Top Methods and results Comment References

Most of the occupational health departments in the South and West region, in accordance with the Department of Health's guidelines, had local policies for risk assessment and counselling, 24 hour availability of post-exposure prophylaxis, and follow up protocols. However, despite national and local publicity, surgeons in the region were poorly informed about these guidelines, and their knowledge about percutaneous exposure to HIV was inadequate.

The risk of seroconversion to HIV after a percutaneous exposure may be increased if a large volume of infectious material is transferred or if the viral titre in the material is high.⁴ Antiretroviral treatment reduces the ability of the virus to replicate, allowing the intact immune system an opportunity to clear the virus and thereby reduce the risk of seroconversion. Treatment with zidovudine has been shown to reduce the risk of seroconversion by 80%.⁴ The use of triple antiretroviral therapy is thought to reduce further the risk of transmission and prevent an increase in zidovudine resistance.

It is important that information about percutaneous exposure to HIV and appropriate prophylactic treatment is circulated to surgeons effectively, especially as the recommended prophylaxis needs to be given within one hour of exposure. Further work is necessary to determine national trends in both the implementation of the Department of Health's guidelines and surgeons' awareness of them.

	Acknowledgments

   Contributors: SED wrote the questionnaire, collected and analysed the data, and wrote the paper. CKMW had the original idea for the study, advised on the questionnaire design, and helped to write the paper. REM advised on the questionnaire design and helped to write the paper. SED will act as guarantor for the paper.

	Footnotes

Funding: None.

Competing interests: None declared.

	References

Top Methods and results Comment References

1.	Henderson DK, Fahey BJ, Willy M, Schmitt JM, Carey K, Koziol DE, et al. Risk for occupational transmission of human immunodeficiency virus type-1 (HIV-1) associated with clinical exposures. A prospective evaluation. Ann Intern Med 1990; 113: 740-746.
2.	Tokars JI, Marcus R, Culver DH, Schable CA, McKibben PS, Bandea CI, et al. Surveillance of HIV infection and zidovudine use among health care workers after occupational exposure to HIV-infected blood. Ann Intern Med 1993; 118: 913-919[Abstract/Free Full Text].
3.	Gerberding JL. Incidence and prevalence of human immunodeficiency virus, hepatitis B virus, hepatitis C virus, and cytomegalovirus among health care personnel at risk for blood exposure: final report from a longitudinal study. J Infect Dis 1994; 170: 1410-1417[Medline].
4.	Cardo DM, Culver DH, Ciesielski CA, Srivastava PU, Marcus R, Abiteboul D. Case-control study of HIV seroconversion in health care workers after percutaneous exposure. N Engl J Med 1997; 337: 1485-1490[Abstract/Free Full Text].
5.	Department of Health. Guidelines on post-exposure prophylaxis for health care workers occupationally exposed to HIV. London: DoH , 1997.

(Accepted 18 February 1999)