Surgeons' and occupational health departments' awareness of guidelines on post-exposure prophylaxis for staff exposed to HIV: telephone survey
BMJ 1999; 319 doi: https://doi.org/10.1136/bmj.319.7203.162 (Published 17 July 1999) Cite this as: BMJ 1999;319:162
- S E Duff, senior house officer (cduff68{at}aol.com),
- C K M Wong, registrar,
- R E May, consultant
- Correspondence to: Dr S E Duff, Department of Surgery, Winchester and Eastleigh Healthcare NHS Trust, Royal Hampshire County Hospital, Winchester SO22 5DG
- Accepted 18 February 1999
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
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).
Survey questions
To both groups
Are you aware of the guidelines from the Department of Health relating to post-exposure prophylaxis after occupational exposure to HIV?
In your hospital, are there established guidelines for prophylactic action to be taken in the event of an accidental exposure to HIV?
What do the guidelines recommend?
To occupational health departments only
Do you give prophylaxis?
What drugs does it consist of?
When do you give post-exposure prophylaxis?
For how long?
How many healthcare workers have presented for consideration of post-exposure prophylaxis?
How many have declined post-exposure prophylaxis? Why?
How many have completed the course?
How many have abandoned the course? Why?
Is post-exposure prophylaxis available 24 hours a day? Where?
To surgeons only
If you were accidentally exposed to HIV via a needlestick injury, do you know in what timeframe you should be taking prophylactic treatment?(a) 1 hour; (b) <24 hours; (c) 24-72 hours
If you needed to get post-exposure prophylaxis out of hours, do you know where it is available in your hospital?
Can you estimate the risk of seroconversion after a needlestick injury from an HIV positive patient?
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
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
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Funding None.
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Competing interests None declared.