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Failure of postexposure prophylaxis after sexual exposure to HIV

Fournier, Sandraa; Maillard, Anneb; Molina, Jean-Michela

Correspondence
Free
SDC

aDepartment of Infectious Diseases, and bLaboratory of Virology, Saint Louis Hospital, Paris, France.

Received: 10 November 2000; accepted: 16 November 2000.

Treatment with zidovudine after occupational exposure to HIV decreased the chance of HIV infection by 79% in a case–control study [1]. The study led to recommendations that prophylaxis should be considered for persons with HIV sexual exposure [2,3]. Failures of zidovudine postexposure prophylaxis (PEP) have, however, been reported among healthcare workers [4]. We report here a case of failure of PEP after sexual exposure to HIV.

A 20-year-old woman presented to the hospital in October 1999 because she had had receptive vaginal intercourse with an HIV-infected man 70 h earlier. The man had been off antiretroviral therapy for the past 2 years. An initial HIV antibody test (enzyme-linked immunosorbent assay) was negative. Treatment combining zidovudine, lamivudine and nelfinavir was prescribed for 4 weeks. The woman did not come to the follow-up visits. In December 1999, she developed a probable acute retroviral illness with unexplained fever, cervical lymph nodes and skin eruption of the trunk, which resolved spontaneously within 5 days. In February 2000, she presented again at the hospital, and HIV-1 infection was diagnosed with two positive enzyme-linked immunosorbent assay tests and a typical Western blot pattern. The woman denied any new exposure to HIV and indicated that she had taken the treatment for 4 weeks as prescribed. The plasma HIV-1 viral load was 69 200 copies/ml (Amplicor HIV-1 1.5 Monitor, Roche Molecular Systems, Branchburg, NJ, USA). A genotypic analysis of plasma HIV-1 failed to detect any mutation in the reverse transcriptase or protease genes.

This observation is the first documented failure of PEP after non-occupational HIV exposure. This failure could be explained in different ways: (i) the delay between exposure and the beginning of prophylaxis, 70 h, was perhaps too long, although it is the cut-off suggested for occupational exposure [5]; (ii) antiretroviral resistance of the contaminating viral strain; (iii) poor adherence to therapy; and (iv) a new exposure to HIV.

This observation emphasizes the importance of close follow-up after HIV exposure. It is also a reminder that PEP is not always effective, and that behavioural risk reduction remains essential to prevent HIV infection.

Sandra Fourniera

Anne Maillardb

Jean-Michel Molinaa

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References

1. Cardo D, Culver D, Ciesielski C. et al. A case–control study of HIV seroconversion in health care workers after percutaneous exposure. N Engl J Med 1997, 337: 1485 –1490.
2. Centers for Disease Control and Prevention. Management of possible sexual, injecting-drug-use, or other nonoccupational exposure to HIV, including considerations related to antiretroviral therapy. Morb Mortal Wkly Rep 1998, 47: 1 –13.
3. Katz M, Gerberding J. The care of persons with recent sexual exposure to HIV. Ann Intern Med 1998, 128: 306 –312.
4. Jochimsen E. Failures of zidovudine postexposure prophylaxis. Am J Med 1997, 102: 52 –55.
5. Gerberding J. Prophylaxis for occupational exposure to HIV. Ann Intern Med 1996, 125: 497 –501.
© 2001 Lippincott Williams & Wilkins, Inc.