The efficacy of postexposure prophylaxis (PEP) in healthcare workers exposed to HIV was first reported in a case–control study in which one month's therapy with zidovudine after percutaneous or mucous exposures to HIV was associated with an 81% reduction in the risk of HIV infection .
The use of antiretroviral PEP for postsexual exposure has been evaluated since 1997 , and in 1998 the Morbidity and Mortality Weekly Report published the first guidelines .
The effectiveness of postsexual exposure prophylaxis, in comparison with PEP, is less known. Failures have been described with both PEP and postsexual exposure prophylaxis , and some studies have shown that seroconversion can develop in 1% of patients treated with HAART shortly after sexual exposure to HIV [5,6].
‘L. Sacco’ Hospital is an institution of reference in Italy for AIDS care with three infectious diseases wards and 100 beds available for patients. Since 1994, as part of the Italian Register of PEP, we have developed an organized programme for our healthcare workers, and since July 1997 for healthcare workers employed in public and private hospitals in the Milan area as well as for other categories at risk of HIV exposure. Up to now 404 patients have been evaluated in our cohort, 94 of them have reported sexual exposure.
We describe a case of PEP failure after sexual exposure to HIV with concomitant hepatitis C virus (HCV) seroconversion.
A 24-year-old homosexual man presented to our hospital in December 2003 after receptive anal intercourse had occurred 30 h earlier with an occasional HIV-infected male partner. The condom had ruptured during sexual intercourse.
An initial HCV and HIV (Western blot and enzyme-linked immunosorbent assay) screening antibodies and an HIV-DNA assay were negative.
Treatment with zidovudine plus lamivudine (combivir) twice a day and indinavir (crixivan) 800 mg three times a day was prescribed for 4 weeks, according to the current guidelines and the patients entered in a clinical and haematological follow-up. The patient refused hepatitis B virus vaccination.
In March 2004, the presence of HCV antibodies (negative in January) was detected and confirmed with a positive HCV-RNA assay. Serum transaminase levels were slightly elevated (serum glutamate-pyruvate transaminase 78 U/l and serum glutamic-oxaloacetic transaminase 42 U/l). An HIV antibody test was negative on this occasion and subsequently also in May.
In July 2004, HIV infection was diagnosed with two positive enzyme-linked immunosorbent assay tests, a typical Western blot pattern and positive HIV DNA. The man confirmed complete adherence to the therapy and denied any further instances of at-risk sexual intercourse. In August, the plasma HIV-1 viral load was 8940 copies/ml (Amplicor; Roche Diagnostics, Branchburg, New Jersey, USA) and the CD4 cell count was 540 cells/ml.
The potential efficacy of PEP is known to be related to the early initiation of therapy. Animal studies have shown more efficacy when therapy was started within 24 h ; in this case the delay was 30 h.
The concomitant HCV–HIV infection has been described in other case reports [8,9], but not to our knowledge after sexual exposures. Transmission of HCV between HIV-negative men is extremely rare, according to a Canadian study , but some observations [7,8,11] have suggested that HIV may enhance the sexual transmission of HCV. Similarly, HCV could have delayed HIV seroconversion and the failure of PEP as a result of supposed pathogenic interactions between the two viruses . In the case of sexual or professional exposure to both viruses a prolonged follow-up is recommended to cover the risk of late seroconversion.
1. Cardo DM, Culver DH, Ciesielski CA, Srivastava PU, Marcus R, Abiteboal D, 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. Backgrounder: CDC-sponsored external consultants meeting on post-exposure therapy (PET) for non-occupational exposures to HIV
. Fact sheet prepared by the CDC. Atlanta, GA: CDC; July 1997.
3. Centers for Disease Control and Prevention. Management of possible sexual, injecting-drug-use, or other non-occupational exposure to HIV, including considerations related to antiretroviral therapy
. Public Health Service Statement. MMWR
4. Jochimsen EM. Failures of zidovudine post-exposure prophylaxis. Am J Med 1997; 102:52–55.
5. Fournier S, Maillard A, Molina JM. Failure of postexposure prophylaxis after sexual exposure to HIV. AIDS 2001; 15:430.
6. Roland ME, Neilands TB, Krone MR, Katz MH, Franses K, Grant RM, et al
. Seroconversion following non-occupational post-exposure prophylaxis against HIV. Clin Infect Dis 2005; 41:1507–1513.
7. Panlilio AL, Cardo DM, Grohskopf LA, Heneine W, Ross CS. Updated US Public Health Service guidelines for the management of occupational exposures to HIV and recommendations for post-exposure prophylaxis. MMWR 2005; 54(RR09):1–17.
8. Ridzon R, Gallagher K, Ciesielski C, Mast EE, Ginsberg MB, Robertson BJ, et al
. Simultaneous transmission of human immunodeficiency virus and hepatitis C virus from a needle-stick injury. N Engl J Med 1997; 336:912–922.
9. Abel S, Cesaire R, Cales-Quist D, Bera O, Sobesky G, Cabie A. Occupational transmission of human immunodeficiency virus and hepatitis C virus after a punch. Clin Infect Dis 2000; 31:1494–1495.
10. Alary M, Joly JR, Vinvelette J, Lavoie R, Turmel B, Remis SR. Lack of evidence of sexual transmission of hepatitis C virus in a prospective cohort study of men who have sex with men. Am Pub Health Assoc 2005; 95:502–505.
11. Filippini P, Coppola N, Scolastico C, Rossi G, Onofrio M, Sagnelli E, Piccinino F. Does HIV infection favor the sexual trasmission of hepatitis C? Sex Transm Dis 2001; 28:725–729.