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To the Editor: To date, 55 health care workers are known to have become infected with human immunodeficiency virus (HIV) from occupational exposures in the United States.¹ Although US Public Health Service guidelines call for immediate administration of a 28-day course of antiretroviral prophylaxis to health care workers significantly exposed to HIV-infected blood or body fluids,^2-3 relatively little attention has been paid to prophylaxis for medical personnel working in other areas of the world. Despite a significant risk of exposure, most of these workers do not have access to a triage system or to antiretroviral medications.

An active international health program at Yale-New Haven Hospital and the Yale University School of Medicine places 35 to 40 medical residents each year at remote sites in locations including Haiti, Zimbabwe, South Africa, Nicaragua, Russia, the Fiji Islands, China, and Cuba. In addition, medical students and residents in other Yale training programs frequently pursue independent overseas rotations. Because international sites generally lack antiretroviral medications, we organized a system to provide an initial package containing a 6-day supply of zidovuvine and lamivudine (combivir) and nelfinavir.

The regimen was chosen based on ease of dosing, favorable adverse effect profile, and current US Public Health Service guidelines for antiretroviral prophylaxis.³ We did not attempt to tailor specific regimens to local resistance rates, which are likely to be low at most developing world sites. Because of the worldwide prevalence of HIV, the antiretroviral package is provided regardless of HIV prevalence at the site.

A telephone number at our institution is staffed 7 days a week, and traveling residents are instructed to call if they experience a significant exposure to known or probable HIV-positive blood or body fluids. In that event, the remainder (initially residents leave with a 6-day supply) of the 28-day prescription would be shipped to the site via a commercial express delivery service and arrive in 3 to 4 days. Program costs include approximately $200 for 6-day medication packages, $1000 for 28-day packages, and $130 to $250 for express delivery. For sites where express mail delivery cannot be accomplished within 4 days, a 28-day supply of medication is provided prior to departure.

Prior to the medical resident's departure, he or she meets with a physician to discuss indications for taking the medications (including the choice of a regimen with or without protease inhibitor), adverse effects, proper follow-up testing, testing of source patient specimens, and blood and body fluid precautions. Traveling residents are given a letter that details this information and provides the appropriate telephone numbers. A physician with substantial experience in administration of antiretroviral prophylaxis is available for telephone counseling and risk assessment. Approximately 20 individuals have received counseling and medication packages to date; thus far, no blood-borne pathogen exposures have occurred.

Needle-stick exposures are not uncommon in third-world settings. A study of 9 hospitals in Tanzania found that the average health care worker sustained 5 needle sticks per year and was splashed with blood or body fluids 9 times per year.⁴ A study of Dutch medics working in acquired immunodeficiency syndrome–endemic areas found that 61% had at least 1 percutaneous exposure during an average stay of 21 months.⁵ Given the increasing prevalence of HIV in developing world populations served by US health care workers and the probability that such health care workers could benefit from immediate prophylactic therapy, it is imperative that sponsoring institutions make antiretroviral medications available.

Mark Russi, MD, MPH; Michael Hajdun, BA; Michele Barry, MD
Yale University School of Medicine
New Haven, Conn

1. Preventing occupational HIV transmission to health care workers [National Center for HIV, STD and TB Prevention, Divisions of HIV/AIDS Prevention]. Available at: http://www.cdc.gov/nchstp/hiv_aids/pubs/facts/hcwprev.htm. Accessed February 8, 2000. 2. Centers for Disease Control and Prevention. Provisonal Public Health Service recommendations for chemoprophylaxis after occupational exposure to HIV. MMWR Morb Mortal Wkly Rep. 1996;45:468-472. PUBMED 3. Centers for Disease Control and Prevention. Public Health Service guidelines for the management of health-care worker exposures to HIV and recommendation for postexposure prophylaxis. MMWR Morb Mortal Wkly Rep. 1998;47(RR-7):1-33. 4. Gumodoka B, Favot I, Berege ZA, Dolmans WM. Occupational exposure to the risk of HIV infection among health care workers in Mwanza Region, United Republic of Tanzania. Bull World Health Organ. 1997;75:133-140. WEB OF SCIENCE | PUBMED 5. De Graaf R, Houweling H, van Zessen G. Occupational risk of HIV infection among western health care professionals posted in AIDS endemic areas. AIDS Care. 1998;10:441-452. FULL TEXT | WEB OF SCIENCE | PUBMED

Letters Section Editors: Phil B. Fontanarosa, MD, Deputy Editor; Stephen J. Lurie, MD, PhD, Fishbein Fellow.

JAMA. 2000;283:1292-1293.

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