Saturday, January 22, 2005

HIV Drugs for Rape Victims

Apparently, the CDC is now recommending post-exposure prophylaxis for anyone exposed to HIV from rapes, accidents or isolated episodes of drug use or unsafe sex:

Health professionals applauded the government's new recommendation that rape victims and occasional intravenous drug users get emergency drug treatment to prevent the AIDS (news - web sites) virus, describing it as "progressive" and "a safety net."

...

People accidentally or incidentally exposed to the AIDS virus are usually given a three-drug combination that includes AZT and 3TC. Treatment should start no more than 72 hours after the exposure to the virus, and the drugs should be used for 28 days, according to the CDC.

The CDC said it hesitated to recommend wider use of AIDS drugs for curbing the spread of HIV because it did not have enough information on their effectiveness in reducing infection rates. But the agency said recent animal and lab studies and data from state and city programs that offer HIV drugs to rape victims and others provided a foundation for revising the guidelines.

"The severity of the HIV epidemic dictates we use all available tools to reduce infection," said Dr. Ronald Valdiserri of the CDC.

He stressed that emergency drug treatment is a "safety net," not a substitute for abstinence, monogamy, and the use of condoms and sterile needles.

"It is clearly not a 'morning-after pill,'" he said.

In tests on primates, drug cocktails prevented infection with the monkey version of HIV 100 percent of the time if given within 24 hours of exposure to the virus, and 52 percent of the time if administered within 72 hours, said Dr. Charles Gonzalez, assistant professor of medicine at New York University School of Medicine and a member of the New York State AIDS Institute medical guidelines board.

But no data exists on how effective the drugs are in stemming HIV infection in people.

...

The CDC said the regimen is not recommended for habitual drug users who share needles or for people who frequently engage in risky sex. Those people would have to take medication practically nonstop, which the health agency does not endorse.


I'm not too keen to admit this publicly, but here it goes. I didn't know post-exposure prophylaxis for rape victims wasn't the standard of care in all emergency departments. [In my defense, I don't get out much--school, residency, and work all in one state.] In any case, the important point to remember is that a rape patient should not leave the ER without the standard HIV prophylaxis meds (usually, a 1-week supply).

Posting this has made me think back to my first exposure experience. [Since I don't feel comfortable talking about cases involving patients or colleagues, you're stuck with stories about me.]

I truly remember it like it was yesterday. I had just started my internship and had managed to gain permission to scrub in on a cesarean section as the 3rd hand--the assistant to the surgeon's assistant. [Don't even ask what levels of servitude I had to sink to make that happen. Suffice it to say the senior resident owned me.] My lowly station notwithstanding, I was elated to be in the OR with one of the best attendings we had. I even got to do some suturing--how cool was that! But I digress.

What happened was that, halfway through the operation, the brilliant surgeon stuck me with a needle. And no all you smarty-pants, it wasn't my fault. The surgeon actually apologized to me! [For all you nonmedical readers, surgeons do not, ever, ever, apologize to an intern, unless they do something monumentally wrong, and even then it's not a given. If something is the intern's fault, what usually happens is this: the surgeon yells and swears at you, slaps your hand, calls you a moron and throws you out of the OR.]

The interesting part was not what happened, but how everybody reacted. The surgeon asked if I was feeling OK [scary], and if I wanted to scrub out (I didn't). The senior resident told me I could go home [unheard of] if I wanted (I didn't). And the nurses were especially attentive to me, and voluntarily acknowledged I was in the room [eerie]. For the rest of the surgery there was a strange silence in the OR, and everybody treated me like I was made of porcelain.

When the needle went into my finger I registered the event, but I didn't really react to it. I just went through the motions--gloves off, betadine, gloves back on--and continued assisting. I was more unnerved by everybody's concern and focus on me, than the actual needle stick.

The second the surgery was over however, that's when the autopilot switched off. While I was pouring every disinfectant I could find on my hand, it hit me. My first thought was: This. Is. It. I'm going to die now. My second thought was, shall we say, of a naughtier nature; something along the lines of "could there be a lamer way to acquire HIV?". Before you judge my reaction, keep in mind I was actually hyperventilating at this point. I was hanging on to the scrub sink for dear life. Everything was in slow motion as I was confronting my mortality for the first time.

And then I had a moment of clarity. There were only two options, and I had to make a decision. Either I walk out of the OR and out of the hospital, and never come back, or I return to the OR, help them move the patient, and accept the risk of death as part of taking care of my patients, and never think about it. I went back to the OR.

And that was it. I never gave it a second thought. I've been stuck a few more times since then, but I never had that odd reaction again. Of course, I've also been fortunate enough to have patients I could follow up on, and who were nice enough to consent to being tested, so I've never actually had to take the prophylaxis meds. But I know people who have, and it's not an easy thing to do. And, despite my own experience, I can't even begin to imagine what it must be like for a rape victim to consider the implications of HIV exposure.

2 Comments:

At 1:26 AM, Anonymous Anonymous said...

I had a needle stick as a third year during my vascular surgery rotation. We were closing, and I stuck myself with a grossly bloody needle. The patient was an 80 yo woman, and I wasn't too scared about there being an HIV risk.

Anyway, I took off my gloves and disinfected my hand with alcohol, and the circulator kindly pulled out the sheet with the hospital procedures.

The surgeon was very angry that I broke scrub. He yelled at me, didn't want me to report the incident, and wanted me to get back to work. Afterwords, he gave me grief for having to write an order for the HIV tests.

I didn't get the prophylaxis either. But a positive attitude from the surgeon would have been helpful.

-Matt

 
At 10:54 AM, Blogger patricia said...

where do iget the drug

 

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