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Managing non-occupational exposure to blood-borne diseases and STDs
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Managing non-occupational exposure to blood-borne diseases and STDs

A recent NSW Department of Health circular offers guidelines for the management of persons exposed to blood borne diseases and sexually transmitted diseases in a non ñ occupational setting. This circular complements one issued previously that concerned management of health care workers exposed to HIV, hepatitis B and C in the workplace.

The recent circular has significant implications for GPs as it refers to people and incidents that are community based as opposed to the earlier circular, which by and large involved incidents that occurred in healthcare settings.

All GPs could expect to be called upon to manage one of these exposures from time to time. Not a week goes by at SHAIDS without receiving a call for advice from GPs on how to manage these situations and not infrequently it is the GP who is the subject of the exposure, often a needlestick injury.

It is now timely to revisit the management of some of the more common scenarios. These, as well as less common presentations, can be referred to SHAIDS on (02) 6620 2980 or the Statewide Needlestick Hotline on 1800 804 823 for management advice.

1. 'The discarded syringe in the park' scenario

There are no documented cases of contracting any of the above infections from injuries sustained from discarded syringes. This fact is most important to emphasise when reassuring injured persons or concerned parents. It may be an opportunity to initiate vaccination against hepatitis B and tetanus. Prevalence of HIV and hep B carrier status amongst local injecting drug users is unknown but thought to be very low. Hepatitis C carrier status is probably quite high and it may be reassuring to both patient and practitioner to follow up with a hep C antibody test six months down the track.

2. 'I met this gorgeous guy/gal at the pub last night & the condom broke/came off' scenario.

For a heterosexual tryst, counselling about the relevant risks of acquiring an STD needs to occur. Knowledge of local prevalence is relevant. Viral STDs such as herpes and HPV need to be discussed as well as chlamydia and gonorrhoea. The morning after contraceptive pill may need to be considered but it is too early to do any STD tests.

Follow up testing for chlamydia and gonorrhoea should be done two weeks later and syphilis serology could be done at 2-3 months.

HIV is often a concern in these scenarios. Once again local HIV prevalence in heterosexuals is very low and the risk of transmission with a known positive partner is between one and two in a thousand for receptive vaginal intercourse and less for insertive vaginal intercourse. A follow up HIV Ab test at three months will reassure and opportunistic hepatitis B vaccination may also be appropriate.

For male to male sexual contact HIV transmission may be a much more likely scenario. The risk of transmission for unprotected receptive anal intercourse when the insertive partner is known positive can be as high as 3% and the Department's circular makes provision for the prophylactic use of antiretroviral (ARV) drugs in these circumstances. These situations are best dealt with by an immediate referral to the Sexual Health Service or the local A&E department as the counselling issues can be complex and time consuming.

Although there is no evidence to suggest that antiretrovirals can prevent HIV transmission in these instances, patients who elect to take the prescribed one month's course should initiate treatment as soon as possible after exposure.

Access to relevant starter packs of antiretrovirals within the Northern Rivers is through the local hospital emergency department. Patients starting ARV medication should be followed up at SHAIDS.

3. People in serodiscordant sexual or domestic relationship scenario.

Hepatitis B

Sexual partners and household contacts of hep B carriers should be vaccinated and this can be done with vaccines provided free from the local hospital pharmacy or A&E department.

Hepatitis C

There is no documented evidence of sexual transmission of hep C. Patients who have had a recent serious exposure to hepatitis C should probably be advised to have safe sex during the six month window period to exclude a theoretical transmission during seroconversion when the hep C viral load in semen or vaginal fluid may be high. There is no need for use of condoms to prevent transmission in the chronic carrier state to an uninfected partner. There is no vaccine against hepatitis C at this stage.

Interferon may be offered to health care workers only if they have had an occupational exposure and are showing evidence of seroconversion. This treatment is only available locally through SHAIDS and exposed HCWs are enrolled in a protocol to study efficiency and side effects.

HIV

People in HIV discordant relationships need to be advised of the availability of prophylactic antiretroviral medication in case there is a breakdown of safe sex (for whatever reason). Patients requiring attention should be immediately referred to A&E.

4. Sharing drug injecting paraphernalia scenario

This a scenario that doesn't often present the morning after. It would have to be considered high risk for transmission of HCV because of the high local prevalence and the potential of direct blood to blood contact. Hep B vaccination can be initiated through A&E and HIV prophylaxis also discussed and offered through A&E.

Kieran Mutimer is a venereologist and is the medical director of SHAIDS in Lismore. 20/6/99

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