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“The only thing necessary for these diseases to the triumph is for good people and governments to do nothing.”

    

Hepatitis B, C, and HIV Post-exposure Prophylaxis in Correctional Settings
By Anne S. De Groot*, M.D., and Roland C. Merchant**, M.D., M.P.H., Brown University

 
Consider these real-life scenarios:
-Two HIV-infected inmates (one also infected with hepatitis shared injecting-drug needles with at least 104 inmates in an Australian prison.
-A male inmate was repeatedly sexually assaulted by a prisoner who was known to be HIV- and hepatitis C-infected.
-A male inmate reported having unprotected, anal receptive consensual sex with someone of unknown hepatitis and HIV status.
-A female inmate was stuck by a needle she found while cleaning a bathroom.

How should these blood or body fluid exposures be managed in the correctional setting, and what are the infections of concern? Are correctional professionals prepared to manage these exposures?

HIV transmission is believed to be a rare consequence of blood or body fluid exposures in the correctional setting. However, if transmission occurs, the consequences are permanent and potentially deadly. Likewise, hepatitis C and hepatitis B transmission can lead to lifelong illness and sometimes a shortened life expectancy. Fortunately, post-exposure interventions that might reduce the transmission risk, and thereby diminish the consequences of an exposure, do exist and appear to be effective.

Post-exposure prophylaxis (PEP) protocols that incorporate such interventions have been implemented in many settings, particularly for health care staff. However, few correctional institutions have implemented blood or body fluid post-exposure protocols for inmates exposed to bloodborne pathogens by any route (injection-drug use, consensual sex, or sexual assault). This deficit is especially noteworthy given recent calls for PEP implementation in jails and prisons.1,2 Given the acceptance of PEP outside the correctional setting, adoption of PEP protocols in the correctional setting may help reduce the legal, emotional, and medical ramifications of an exposure event for this vulnerable population.

Of course, prevention of blood or body fluid exposures is preferable over post-exposure interventions since such post-hoc measures are not completely effective, are costly, and carry the potential for adverse side effects. However, not all exposures can be prevented, particularly in jails and prisons. It therefore is advisable that both pre- and post-exposure bloodborne pathogen transmission preventive measures be enacted in correctional settings.

In this article we discuss the management of PEP for incarcerated individuals. Of course, the same principles also apply to the management of a post-exposure intervention for correctional staff. The risk for transmission of three common bloodborne infections - HIV, hepatitis B (HBV) and hepatitis C (Hepatitis C Virus) - is reviewed, as well as PEP options for potential exposures to these pathogens.

Transmission Risk
Bloodborne pathogen transmission depends upon the nature of the exposure and the infectious status of the exposure source. Prisoners are at risk for HIV, HBV, and Hepatitis C Virus infections from sexual contacts, medical percutaneous injuries, and injecting-drug paraphernalia sharing. The transmission risk from these events is influenced by the amount of infectious material involved, the characteristics of the event, and the severity of the exposure source's illness.

    



The risk of infection following a given blood or body fluid exposure depends first and foremost upon the likelihood that the exposure source is infected. In the correctional setting, the likelihood of the source being infected with HIV, HBV or Hepatitis C Virus is higher than outside the prison walls. Correctional professionals are familiar with the high prevalence of HIV, Hepatitis C Virus, and HBV in inmate populations, ranging as high as 3% for HIV (and up to 8.5% in some state prison systems3) and 35% for Hepatitis C Virus.4,5 Data have recently been released from the Maryland AIDS Administration announcing that one in three prison inmates in Maryland is infected with HIV, syphilis, HBV, or Hepatitis C Virus - many having more than one infection.6

Transmission Estimates
HIV Transmission
HIV transmission estimates vary by the type of exposure. Per-event transmission probability estimates are 0.3% - 0.4% after a percutaneous (e.g., needlestick) exposure, and 0.09% after a mucous membrane exposure.8 The risk for HIV transmission per episode of intravenous needle or syringe sharing is estimated at 0.7%.7 The risk for HIV transmission per episode of receptive penile-anal sexual intercourse is estimated at 0.1% - 3%, while the risk per episode of receptive vaginal intercourse is estimated at 0.1% - 0.2%. No published estimates of the risk for transmission from receptive oral exposure exist, but instances of suspected transmission have been reported.7

These estimates are approximate, and depend upon other factors, such as the stage of HIV disease of the exposure source, the presence of other sexually transmitted diseases, and effective use of antiretroviral medication with suppression of viral load.

According to Centers for Disease Control and Prevention (CDC) PEP guidelines, several factors could affect the risk of HIV transmission after exposure. The risk is increased after an exposure to a large quantity of blood from the source (e.g., a device visibly contaminated with blood, a procedure that involved a needle being placed directly in a vein or artery, a deep injury, etc.), as well as from exposure to a source with an advanced HIV infection (i.e., a high viral load).8

HBV Transmission
According to the CDC, the risk of HBV infection is primarily related to the degree of contact with blood and the hepatitis B e antigen (HBeAg) status of the source.8 Exposures to sources harboring HBeAg confer a greater risk of HBV transmission. In studies of health care workers who sustained injuries from needles contaminated with blood positive for both HBsAg and HBeAg, the risk of developing clinical hepatitis was 22% - 31% and the risk of serologic evidence of HBV infection was 37% - 62%. In comparison, the risk of developing clinical hepatitis from a needle contaminated with HBsAg-positive, HBeAg-negative blood was 1% - 6%, while the risk of developing serologic evidence of HBV infection was 23% - 37%.8,9

The highest risk for transmission of HBV is through exposure to blood, although saliva, semen, sweat, feces, and bile may contain infectious particles. However, most body fluids contain low quantities of infectious HBV, and are therefore not efficient transmitters of infection.8

Hepatitis C Virus Transmission
Although less well understood, Hepatitis C Virus is likely transmitted in the same manner as HIV and HBV.10 Transmission rarely occurs from mucous membrane exposures to blood, and rarely, if at all, after percutaneous exposures to blood with needles that are not hollow bore. The risk for transmission from exposure to fluids or tissues other than Hepatitis C Virus-infected blood has not been quantified, but is expected to be low. The average risk of anti-Hepatitis C Virus seroconversion after an accidental percutaneous exposure to an Hepatitis C Virus-infected source is 1.8%, with a range of 0%-7%.8

PEP Options
HIV PEP
HIV PEP involves two or three antiretroviral medications that are begun no later than 72 hours after a potential HIV exposure (within 24 hours is best) and taken for 28 days.11,12 HIV PEP efficacy, although not proven through randomized, placebo-controlled trials, is suggested from clinical trials that showed a reduction of perinatal HIV prevention with antiretroviral medications use, animal studies which employed various chemoprophylactic regimens, immunologic investigations on HIV transmission mechanisms, and a multi-national observational study of health care workers demonstrating decreased HIV transmission among those who took zidovudine after a percutaneous injury.13

For more detail on the management of occupational blood exposures to HIV, see the HEPPigram on page 5.

The CDC currently only endorses HIV PEP for health care workers who have been possibly exposed to HIV at their workplace.7,8 A number of other groups in the US and elsewhere have created their own HIV PEP recommendations or guidelines for people who are not health care workers and have sustained so-called "nonoccupational" exposures to HIV, such as from sexual contact or injecting-drug use.2,14,15 California and New York have statewide guidelines on HIV PEP after sexual assault, Massachusetts has a clinical advisory on HIV PEP, and Rhode Island has Department of Health-endorsed guidelines on HIV PEP provision after all types of potential HIV exposures.16,17,18,19 New York is expected to release similar comprehensive HIV PEP guidelines soon, and the CDC is considering recommendations for nonoccupational PEP.

HBV PEP
The CDC recommends vaccinating any non-immune person who is potentially exposed to hepatitis B from any type of transmissible event.5,20 The CDC reserves hepatitis B immunoglobulin for unvaccinated individuals, and those who failed to respond serologically to HBV vaccine who are then exposed to infectious body fluids from someone with known or suspected hepatitis B infection. Although the efficacy of HBV PEP has not been validated by randomized, blinded, placebo-controlled trials, HBV PEP experiments using vaccinations and/or immunoglobulin infusions in the perinatal and occupational settings provide strong evidence suggesting efficacy.8

Management of HBV exposure involves determining the HBV status of the source, if the source is known. Treatment of the exposed individual can be delayed for up to three days until this information is available.

    



All correctional employees should be vaccinated against HBV. The CDC also recently recommended that susceptible inmates be vaccinated as well. Vaccinating inmates in prisons has been demonstrated to be feasible and cost-saving from both the prison and community perspectives.5

Hepatitis C Virus PEP
The CDC does not currently recommend any form of Hepatitis C Virus post-exposure prophylaxis following potential Hepatitis C Virus exposures. However, if acute Hepatitis C Virus infection is confirmed in the exposed person, recent data suggest that early treatment of the acute infection with alpha interferon may be highly effective in preventing the development of chronic Hepatitis C Virus infection.21 Therefore, individuals who are exposed to Hepatitis C Virus should be referred to experienced clinicians who can provide updated counseling and treatment.

PEP Experience in the Correctional Setting
A recent article published in the Medical Journal of Australia describes a cohort study conducted in two Australian prisons involving HIV, HBV, and Hepatitis C Virus transmission and PEP.1 Two inmates infected with HIV and Hepatitis C Virus (one of whom also had chronic HBV), and more than 100 inmates who shared needles and syringes with either of the two were followed in this study.

The two source patients (in two different prisons) informed the staff at their respective medical clinics that they had shared needles with other injecting-drug users within the previous weeks. One inmate identified his sharing partners, while the other inmate did not. Inmates in both prisons who may have shared needles with the source cases were contacted and were invited to attend the prison clinic if they had shared needles or syringes during a specified period (the period of possible contact with the source patients). One hundred and seventy inmates attended the clinic in response to the invitation, and 104 inmates were determined to be potentially exposed.

Of the 104 inmates potentially exposed to HIV, 56 had been exposed within the previous 72 hours and were therefore eligible based upon the prison's protocol for post-exposure prophylaxis (PEP). Forty-six inmates (82% of those eligible) were offered PEP, and 34 of these (74%) elected to receive it. Thirty-four men took PEP with zidovudine (AZT) and lamivudine (3TC) for an average of 18 days. Some trading of PEP drugs was reported amongst prisoners and as a result prison health staff began administering PEP as directly observed therapy (DOT). Only eight (24% of the 34) completed the full PEP course of 28 days. Among the 26 inmates who did not complete the full course of PEP, 11 did not give a reason for stopping, though some discontinuation occurred when the inmates were transferred or released. The authors conclude that another reason for stopping therapy may have been the use of DOT, instituted after the pill trading was discovered.

No cases of HIV infection were found at follow-up testing a year later. However, only 61% of the 104 potentially exposed prisoners received follow-up testing, and the researchers acknowledged that seroconversions might have occurred among those lost to follow-up.

Inmates susceptible to HBV infection at baseline received HBV vaccination or immunoglobulin and no new cases of HBV were detected during follow-up.

While only 29 men were susceptible to Hepatitis C Virus infection at baseline, four (14%) of these were found to be infected with hepatitis C at follow-up testing. Researchers were reluctant to attribute these Hepatitis C Virus seroconversions to the documented exposures due to multiple exposures and ongoing risk behaviors by the prisoners involved. Nevertheless, they concluded that their findings are consistent with the higher probability of transmitting Hepatitis C Virus compared with HIV through sharing needles and syringes.

Conclusion
Many correctional facilities have adopted PEP guidelines for the management of staff needlestick and sharp exposures. Nonoccupational PEP is a newer concept that has been implemented in community settings. As described in the report from Australia, inmates can be exposed to HIV, Hepatitis C Virus and HBV in correctional settings. Thus, familiarity with post-exposure preventive prophylaxis is an important aspect of medical care in correctional settings, both for inmates and staff who may become exposed to HIV, HBV or Hepatitis C Virus in the course of their work. Despite the best efforts of correctional staff, it is likely that exposures will continue to occur. The best prevention is good preparation.

DISCLOSURES:
* Consultant and Speaker's Bureau: Abbott Laboratories, Agouron Pharmaceuticals, Boehringer Ingelheim Pharmaceuticals, GlaxoSmithKline, Gilead Sciences, Merck, Roche Pharmaceuticals and Schering
** Dr. Merchant is supported by a National Institutes of Health training grant through the Division of Infectious Diseases, Brown Medical School, The Miriam Hospital, from the National Institute on Drug Abuse, 5 T32 DA13911-02.

REFERENCES:
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