Page 236 - SAHCS HIVMed Journal Vol 20 No 1 2019

Page 5 of 6 Original Research

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infections amongst HCWs annually. The risk of HIV Of further concern is that 18.1% of subjects were unaware of
transmission has been estimated as 0.3% after percutaneous alternate PEP regimens with better tolerability. The World
exposure and 0.1% after mucocutaneous exposure to HIV- Health Organization advocates the use of PEP regimens
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infected blood. A meta-analysis that included 5810 patients containing a third drug with improved tolerability and
from 22 studies reported a pooled infectivity estimate of higher associated completion rates (e.g. dolutegravir,
0.23% (95% CI: 0.00–0.46), with 15 of these studies reporting a duranvir and raltegravir). Because of cost implications,
31
transmission risk of 0%. Comparatively, the seroconversion these newer and more tolerable drug regimens have only
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rate was four- to fivefold higher in this study (n = 2, 1.1%). recently been made available in some public sector hospitals
Both the subjects had completed the 28-day PEP regimen. in South Africa (pers. comm. with National Department of
However, a two-drug and not a three-drug regimen was Health personnel). Even though these regimens are more
prescribed in both cases. Although most PEP guidelines expensive, their higher cost cannot be compared to the cost of
recommend a three-drug regimen, there is no evidence to reduced tolerability, which may lead to days off and the risk
suggest that a three or more drug regimen is superior to a of acquiring HIV associated with not completing the entire
two-drug regimen. 23 28-day course of PEP. Widespread availability of these
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newer PEP regimens in public hospitals would go a long way
More than half (55.5%) of the OBBFEs in this study occurred in ensuring PEP completion.
when subjects were working shifts of > 12 h , with 20.2% of
subjects reporting tiredness and fatigue as a contributory In summary, this study highlights the high prevalence of
factor. These findings are in line with the findings of a large OBBFEs amongst intern doctors. We strongly advocate for
systematic review that included 65 studies from 21 African better working hours for junior doctors, the widespread
countries. The authors concluded that a lack of training and availability of triple drug PEP regimens with more
working more than 40 h per week were risk factors for tolerable side effect profiles and strict adherence to
acquiring an OBBFE. 24 approved institutional guidelines. We also recommend the
implementation of targeted educational programmes and the
A long-standing tradition in healthcare institutions is strict training of junior HCWs on local policies and guidelines
adherence and advocacy for the use of personal protective relating to OBBFEs. Furthermore, healthcare institutions in
equipment (PPE) to minimise contact with blood and body conjunction with the National Department of Health should
fluids. Such measures include, but are not restricted to, the ensure that these strategies comply with locally and
use of gloves, goggles and aprons. Most of the participants in internationally acceptable standards and recommendations.
this study used gloves (97.3%), which is considerably higher
than the findings of other studies that reported figures of Limitations
89% and 52%. 25
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This is a regional study that was conducted in four hospitals
in Gauteng province. Hence, the findings may not be
Poor adherence to standard PEP protocols has been associated
with a high risk of seroconversion to HIV and other representative of other regions in South Africa. Furthermore,
other limitations that are associated with questionnaire-
pathogens. 26,27 One study reported that 45% of HCWs did not based studies also apply here, which include recall bias and
use PEP after an OBBFE, whilst 50% in the same study had to selective non-disclosure.
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purchase the PEP themselves. This research study reported
initiation of PEP amongst 77.5% of exposed respondents, Conclusion
which is suboptimal in a setting where HIV is endemic.
Reasons for the suboptimal initiation of PEP include a lack of Occupational blood and body fluid exposures are common
insight as well as a lack of strict enforcement and education amongst intern doctors. It is recommended that regular
regarding PEP protocols. 27,29 Following education and training, health education and monitoring compliance
implementation of institutional protocols, PEP uptake was should be incorporated during the induction of medical
observed to have a trajectory increase from 12% to 90% in a internship doctors in hospitals. The availability of PEP
study by Peponis et al. 27 regimens with better tolerability will encourage compliance.

This study revealed a PEP completion rate of 63.8% as Acknowledgements
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compared to 79% recorded by Kassa et al. Established The authors would like to thank Dr Callistus Enyuma for his
reasons for non-completion of PEP include fatigue, assistance with analysis of the data.
gastrointestinal side effects and drug rash, amongst others.
30
Amongst the 77.5% of subjects who started PEP, 36.2% did
not complete the course, predominantly because of poor Competing interests
tolerability of drug side effects. In light of this discussion, The authors declare that this article is not under publication
we strongly recommend that there should be psychological, consideration elsewhere and that they have no financial or
social and emotional supports to exposed HCWs who are personal relationship(s) that may have inappropriately
using PEP. influenced them in writing this article.

http://www.sajhivmed.org.za 229 Open Access