Post-exposure prophylaxis against HIV infection is hard to supply for expatriate staff

Editor—Gilks and Wilkinson raise important issues on nosocomial HIV infection.¹ Healthcare workers planning to work overseas must be fully briefed about the risks of HIV infection and what to do. At the time of my own needlestick injury in 1993² I was reassured by the quoted risk of seroconversion of 0.3%. I did not know that my coeliac disease, along with other autoimmune conditions, might confer an increased genetic susceptibility to HIV. Seroconversion later occurred.

I had two subsequent exposures to blood from terminally ill patients with AIDS on to small cuts on my hands, from which I had removed gloves in order to feel collapsed veins. At that time the place of zidovudine in prophylaxis had not been clearly established, and the drug was not available. Surgeons may sustain more needlestick injuries than physicians, but physicians, and nurses, are at greater risk of seroconversion,³ probably because of a larger innoculum from hollow needles and because they care for more terminally ill patients, with high viral loads.

The moral and ethical case for providing post-exposure prophylaxis is strong, but the practical obstacles are great. Gilks and Wilkinson quote a figure of £456 for a four week course of triple therapy. In some sub-Saharan African countries the total annual spending on health is less than £3 a head. The short shelf life of these drugs (five years for zidovudine, two years for lamivudine, 18 months for indinavir) would require frequent replenishment of stocks, which adds to the prohibitive costs. Dedicated supplies, from whatever source, for expatriate staff might cause justified resentment among local workers and is ethically questionable. Could manufacturers be persuaded to donate relatively small quantities of their drugs to individual healthcare facilities in the Third World?

The small risk of nosocomial HIV infection should not deter health professionals from working overseas. Confidence will be boosted by a full and open debate leading to appropriate guidelines for post-exposure prophylaxis.