EM5 HIV post-exposure prophylaxis in the austere, forward deployed environment. (Emergency Medicine).

EM5 HIV POST-EXPOSURE PROPHYLAXIS IN THE AUSTERE, FORWARD DEPLOYED ENVIRONMENT. Shawn F. Taylor, MD, Robert H. Lutz, MD, Casey Carlton, MD, MPH, and John A. Millward, PA-C, MS. 3rd and 7th Special Forces Groups (Airborne), Fort Bragg, NC.

The US Centers for Disease Control (CDC) published guidelines for the management of worker exposures to HIV and post-exposure prophylaxis (PEP). These guidelines were designed for exposures in the US hospital setting where providers have a known source, medical history, and risk factors. US Special Forces often travel to under-developed nations with high HIV incidence and inadequate medical infrastructure. We designed an HIV PEP protocol for these areas due to the following incident. Previously in SubSaharan Africa, a Special Forces soldier sustained a deep bite in an altercation with armed criminals. The criminal had blood in his mouth from wounds sustained during the encounter. At that time, no HIV PEP program was in place and the service member presented to the U.S. Embassy and was evacuated to the US. Host nation officals subsequently reported that the criminal was HIV positive. Our members frequently deploy to nations with markedly increased HIV incidence relative to the U.S. The reported HIV incidence i n certain Sub-Saharan African nations is 35%, with some sub-groups to 68%. The CDC has published Public Health Guidelines for the Management of Health-Care Worker Exposures to HIV and Recommendations for PEP. The guidelines were based on available literature which showed that PEP can prevent infection with HIV after significant exposure. However, the guidelines for this 3-step process require information difficult to obtain in austere environments. In many third world countries the medical system is not developed enough to determine step 2 of the CDG's process. This has also been noted as a problem for civilian health care providers working in similar overseas locations. To overcome this, we developed a program in which personnel deploy with a 5-day supply of zidovudine, lamivudine, and nelfinavir. They are instructed on the indications, dosage, and side effects of the PEP medications. We include a bottle of loperamide to control the gastrointestinal side effects. They are instructed to start HIV PEP within o ne hour of a significant exposure and plan for evacuation for testing and continued therapy. We document the personnel receiving proper HIV PEP who would not have prior to initiation of the program. We feel that the standard of care HIV PEP treatment should be available to all of our personnel, regardless of deployment to an austere, under-developed, pre-hospital environment.