Hepatitis C transmission and HIV post-exposure prophylaxis after needle- and syringe-sharing in Australian prisons

OBJECTIVES: To determine whether infection with human immunodeficiency virus (HIV), hepatitis B virus (HBV) or hepatitis C virus (HCV) occurred after two potential episodes of exposure through needle- and syringe-sharing in Australian prisons, and to examine use of post-exposure prophylaxis (PEP) against HIV infection in the prison setting. DESIGN: Cohort study of potential contacts of two prisoners infected with HIV, HBV and HCV followed up for up to 14 months. SETTING: Two Australian prisons between November 2000 (time of exposure) and December 2001. PARTICIPANTS: Two index patients (both infected with HIV and HCV; one also infectious for HBV) from two different prisons, and 104 inmates who shared needles and syringes. MAIN OUTCOME MEASURES: Seroconversions to HIV, HBV and HCV related to the high-risk exposure and uptake and completion of HIV PEP determined from medical records of inmates. RESULTS: There were four seroconversions to HCV within 14 months of the potential exposure (14% of those susceptible in the cohort), but no recorded HIV or HBV seroconversions. Forty-six inmates (82% of those eligible) were offered PEP, and 34 of these (74%) elected to receive it. Only eight (24% of the 34) completed the full PEP course. CONCLUSIONS: HCV transmission in the prison setting is related to high-risk needle- and syringe-sharing. Administering HIV PEP in the prison setting is complicated by challenging risk assessment and follow-up.     

Antibiotic prophylaxis

The use of antibiotic prophylaxis has long been established to prevent the development of invasive infections. In many settings, it is currently considered to be the standard of care to administer antibiotics prior to surgical procedures. The aim is to decrease the load of organisms at the site of manipulation and therefore minimize the appearance of local as well as distant infection. With the increasing number of antimicrobial agents available on the market, physicians are often faced with a dilemma when trying to decide which agent to use. This review addresses the current recommendations of antimicrobial prophylaxis in surgical procedures, in the prevention of infective endocarditis, as well as the prophylaxis required following exposure to highly infective bacteria.     

Migraine prophylaxis

There is a wide array of options for migraine prophylaxis; many of the available drugs are clearly proven to be effective and yet are underused in Australia. "New" drugs which are gaining favour for migraine prophylaxis include topiramate, candesartan, gabapentin and botulinum toxin. The evidence for efficacy is excellent for topiramate and reasonably good but limited for candesartan and gabapentin. The use of botulinum toxin is controversial and has gained substantial popularity through anecdotal experience rather than convincing published evidence. Transformed or chronic migraine with medication overuse is a particularly difficult problem. New strategies to aid in medication withdrawal are reviewed. The approach to menstrual migraine and migraine with prominent aura may differ from that for typical migraine. Novel approaches are being explored for these problems.     

Silver nitrate prophylaxis

In many countries the statutory use of silver nitrate prophylaxis as soon as possible after birth has recently been reviewed from both a human rights and a medical standpoint. It has been argued that silver nitrate does not prevent all cases of gonococcal ophthalmia neonatorum (GON) and that it causes chemical conjunctivitis, pain and visual impairment, which may interfere with parent-infant bonding. Furthermore, the low incidence of GON, better methods of prenatal diagnosis, and the availability of suitable alternative prophylactic medication and of effective methods of treatment of GON have prompted recommendations that alternative prophylaxis be legally allowed or that mandatory prophylaxis be eliminated altogether. This paper reviews the situation and provides updated recommendations.