May 18, 2020

Prophylaxis

A few years ago, I did a skin excision on a colleague’s patient with a cancerous lesion. During the procedure, we chatted and he told me how he was feeling better than he had in a long time and felt his health was improving. Right then, I felt the needle driver push the suture needle through my glove into my index finger. “Ouch” I thought to myself, but calmly finished suturing the incision in this patient with HIV. “Don’t worry- he says his health is good, I am sure he is undetectable” I thought quietly. I finished up, took off my glove covered in his blood, saw my blood on my finger tip, washed my hands thoroughly, and turned to look at his chart. Damn- he was off his HIV meds and had a viral load of 85,000. That meant that for each drop or milliliter of blood, there were 85,000 HIV viruses. That meant I was very likely exposed at a risky level.

Fortunately, not only was this at a time when Post Exposure Prophylaxis was shown to be effective, newer and more tolerable meds were available that could prevent infection. My clinic had the meds available and within an hour of exposure, I took my first dose of the combination of meds. I took them for a month with no real side effects and they worked as intended. The meds prevented HIV infection, for which I am grateful. Most of the month I was not worried, but there were a few moments when I could imagine the little viruses entering my cells and trying to reproduce, a very real fear, even if it wasn’t realistic. The meds did their job. What a relief to have that effective preventive medication and sobering that my job could put me at risk. That is what prophylaxis is. It is an action taken to prevent a disease. Most commonly used pre or post exposure.

This is on my mind today with the news that the President is taking hydroxychloroquine as a preventive measure. This is truly a complicated situation with complex questions and I am not to going to judge whether it is right or wrong. We just don’t have enough data to know how safe and effective hydroxychloroquine is. We do know these facts: He was exposed by two staff members who are positive for SARS-CoV-2 virus. I also know that despite not having data on safety and efficacy, hydroxychloroquine is being studied in health care workers as prophylaxis after exposure to see if it can prevent COVID-19. With that data in mind, I understand why he might want to take the meds as a precaution. I am aware of the potentially dangerous arrhythmias it can cause. I worry more about a rush of people having it prescribed to them so they can feel protected, even though the data saying it is safe and effective is lacking. I fear this will ultimately cause a shortage of the meds for people with Rheumatoid Arthritis, Lupus, and Malaria, who depend on them. This is one of the unintended consequences. I hope that ultimately there is no damage done.

But the good news is at least one of the vaccines is promising and moving forward into phase two trials. This is something to hang on to.

Wash your hands and cover your nose.

And finally, my caveat is that this is my experience and my opinions, which are subject to change as more information is available, and not related to the organization I work for. Thanks for reading.

https://www.jwatch.org/fw116652/2020/05/18/covid-19-early-vaccine-results-psychiatric-symptoms

https://www.nytimes.com/2020/05/18/health/coronavirus-vaccine-moderna.html

https://www.nytimes.com/article/hydroxychloroquine-coronavirus.html

https://www.fda.gov/media/137250/download