Simultaneous Infection With HIV and Hepatitis C Virus Following Occupational Conjunctival Blood Exposure

To the Editor.—The rate of transmission of human immunodeficiency virus (HIV) after mucous membrane exposure is estimated at 0.09%,¹ although few data are available for hepatitis C virus (HCV). Cases of simultaneous HIV and HCV transmission after a needlestick² and of HIV or HCV infection after mucosal exposure have been reported.^{1 ,3} In 1 case of simultaneous HIV and HCV transmission after a needlestick,² the clinical course was remarkable for rapid progression to hepatic failure and death, suggesting that the accelerated course of hepatic failure could have been related to high HCV load due to simultaneous acquisition of HIV. We previously reported a case of non-A, non-B hepatitis and HIV infection in a health care worker (HCW) after a massive exposure of conjunctiva and oral mucosa to blood, in which the patient progressed to the acquired immunodeficiency syndrome at 4 years.¹ Similar findings have been reported after simultaneous infection with HIV and cytomegalovirus.⁴ We now report a case of simultaneous infection of HIV and HCV following conjunctival blood exposure in a health care worker.

In a clinical laboratory of one of the hospitals participating in the Italian Study of Occupational Risk of HIV infection, a health care worker sustained a blood splash of approximately 0.5 mL to the conjunctiva when disposing of open blood tubes into a plastic-lined, cardboard disposal container. There was no contact of blood with the worker's mouth, and there were no open lesions on the skin. The health care worker immediately washed the contaminated site and contacted the hospital employee health service. Among the disposed blood tubes were at least 6 blood samples from HIV-infected patients who were at different stages of the disease. The HCW consented to zidovudine postexposure prophylaxis, as was recommended at that time, and treatment was started 3 hours after the exposure. The HCW received no prophylaxis for HCV as there is none recommended or effective. The HCW developed simultaneous infection with HIV and HCV. The clinical course is summarized in Table 1.

The HCW was questioned about injecting drug use, number of sexual partners, and transfusions, and no risk factors for HIV or HCV were identified. The HCW's spouse tested negative for HIV and HCV. The HCW reported absolute compliance with postexposure prophylaxis, without intolerance, dose reduction, or interruption. Further data about HIV (ie, HIV RNA viral load, viral culture, type of strain, and antiretroviral resistance) or HCV status of the source patients were not available because blood samples were not stored.

We postulate that in acute coinfection, the pathogenetic interactions between HIV and HCV could interfere with the initial immune response that occurs following primary HIV infection and could lead to an extremely high HIV burden with a more rapid HIV disease progression. In this case, the source of either infection could not be pinpointed, and the investigation was limited because of lack of sequencing and drug resistance ascertainment.

Two additional issues in the present case should be considered. As suggested by other cases of failure, zidovudine should no longer be considered as a monotherapy for HIV-exposed heath care workers, and postexposure prophylaxis should include a 3-drug regimen.⁵ Finally, the mechanisms of this occupational exposure suggest that all steps in blood processing should be designed to eliminate the possibility of health care workers coming into contact with any blood specimen. A policy to keep blood tubes covered at all times would help to prevent this particular type of exposure.