Page 128 - Journal of Special Operations Medicine - Winter 2014

blood has been estimated to be approximately 0.3% for exposure should deploy with a full regimen of HIV
17
and that after a mucous membrane exposure to be ap- PEP to be started as soon as possible after occupational
proximately 0.09%. Preventing exposures to blood exposure to HIV, but evacuation off the continent is rec-
18
and body fluids is the most important strategy for pre- ommended to complete the full 4 weeks of treatment.
venting occupationally acquired HIV infection. Individ- Complete blood counts and renal and hepatic func-
ual healthcare providers and leaders in SOF units should tion tests should be obtained at baseline and 2 weeks
ensure strict adherence to the principles of standard pre- after exposure (further testing may be indicated if ab-
cautions, including consistent use of personal protective normalities are detected). HIV testing is recommended
equipment. 19 at baseline and at 6 weeks, 12 weeks, and 6 months
after exposure. Because of the potential for toxicities
19
The point-of-care diagnostic kit, OraQuick Advanced associated with PEP regimens and the need for further
Rapid HIV-½ Ab test (NSN 6550-01-526-7431, avail- laboratory follow-up, the SOCAFRICA policy is for all
able through medical supply channels; OraSure Tech- personnel undergoing HIV PEP treatment to be trans-
nologies Inc., Bethlehem, PA, USA; www.orasure.com) ferred off the continent to a US MTF for further evalu-
has an extremely high sensitivity and results are avail- ation and treatment. In addition to supplying patients
able in about 30 minutes. If the test is negative, the pa- with enough PEP medications for travel, it is wise to
tient is highly likely to be HIV negative. This may be supply them with an antiemetic, as well.
useful to test the source of an accidental needle stick
or blood splash, but should not be used to screen for Snake Envenomation
acute HIV infection (sensitivity will be much lower un- It is no surprise that snake envenomation is one of the
der these circumstances). For a US Servicemember with most feared consequences of operations on the Afri-
body-fluid exposure from a person whose HIV status can continent. Africa is home to more than 400 snake
is unknown, it is prudent to begin postexposure pro- species and 30 of these are known to have caused hu-
phylaxis as soon as possible and begin the evacuation man death. The incidence of snakebites in Africa
20
procedures off the continent. is difficult to characterize, as reporting methods are
fragmented. Based on literature meta-analysis, the inci-
The US Public Health Service Working Group published dence of African snakebites is around 315,000 per year
new HIV postexposure prophylaxis (PEP) guidelines in with more than 700 amputations and between 7,000
2013. A new recommendation was for all PEP medica- and 32,000 deaths. The majority of snake envenom-
19
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tion regimens to contain three (or more) antiretroviral ations occur among the rural indigenous population.
drugs for all occupational exposures to HIV. The pre- Current disease and nonbattle injury (DNBI) statistics
ferred HIV PEP regimen recommended by SOCAFRICA for the AFRICOM area of responsibility reveal a 0%
is: raltegravir (Isentress ; Merck & Co., Whitehouse incidence of snake envenomations for personnel de-
®
Station, NJ, USA; www.merck.com) 400mg by mouth ployed to the continent.
twice daily plus tenofovir 300mg/emtricitabine 200mg
(Truvada ; Gilead Sciences Inc., Foster City, CA, USA; Six main clinical syndromes, outlined in Table 2, char-
®
www.gilead.com), by mouth once daily. Medical person- acterize snake bites. While it is often difficult to identify
nel participating in activities that put them at high risk the snake, syndromic classification of envenomation is

Table 2 Envenomation Syndromes*
Syndrome Clinical Presentation Treatment
Syndrome 1 Marked local swelling with coagulable blood Polyspecific antivenin and volume repletion
Syndrome 2 Marked local swelling with incoagulable blood South of Sahara and north of equator use
and/or spontaneous bleeding monospecific Echis antivenin, all of Africa:
polyspecific antivenin
Syndrome 3 Progressive paralysis (neurotoxicity) Polyspecific antivenin
weakness syndrome Consider trial of anticholinesterase therapy
Advanced airway
Syndrome 4 Mild swelling alone No antivenin
Palliative treatment only
Syndrome 5 Mild or negligible swelling with incoagulable blood Monospecific antivenin for boomslang (Dispholidus)
Supportive treatment for vine snake
Syndrome 6 Moderate to marked local swelling associated No antivenin available
with neurotoxicity Supportive treatment
Source: *From World Health Organization Guidelines for the Prevention and Clinical Management of Snakebite in Africa.

118 Journal of Special Operations Medicine Volume 14, Edition 4/Winter 2014