Correspondence

Enfuvirtide for Prophylaxis against HIV Infection

N Engl J Med 2003; 349:2169-2170November 27, 2003

Article

To the Editor:

In their letter to the editor, Ferranti and Menichetti (Aug. 21 issue)1 propose that enfuvirtide “should be considered for prophylaxis against HIV-1 [human immunodeficiency virus type 1] infection in cases of high-risk exposure to a patient with multidrug-resistant virus.” To be useful as part of a prophylactic strategy, drugs have to be easy to administer and inexpensive, have few side effects, and have proven efficacy.2 Enfuvirtide is not easy to administer (requiring two injections per day and 45 minutes of preparation), is in permanently short supply because of technical complexity, has at least mild side effects (there are very few data on its biologic toxicity), and costs $1,500 for a month's supply. Moreover, the efficacy of enfuvirtide has been proven in an atypical population of patients.3,4

Even in “cases of high-risk exposure,” the greatest rate of HIV transmission has been estimated to be about 0.3 percent. Some developed countries have generalized the use of postexposure prophylaxis to all persons who are in need. There are major concerns about individual tolerance and adherence and about cost effectiveness at a population level. We think that in this situation, it is wise to use well-known drugs and, if possible, the less expensive ones. Enfuvirtide has no place in this setting in 2003.

Lise Cuzin, M.D.
Muriel Alvarez, M.D.
Purpan Hospital, 31059 Toulouse, France
cuzin.l@chu-toulouse.fr

4 References

1. 1

   Ferranti S, Menichetti F. Enfuvirtide for prophylaxis against HIV infection. N Engl J Med 2003;349:815-815
   Full Text | Web of Science | Medline

2. 2

   Beaman MH, Luft BJ, Remington JS. Prophylaxis for toxoplasmosis in AIDS. Ann Intern Med 1992;117:163-164
   Web of Science | Medline

3. 3

   Lazzarin A, Clotet B, Cooper D, et al. Efficacy of enfuvirtide in patients infected with drug-resistant HIV-1 in Europe and Australia. N Engl J Med 2003;348:2186-2195
   Full Text | Web of Science | Medline

4. 4

   Lalezari JP, Henry K, O'Hearn M, et al. Enfuvirtide, an HIV-1 fusion inhibitor, for drug-resistant HIV infection in North and South America. N Engl J Med 2003;348:2175-2185[Erratum, N Engl J Med 2003;349:1100.]
   Full Text | Web of Science | Medline

To the Editor:

Drs. Cuzin and Alvarez report that “in cases of high-risk exposure” the highest rate of HIV transmission is around 0.3 percent. Prospective studies suggest that this rate represents the average risk of transmission after percutaneous exposure to HIV-infected blood, but the risk is probably higher after exposure involving an increased volume of blood or a high viral load,1,2 both of which might apply to health care workers exposed to patients with resistance to antiretroviral drugs — a possible reason for the failure of postexposure prophylaxis. We recommend the restricted use of prophylactic enfuvirtide in high-risk persons,3 such as health care workers, in a setting where the storage, preparation, and administration of the drug are performed by skilled personnel.

Simone Ferranti, M.D.
Francesco Menichetti, M.D.
Azienda Ospedaliera Pisana, 56124 Pisa, Italy
sim17one@hotmail.com

3 References

1. 1

   Updated U. S. Public Health Service guidelines for the management of occupational exposures to HBV, HCV, and HIV and recommendations for postexposure prophylaxis. MMWR Recomm Rep 2001;50:1-52
   

2. 2

   Bell DM. Occupational risk of human immunodeficiency virus infection in healthcare workers: an overview. Am J Med 1997;102:Suppl 5B:9-15
   CrossRef | Medline

3. 3

   Ferranti S, Menichetti F. Enfuvirtide for prophylaxis against HIV infection. N Engl J Med 2003;349:815-815
   Full Text | Web of Science | Medline

Citing Articles (3)

Citing Articles

1. 1

   Frédéric Méchai, Yann Quertainmont, Sabrinel Sahali, Jean-François Delfraissy, Jade Ghosn. (2008) Post-exposure prophylaxis with a maraviroc-containing regimen after occupational exposure to a multi-resistant HIV-infected source person. Journal of Medical Virology 80:1, 9-10
   CrossRef

2. 2

   Zhiyong Lou, Yanhui Xu, Kehui Xiang, Nan Su, Lan Qin, Xu Li, George F. Gao, Mark Bartlam, Zihe Rao. (2006) Crystal structures of Nipah and Hendra virus fusion core proteins. FEBS Journal 273:19, 4538-4547
   CrossRef

3. 3

   Yanhui Xu, Shan Gao, David K. Cole, Junjie Zhu, Nan Su, Hui Wang, George F. Gao, Zihe Rao. (2004) Basis for fusion inhibition by peptides: analysis of the heptad repeat regions of the fusion proteins from Nipah and Hendra viruses, newly emergent zoonotic paramyxoviruses. Biochemical and Biophysical Research Communications 315:3, 664-670
   CrossRef