Officers at Risk of AIDS Given a Tough Choice : Health: O.C. public safety personnel vulnerable to the deadly disease are offered drug AZT as a preventive.

On the verge of making an arrest while working undercover, Paul Brown simply had no time--or reason--to think about AIDS.

During a routine search of a known drug user two years ago, a dirty needle was accidentally thrust into the young officer’s thumb. Though only a puncture wound, its impact would carry the psychological force of a blast from a .357 magnum.

About five days later, Brown--whose work requires that his true name not be revealed--learned that the drug user had tested positive for the dreaded human immunodeficiency virus that causes AIDS.

“My first response was fear,” Brown said of that moment two years ago. “My health became my primary concern. I remember squeezing my thumb trying to get the blood out.”

On average, experiences like Brown’s occur every other day in Orange County for law enforcement officers, firefighters and paramedics. All have been exposed to blood products or body fluids from people considered to be possible carriers of HIV.

During that time, county health officers have engaged in an unusual and somewhat risky course of action: offering the drug zidovudine--or AZT--as a preventive medical treatment to those most vulnerable to contracting the fatal disease while on duty.

Of the 678 public safety officers who have reported exposures during the past three years, 154 were offered AZT; of those, only 17 people--including Brown--have agreed to the treatment.

The numbers point to an intriguing, yet largely unpublished dilemma in firehouses and police stations, where employees responding to emergencies must weigh the possible benefits of taking the powerful drug against its many serious side effects.

Most have shunned the treatment out of fear of complications that range from mild disorientation to cancer found in some laboratory animals.

“When it comes to HIV and all that goes with it, there is a feeling that we’re not being told everything,” said Orange County paramedic John Stokes.

But unless they are confronted with an exposure case, Orange County Fire Capt. Tom Connors said, there is little talk about the subject among his colleagues.

“You kind of have to trust your government,” he said. “They wouldn’t be giving this stuff out to kill people. Inherent in all firefighting is a modicum of danger. All take a silent pledge that they are here to help people and trust in God that he’ll do the rest.”

Health officials in Orange County, whose exposure and AZT program was used as a model in developing a similar policy in the city of Los Angeles, admit there is very little information about the drug’s effectiveness in preventing AIDS.

A 1990 report by the Centers for Disease Control in Atlanta states that AZT’s effectiveness in controlling the virus’s growth in humans could not be determined. Data collected during animal studies has been only slightly more encouraging, but still “inadequate,” according to the report.

At best, the CDC report states, while the HIV infection was not prevented in any of the animals studied, the “course of infection was modified.”

The lack of definitive medical knowledge, coupled with the drug’s possible side effects, also make its use a much-debated public policy issue.

“AZT is not like a magic panacea,” said Dr. Donald Ramras, health officer for the county of San Diego, where public safety employees are referred to outside physicians for AZT treatments. “It’s a controversial issue. . . . It is often toxic. You have to say: ‘Here are the pros and cons,’ and you can’t in good conscience urge” its use.

Said Phyllis L. Spechko, coordinator of the post-exposure management program at the UC San Diego Medical Center: “My personal belief is that (AZT) doesn’t have a snowball’s chance in hell of working. But the bottom line here is that we don’t know everything. If an individual wants to take the drug, I’ll be here.”

Yet, for those who have agreed to the treatment, the drug seems to provide at least a measure of psychological comfort during particularly anxious times when there is no other medical alternative, said Dr. Penny Weismuller, Orange County’s exposure program coordinator.

“With HIV, the risk of certain fatality is so anxiety-producing you can’t imagine,” she said. “To some, (taking AZT) makes all the difference in the world and means having some power of what’s going to happen to your body.

“We don’t give them any false sense of protection. We are not withholding any information. We don’t know whether it works or not.”

Of all the local exposures, including the Brown case, there have been no reports of public safety officers or health care workers contracting the virus, whether they have taken AZT or not, Weismuller said. All public safety employees who have been exposed to infected blood are regularly tested for signs of HIV.

Chances of transmission during needle sticks are relatively small: 0.4%, according to the CDC.

In the Brown case, the young officer said the exposure and his subsequent decision to submit to AZT treatment proved so traumatic that he remains uncomfortable recounting the events two years later.

“When I’m working now,” Brown said, “every time I see blood I think about it. And you are going to get blood on you in this line of work. It’s just going to happen.”

After his exposure, Brown was referred by his supervisors to the County Health Care Agency--as is the case with all exposure reports--where the incident was evaluated as a definite contact with an HIV carrier.

Under the county’s program, one of the few in the nation that offers AZT to public safety officers, exposures are classified according to levels of seriousness.

In the most serious cases, the offer of AZT comes with a warning of the many potential side effects. They may include anemia, headaches, nausea, vomiting, gastrointestinal bleeding and alteration in liver and kidney functions.

Those risks have been the subject of a recent study involving health care workers in 15 hospitals throughout the nation, including UCI Medical Center in Orange. Coordinated by the National Institutes of Health and San Francisco health officials, the study focused on health care workers who used AZT after exposures.

Rita Fahrner, clinical director of the occupational health and infectious disease program for the San Francisco Department of Health, said none of the workers participating contracted the disease. She said the study also found that the drug’s toxicity was relatively mild and “well tolerated” during a 28-day course of treatment.

Within a short time after the workers stopped taking the drug, Fahrner said, side effects of fatigue, headaches and nausea disappeared.

Long-term dosages have been shown to cause cancer in animals, according to the county consent forms. And because of the possible risks to unborn children, the drug is not offered to pregnant officers.

Armed with that information, Weismuller said, a majority of the officers--not surprisingly--reject the treatment.

“Because of the scientific uncertainty, we can only make it available,” she said. “We give people the information about the risks and potential benefits and only recommend (its use) when there are massive and definite exposures. For me personally, I would start it immediately. That’s just me. There is nothing else available.”

That hopeful optimism about the drug’s effectiveness is not shared in Los Angeles County, where Dr. Martin Finn, medical director of the AIDS program for the Department of Health Services, said the resources do not exist to cover any employee group other than high-risk hospital workers.

“There is just a lot of conjecture out there,” Finn said. “There aren’t any known benefits.”

In cases of AZT treatment where the side effects became extremely debilitating, Finn said, some would have “rather gone to the grave than take it any longer.”

Brown said his decision to start the four-week treatment came fairly quickly, although it was accompanied by the same anxiety that counselors said is exhibited in nearly every serious exposure case.

“It’s one thing to sign (the consent form), but it was another to start taking the medication,” he said. “I just hoped that it would do me some good and the long-term effects would only affect the lab animals and not me. . . . I felt it was worth the risk.”

In Brown’s case, the side effects began appearing almost immediately. He suffered constant headaches, nausea and vomiting. He discontinued the treatment after only 10 days.

“I knew it was doing something, but I got to where I couldn’t cope with it. I couldn’t keep any food down,” he said.

Although he stopped the medication, the officer did continue the program’s standard HIV testing at regular intervals for a year after the exposure. All results were negative. But Brown said the county has also offered to provide extended follow-up HIV testing in his case.

The county program “was like a support network for me,” he said. “Immediately, you have this fear and confusion. They cannot guarantee that it will help you, but (the counselor) did more than her job to make me feel comfortable.”

Weismuller said the county began extending the offer of AZT to public safety workers after an incident in 1990, when an officer became involved in an altercation with a suspect known to be infected with HIV.

During that incident, in which the two were rolling around in a flower bed, the suspect cut his head and his blood came into contact with an open wound on the officer’s arm, resulting in a serious exposure, Weismuller said.

Before that incident, AZT’s use as a preventive treatment had only been extended to county health care workers who were believed to be more prone to accidental needle sticks and other forms of traditional medical exposure.

“That (altercation) forced our hand,” Weismuller said.

Once the county’s program--which costs about $70,000 each year and is patterned after a pilot project in San Francisco--was in place, Weismuller said, it “took only a week to see what kinds of exposures public safety workers were experiencing.”

For years--and well before AIDS awareness prompted the use of rubber gloves and protective goggles among safety workers--Weismuller and other health care officials said, little attention was paid to the exposures routinely encountered by police, firefighters and paramedics.

“Once we became aware of the extent of those exposures, it only made sense to offer post-exposure counseling and follow-up care,” Weismuller said.

Dr. Jothan Staley, medical director for the city of Los Angeles’ occupational health office, said he was impressed by the Orange County plan and used it as a model for a similar program covering municipal public safety workers in that city.

While acknowledging that there are differing philosophies regarding the use of AZT, Staley said the possible benefits--physical and psychological--make it worth offering.

He said the CDC report of 1990 provided little direction for its use and may have muddied the water for governments and other institutions considering the drug’s application.

“Nobody knows whether this is a carcinogen,” Staley said. “But there is some talk that the virus can be maintained in a dormant state. In situations where you have employees facing a deadly disease, some people think that (AZT) helps to calm people.”

Staley said his office has received about 100 HIV-exposure reports each year since the AZT program started several months after the Orange County plan began in early 1989. Since that time, only five safety employees have submitted to the treatment.

The difference in the number of exposures reported in Los Angeles and Orange counties can probably be attributed to a lack of knowledge among public safety workers of their responsibility to report exposures, he said. Staley estimated that many officers in Los Angeles could be overlooked in the process because they elect to seek private medical advice.

Brown said he was not aware of the AZT program until he was referred to the County Health Care Agency.

Until recently, neither was Sgt. Jerry Pierson, president of the 1,192-member Deputy Sheriff’s Assn. of Orange County. Pierson called the program the “best-kept secret in Orange County.”

“The issue (of exposure) wasn’t discussed before,” Brown said. “There seemed to be other more pressing problems. . . . But people are probably going to think about it more, because the stakes are too high.”