Non-occupational Postexposure Prophylaxis (nPEP)

in New York State Emergency Departments

Alexander EndeBruce D. Agins

June 6th, 2006

Who is nPEP for? People who have been exposed to HIV outside of a

healthcare setting through: voluntary sexual exposure sexual assault injection drug use human bites

All of these exposures typically present in the Emergency Department

Background

The AIDS Institute's HIV Guidelines Steering

Committee raised concerns that non-

occupational postexposure prophylaxis (nPEP)

guidelines have not been widely implemented.

Subcommittee formed to elaborate issues and identify strategies to address them.

Guidelines

In December 2004, NY State recommended

nPEP for voluntary sexual exposure as well as

sexual assault.

nPEP should never replace adopting and

maintaining preventive behaviors and is not

routinely recommended in situations in which

high-risk behavior is habitually practiced.

Guidelines Summary - 1

nPEP is recommended only if:-a sexual, percutaneous or other exposure that carries significant risk of HIV transmission occurs

AND -the patient presents within 36 hours of exposure

AND -the source, if available, is HIV infected as

determined by rapid HIV testing

Guidelines Summary - 2

Arrangements should be made to ensure that the

patient receives a continued supply of medication and

is referred to an HIV Specialist.

Behavioral intervention for risk reduction should occur

regardless of whether nPEP is initiated or not.

As of July 2005, physicians with questions have been

encouraged to call the 24-hour PEP lines through

their local CEI sites.

nPEP Survey A survey was developed to better

understand how nPEP is handled in NYS EDs with the long term goal of improving PEP services.

Survey Methods Distributed surveys to every ED in NY State

(207 total) through the Health Emergency Response Data System (HERDS), a system used for emergency incidents and surveys in NY State.

HERDS is a feature of HPN, a web-based information network maintained by NYSDOH.

Examples of Hospital Roles who can use HERDS

BT Coordinator Chair of the Disaster/Emergency

Preparedness Committee Chief Executive Officer Chief Operating Officer Chief of Service Designated Pharmacist Director, Bio-medical Services HRSA Grant Manager Infection Control Practitioner Organizational Security

Coordinator Governing Body, Member

Director, Emergency Department Director, Food and Nutritional Ser

vices Director, Information Technology Director, Nursing Director, Pharmacy Director, Risk Management Director, Safety/Security Emergency Response

Coordinator Governing Body,

Chairman/President

Background Study

A 2003 survey comparing NYS ED practitioners with US ED practitioners found:-“NYS practitioners were more likely to offer HIV PEP for exposures to unknown and low-HIV-risk sources (P<.05) ”

-“In terms of self-reported prescribing of HIV PEP, NYS practitioners prescribed HIV PEP after sexual assault…much more often than did other practitioners (P<.001)”

-“All practitioners offered HIV PEP less often after consensual sexual encounters than after sexual assault and needle-stick injuries”

Merchant RC, Keshavarz R. Emergency prophylaxis following needle-stick injuries and sexual exposures: results from a survey comparing New York Emergency Department practitioners with their national colleagues. Mt Sinai J Med 2003;70(5):338-43

Results 186/207 EDs responded (90%)

-47/60 NYC (78%)-139/147 Upstate (95%)

Of these, 177 (95%) have a protocol for providing nPEP after sexual assault New York City: 46/47 (98%) Upstate: 131/139 (94%)

110 (58%) have a protocol for providing nPEP after voluntary sexual exposure New York City: 32/47 (68%) Upstate: 78/139 (56%)

107 (57%) have a Sexual Assault Forensic Examiner (SAFE) program

Exposures to HIV and PEP Initiation in NYS EDs, 2005

3426

2238

6858

29312454

5224

010002000300040005000600070008000

#Exposures

Seen

# PEPinitiated

#Exposures

Seen

# PEPinitiated

#Exposures

Seen

# PEPinitiated

Occupational Exposure Sexual Assault Voluntary Exposure

42.7%

65.3%

47.0%

010203040506070

OccupationalExposure

Sexual Assault VoluntaryExposure

Percentage of Exposures in which PEP was initiated in NYS EDs, 2005

P< .001

2490

883

2046

1175927

397

2757

1573 13801063

5931

2534

0

1000

2000

3000

4000

5000

6000

7000

#

ExposuresSeen # PEPinitiated

#

ExposuresSeen # PEPinitiated

#

ExposuresSeen # PEPinitiated

OccupationalExposure

Sexual Assault Voluntary Exposure

Upstate

City

2005 NYS PEP Exposure Data, NYC vs. Upstate

% of 2005 Exposures in which PEP was Initiated, City vs. Upstate

43 %

57 %

35%

43%

77 %

57 %

0.00

10.00

20.00

30.00

40.00

50.00

60.00

70.00

80.00

90.00

Occupational Exposure Sexual Assault Voluntary Exposure

Upstate

City

Treatment Practices (n=186), sexual assault vs. voluntary sexual exposure;

p<.001 After Potential Sexual

Assault Exposure: 87% start nPEP and provide

Rx for remaining supply 11% refer patient elsewhere

with no nPEP 3% write a Rx but provide

no nPEP

In total, 14% do not intitiate nPEP in the ED after Sexual Assault

After Potential Voluntary Exposure:

70% start nPEP and provide Rx for remaining supply

24% refer patient elsewhere with no nPEP

6% write a Rx but provide no nPEP

In total, 30% do not initiiate nPEP in the ED after Voluntary Sexual Exposure

Sexual Assault Exposure Treatment Practices: City vs. Upstate City (n=47)

98% start nPEP and provide Rx for remaining supply

0% refer patient elsewhere with no nPEP

2% write a Rx but provide no nPEP

In total, 2% do not initiate nPEP in the ED

Upstate (n=139)

83% start nPEP and provide Rx for remaining supply

14% refer patient elsewhere with no nPEP

3% write a Rx but provide no nPEP

In total, 17 % do not initiate nPEP in the ED

Voluntary Sexual Exposure Treatment Practices: City vs. Upstate

City (n=47)

74% start nPEP and provide Rx for remaining supply

19% refer patient elsewhere with no nPEP

6% write a Rx but provide no nPEP

In total, 25 % do not initiate nPEP in the ED

Upstate (n=139)

69% start nPEP and provide Rx for remaining supply

25% refer patient elsewhere with no nPEP

6% write a Rx but provide no nPEP

In total, 31 % do not initiate nPEP in the ED

Drug Regimen Choice

Only 80/186 (43%) EDs use the ARV regimen recommended by NYS nPEP Guidelines

Recommended regimen: ZDV 300 mg po bid + 3TC 150 mg po bid (or

Combivir 1 bid)PLUS

Tenofovir 300 mg po qd- still analyzing other acceptable regimens

Which staff take responsibility for nPEP follow-up?

After Sexual Assault: Primary Care: 86 ED: 36 Infectious Disease: 31 SAFE or SANE Team: 12 OB/GYN: 5 Local DOH: 4

After Voluntary Exposure: Primary Care: 81 ED: 34 Infectious Disease: 19 OB/GYN: 4 Local DOH: 3

Are we really following up? Only 62 (33%) EDs responded that they have a

mechanism to determine whether ED-recommended

follow-up occurred for sexual assault or voluntary sexual

exposure.

Only 42 (23%) review seroconversion rates in cases

where nPEP is recommended after sexual assault or

voluntary sexual exposure.

Barriers to Providing nPEP Identified by EDs

Lack of dedicated staff: 85 (47%)

Lack of information about nPEP: 28 (15%)

Keeping supply of nPEP: 23 (13%)

Additional Barriers Identified by Subcommittee

Staff turnover Time constraints for training Setting for sexual history taking Lab problems Lack of experience Difficult to retrieve useful data to monitor practices Clinician discomfort with sexual history-taking

Conclusions -1

Voluntary exposures are seen more frequently

in the ED than are occupational or sexual

assault exposures.

Voluntary exposures are more than twice as

common in New York City than in Upstate New

York, though nPEP is initiated with almost the

same frequency in both regions.

Conclusions - 2 Whereas 65 % of sexual assault exposures

are treated with nPEP, only 43% of voluntary exposures are treated with nPEP

ED physicians are less likely to initiate nPEP in the ED for voluntary exposures, perhaps because they are less comfortable or less willing to treat voluntary exposures.

Recommendations

nPEP responsibilities should be delegated to

certain ED staff, who should receive extra

training on handling all types of HIV exposures.

Mechanisms for tracking seroconversion and

ED-recommended follow-up should be

developed.

Recommendations Pursue additional data sources to better

understand practices Work with professional societies to increase

implementation of nPEP guidelines Promote better coordination between HIV

professionals and ED staff

For more HIV-related resources, please visit www.hivguidelines.org