Non-occupational Postexposure Prophylaxis (nPEP) in New York State Emergency Departments

1
Non-occupational Postexposure Prophylaxis (nPEP)
in New York State Emergency Departments

• Alexander Ende
• Bruce D. Agins
• June 6th, 2006

2
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

3
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.

4
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.

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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

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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.

7
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.

8
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.

9
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 Services
• Director, Information Technology
• Director, Nursing
• Director, Pharmacy
• Director, Risk Management
• Director, Safety/Security
• Emergency Response Coordinator
• Governing Body, Chairman/President

10
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 (Plt.05)
• -In terms of self-reported prescribing of HIV
  PEP, NYS practitioners prescribed HIV PEP after
  sexual assaultmuch more often than did other
  practitioners (Plt.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
  200370(5)338-43

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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

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Exposures to HIV and PEP Initiation in NYS EDs,
2005
13
Percentage of Exposures in which PEP was
initiated in NYS EDs, 2005 Plt .001
14

2005 NYS PEP Exposure Data, NYC vs. Upstate
15
of 2005 Exposures in which PEP was Initiated,
City vs. Upstate
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Treatment Practices (n186), sexual assault vs.
voluntary sexual exposureplt.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

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Sexual Assault Exposure Treatment Practices City
vs. Upstate

• City (n47)
• 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 (n139)
• 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

18
Voluntary Sexual Exposure Treatment Practices
City vs. Upstate

• City (n47)
• 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 (n139)
• 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

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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

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Which staff take responsibility for nPEP
follow-up?

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

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

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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.

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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)

23
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

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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.

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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.

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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.

27
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

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