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