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.

5. 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

6. 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 Chair of the Disaster/Emergency Preparedness Committee Chief Executive Officer Chief Operating Officer Chief of Service Designated Pharmacist Director, Bio-medical Services Director, Bio-medicalServices HRSA Grant Manager Infection Control Practitioner Organizational Security Coordinator Organizational Security Coordinator Governing Body, Member Director, Emergency Department Director, Food and Nutritional Services Director, Food and Nutritional Services Director, Information Technology Director, Nursing Director, Pharmacy Director, Risk Management Director, Safety/Security Emergency Response Coordinator Emergency Response Coordinator Governing Body, Chairman/President 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 (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

11. 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

12. Exposures to HIV and PEP Initiation in NYS EDs, 2005

13. Percentage of Exposures in which PEP was initiated in NYS EDs, 2005 P<.001

14. 2005 NYS PEP Exposure Data, NYC vs. Upstate

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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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.

22. 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

24. 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.

25. 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.

26. 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

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