Original research article
Access to post-exposure prophylaxis following sexual exposure for men who have sex with men in an Irish healthcare setting
International Journal of STD & AIDS 2015, Vol. 26(8) 521–525 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0956462414547525 std.sagepub.com
K McFaul1, D Rowley2, A O’Reilly3 and S Clarke2
Summary Men who have sex with men experience disproportionate rates of HIV acquisition. Post-exposure prophylaxis following unprotected sexual exposure reduces HIV transmission. Our aim was to assess access to post-exposure prophylaxis for men who have sex with men in Irish emergency departments. We contacted all national 24-hour adult emergency departments describing two scenarios; a seronegative man who has sex with men receiving unprotected insertive anal intercourse from a seropositive partner and secondly a woman sustaining a needle-stick injury from an unknown source. We recorded and compared responses regarding post-exposure prophylaxis advice in each situation. High proportions of emergency departments offered post-exposure prophylaxis for both situations despite minimal evidence to support use in needle-stick injury. Men who have sex with men were less likely to be asked to attend emergency departments for post-exposure prophylaxis administration than a person experiencing needle-stick injury. Men who have sex with men were less likely to be offered baseline serological testing for blood borne infections. Men who have sex with men were as likely as needle-stick injury to receive advice from healthcare workers in emergency departments and consultation durations were similar. This study identifies a need to educate healthcare workers in emergency departments on appropriate use of post-exposure prophylaxis following sexual exposure for men who have sex with men. Health care workers must appreciate the importance of post-exposure prophylaxis presentations as opportunities for intervention and HIV screening.
Keywords European, homosexual, sexual intercourse, HIV, AIDS, post-exposure prophylaxis, PEP, PEPSE, emergency departments, prevention Date received: 17 January 2014; accepted: 24 July 2014
Introduction HIV infection has increased in men who have sex with men (MSM) despite reductions in other risk groups.1–5 UNAIDS/WHO data from 2012 shows HIV prevalence in urban MSM 13 times that of the general population.6 Irish Health Protection and Surveillance Centre (HPSC) data follow this trend. Since 2009, the majority of new HIV infections have been diagnosed in MSM, and MSM amount to 48.7% (166 of 341) of new HIV diagnoses in 2012.7 Overall HIV prevalence in MSM ranges from 3.1 to 4.4%,8 and infection is associated with individuals’ unawareness of HIV status, lower socio-economic grouping, ‘safe sex fatigue’, and increased recreational drug use.9–11 As MSM are at highest risk for HIV acquisition, they are a group in
which preventative strategies may be targeted. Interventions to reduce onward transmission include increasing HIV testing in MSM, treatment as prevention strategies (TasP) and use of post-exposure prophylaxis (PEP) in defined episodes of high-risk sexual 1
Chelsea & Westminster Healthcare Fdn Trust, London, UK Genitourinary and Infectious Diseases Clinic, St James Hospital, Dublin, Ireland 3 University College Dublin School of Medicine and Health Sciences, Belfield, Dublin, Ireland 2
Corresponding author: Katie McFaul, 56 Dean Street, Chelsea & Westminster Healthcare Foundation Trust, London, UK. Email: [email protected]
Downloaded from std.sagepub.com at Univ. of Tasmania Library on June 13, 2015
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International Journal of STD & AIDS 26(8)
exposure (PEPSE).12,13 Observational studies of occupational HIV exposure demonstrated the efficacy of PEP to reduce HIV acquisition following exposure by 81%.14 Guidelines for use now recommend PEP up to 72 hours after unprotected anal intercourse.8,15–17 PEPSE counselling is recommended during all MSM sexual health reviews.18 PEPSE knowledge varies amongst risk groups. Just under half of HIV-positive MSM are aware of PEPSE indications compared to approximately one-third of HIV-negative MSM.19–21 However, MSM awareness is greater than other sexual orientations, including women and men who have sex with women.22 Campaigns and interventions have succeeded to increase PEP awareness in MSM.23 Injury from discarded needles in the community creates concern for transmission of HIV; however, HIV transmission via community needle-stick injuries (CNSI) has not been documented to date and should be considered extremely low risk, with non-occupational PEP (nPEP) not recommended for these exposures. nPEP was given in less than two-fifths of patients presenting with community-acquired sharps injuries (26.9–39.5%) and no new cases of HIV were documented at follow up.24–26 Despite anxiety surrounding these episodes, HIV transmission via this exposure has not been documented to date and should be considered extremely low risk. Good access to PEPSE is a key factor in reduction of HIV acquisition in MSM. Recommendations state PEPSE should be available on a 24-hour basis, with urgent care providers and emergency departments (EDs) assuming responsibility for PEPSE administration out of normal working hours.8 Evidence suggests a deficit of knowledge of PEP and its uses for non-occupational exposure in EDs.27 We hypothesised that despite widespread availability of PEPSE throughout the healthcare system, MSM may experience disparate access to PEPSE in EDs as compared to other groups. We compared access to PEP for two scenarios. One with an indication for use – post-sexual exposure in MSM (PEPSE),8 and the other with no PEP indication – a community-acquired sharps injury from a discarded needle in the (CNSI).17
Methods
HIV-positive status. Case 1 was worried about acquiring HIV infection. This would be an indication for PEP use. Case 2 was a woman who received a penetrating sharps injury from a discarded needle in the community (CNSI). She was worried regarding infection from her exposure. PEP is not universally recommended in this case. These two cases were our ‘patients’. The authors created a list of questions for each scenario (see Appendices 1 and 2). Each case’s questionnaire contained questions relating to exposure and descriptive characteristics. The patient’s main reason for calling was to seek advice for management following a presumed risk exposure. Calls were placed between the hours of 12.00 pm and 9.00 pm during the months of September and October 2012. The authors posed as patients and rang all 31 adult EDs in the Irish Health Services Executive. The patient asked to be put through to a healthcare worker to advise whether they should attend the ED or follow up elsewhere. Respondents were not told the cases were for study purposes, as we wished to assess individual experience in accessing appropriate care, as opposed to individual knowledge of PEPSE. Details from all phone calls were documented, including ED staff willingness to engage in discussion via telephone, level of assistance and knowledge of PEP. Standardised questions were used in each scenario (see Appendix 1) and answers were defined as containing (‘competent’) or lacking (‘non-competent’) information contained in an ideal response. Specific details included length of time dedicated to the caller by the ED, mean duration of calls (minutes), number of healthcare providers (HCP) involved per call, whether healthcare providers requested information from colleagues. Other details recorded included respondent’s knowledge and awareness of departmental PEP availability, if PEP would be available in each circumstance, whether the patient should present to ED for formal assessment and if baseline serological blood tests would be performed. Data analysis was performed using IBM’s Statistical Product and Service Solutions (SPSS). Independent t-testing was used to compare means and Pearson Chi square test to compare proportions.
Results
A group of Specialist Registrars working in Ireland’s largest HIV tertiary referral service sought to review PEP access in two defined situations. We created two scenarios based on risk exposures. Ethical clearance was requested but not required by the hospital Ethics Committee. Case 1 was an MSM with a recent episode of unprotected anal intercourse (UPAI) with a casual partner who subsequently disclosed their
Consultation details The majority of telephone consultations were conducted by nursing staff. For case 1, (unprotected receptive anal sexual intercourse, UPSI) 31 telephone consultations were managed by 26 nurses and 4 medical doctors, and 1 call was dealt with by a medical administrative staff member. In case 2, (NSI, CNSI) 31
Downloaded from std.sagepub.com at Univ. of Tasmania Library on June 13, 2015
McFaul et al.
523
telephone consultations were managed by 30 nurses and 1 medical doctor.
Phone call details The average duration of the telephone call was similar in each case – mean 3.64 minutes for UPSI and 3.74 minutes for CNSI (p ¼ 0.849). The average number of HCP participating in the call differed between the two groups – mean 1.94 persons for UPSI and 1.29 persons for CNSI (p ¼
Access to post-exposure prophylaxis following sexual exposure for men who have sex with men in an Irish healthcare setting
International Journal of STD & AIDS 2015, Vol. 26(8) 521–525 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0956462414547525 std.sagepub.com
K McFaul1, D Rowley2, A O’Reilly3 and S Clarke2
Summary Men who have sex with men experience disproportionate rates of HIV acquisition. Post-exposure prophylaxis following unprotected sexual exposure reduces HIV transmission. Our aim was to assess access to post-exposure prophylaxis for men who have sex with men in Irish emergency departments. We contacted all national 24-hour adult emergency departments describing two scenarios; a seronegative man who has sex with men receiving unprotected insertive anal intercourse from a seropositive partner and secondly a woman sustaining a needle-stick injury from an unknown source. We recorded and compared responses regarding post-exposure prophylaxis advice in each situation. High proportions of emergency departments offered post-exposure prophylaxis for both situations despite minimal evidence to support use in needle-stick injury. Men who have sex with men were less likely to be asked to attend emergency departments for post-exposure prophylaxis administration than a person experiencing needle-stick injury. Men who have sex with men were less likely to be offered baseline serological testing for blood borne infections. Men who have sex with men were as likely as needle-stick injury to receive advice from healthcare workers in emergency departments and consultation durations were similar. This study identifies a need to educate healthcare workers in emergency departments on appropriate use of post-exposure prophylaxis following sexual exposure for men who have sex with men. Health care workers must appreciate the importance of post-exposure prophylaxis presentations as opportunities for intervention and HIV screening.
Keywords European, homosexual, sexual intercourse, HIV, AIDS, post-exposure prophylaxis, PEP, PEPSE, emergency departments, prevention Date received: 17 January 2014; accepted: 24 July 2014
Introduction HIV infection has increased in men who have sex with men (MSM) despite reductions in other risk groups.1–5 UNAIDS/WHO data from 2012 shows HIV prevalence in urban MSM 13 times that of the general population.6 Irish Health Protection and Surveillance Centre (HPSC) data follow this trend. Since 2009, the majority of new HIV infections have been diagnosed in MSM, and MSM amount to 48.7% (166 of 341) of new HIV diagnoses in 2012.7 Overall HIV prevalence in MSM ranges from 3.1 to 4.4%,8 and infection is associated with individuals’ unawareness of HIV status, lower socio-economic grouping, ‘safe sex fatigue’, and increased recreational drug use.9–11 As MSM are at highest risk for HIV acquisition, they are a group in
which preventative strategies may be targeted. Interventions to reduce onward transmission include increasing HIV testing in MSM, treatment as prevention strategies (TasP) and use of post-exposure prophylaxis (PEP) in defined episodes of high-risk sexual 1
Chelsea & Westminster Healthcare Fdn Trust, London, UK Genitourinary and Infectious Diseases Clinic, St James Hospital, Dublin, Ireland 3 University College Dublin School of Medicine and Health Sciences, Belfield, Dublin, Ireland 2
Corresponding author: Katie McFaul, 56 Dean Street, Chelsea & Westminster Healthcare Foundation Trust, London, UK. Email: [email protected]
Downloaded from std.sagepub.com at Univ. of Tasmania Library on June 13, 2015
522
International Journal of STD & AIDS 26(8)
exposure (PEPSE).12,13 Observational studies of occupational HIV exposure demonstrated the efficacy of PEP to reduce HIV acquisition following exposure by 81%.14 Guidelines for use now recommend PEP up to 72 hours after unprotected anal intercourse.8,15–17 PEPSE counselling is recommended during all MSM sexual health reviews.18 PEPSE knowledge varies amongst risk groups. Just under half of HIV-positive MSM are aware of PEPSE indications compared to approximately one-third of HIV-negative MSM.19–21 However, MSM awareness is greater than other sexual orientations, including women and men who have sex with women.22 Campaigns and interventions have succeeded to increase PEP awareness in MSM.23 Injury from discarded needles in the community creates concern for transmission of HIV; however, HIV transmission via community needle-stick injuries (CNSI) has not been documented to date and should be considered extremely low risk, with non-occupational PEP (nPEP) not recommended for these exposures. nPEP was given in less than two-fifths of patients presenting with community-acquired sharps injuries (26.9–39.5%) and no new cases of HIV were documented at follow up.24–26 Despite anxiety surrounding these episodes, HIV transmission via this exposure has not been documented to date and should be considered extremely low risk. Good access to PEPSE is a key factor in reduction of HIV acquisition in MSM. Recommendations state PEPSE should be available on a 24-hour basis, with urgent care providers and emergency departments (EDs) assuming responsibility for PEPSE administration out of normal working hours.8 Evidence suggests a deficit of knowledge of PEP and its uses for non-occupational exposure in EDs.27 We hypothesised that despite widespread availability of PEPSE throughout the healthcare system, MSM may experience disparate access to PEPSE in EDs as compared to other groups. We compared access to PEP for two scenarios. One with an indication for use – post-sexual exposure in MSM (PEPSE),8 and the other with no PEP indication – a community-acquired sharps injury from a discarded needle in the (CNSI).17
Methods
HIV-positive status. Case 1 was worried about acquiring HIV infection. This would be an indication for PEP use. Case 2 was a woman who received a penetrating sharps injury from a discarded needle in the community (CNSI). She was worried regarding infection from her exposure. PEP is not universally recommended in this case. These two cases were our ‘patients’. The authors created a list of questions for each scenario (see Appendices 1 and 2). Each case’s questionnaire contained questions relating to exposure and descriptive characteristics. The patient’s main reason for calling was to seek advice for management following a presumed risk exposure. Calls were placed between the hours of 12.00 pm and 9.00 pm during the months of September and October 2012. The authors posed as patients and rang all 31 adult EDs in the Irish Health Services Executive. The patient asked to be put through to a healthcare worker to advise whether they should attend the ED or follow up elsewhere. Respondents were not told the cases were for study purposes, as we wished to assess individual experience in accessing appropriate care, as opposed to individual knowledge of PEPSE. Details from all phone calls were documented, including ED staff willingness to engage in discussion via telephone, level of assistance and knowledge of PEP. Standardised questions were used in each scenario (see Appendix 1) and answers were defined as containing (‘competent’) or lacking (‘non-competent’) information contained in an ideal response. Specific details included length of time dedicated to the caller by the ED, mean duration of calls (minutes), number of healthcare providers (HCP) involved per call, whether healthcare providers requested information from colleagues. Other details recorded included respondent’s knowledge and awareness of departmental PEP availability, if PEP would be available in each circumstance, whether the patient should present to ED for formal assessment and if baseline serological blood tests would be performed. Data analysis was performed using IBM’s Statistical Product and Service Solutions (SPSS). Independent t-testing was used to compare means and Pearson Chi square test to compare proportions.
Results
A group of Specialist Registrars working in Ireland’s largest HIV tertiary referral service sought to review PEP access in two defined situations. We created two scenarios based on risk exposures. Ethical clearance was requested but not required by the hospital Ethics Committee. Case 1 was an MSM with a recent episode of unprotected anal intercourse (UPAI) with a casual partner who subsequently disclosed their
Consultation details The majority of telephone consultations were conducted by nursing staff. For case 1, (unprotected receptive anal sexual intercourse, UPSI) 31 telephone consultations were managed by 26 nurses and 4 medical doctors, and 1 call was dealt with by a medical administrative staff member. In case 2, (NSI, CNSI) 31
Downloaded from std.sagepub.com at Univ. of Tasmania Library on June 13, 2015
McFaul et al.
523
telephone consultations were managed by 30 nurses and 1 medical doctor.
Phone call details The average duration of the telephone call was similar in each case – mean 3.64 minutes for UPSI and 3.74 minutes for CNSI (p ¼ 0.849). The average number of HCP participating in the call differed between the two groups – mean 1.94 persons for UPSI and 1.29 persons for CNSI (p ¼
