Abstract
New York State (NYS) established guidelines for nonoccupational post-exposure prophylaxis (nPEP) to HIV in 1997. To assess current nPEP practices in NYS Emergency Departments (EDs), we electronically surveyed all ED directors in NYS, excluding Veterans’ Affairs hospitals, about nPEP and linkage-to-care protocols in the EDs. Basic descriptive statistics were used for analysis. The response rate was 96% (184/191). Of respondents, 88% reported evaluating any patient with a possible nonoccupational exposure to HIV, in accordance with NYS guidelines. Of these, 83% provided the patient with a starter pack of medications, while 4% neither supplied nor prescribed antiretroviral drugs in the ED. Sexually transmitted infection screening, risk reduction counseling, and education about symptoms of acute HIV seroconversion were performed inconsistently, despite NYS guidelines recommendations. Only 22% of EDs confirmed whether linkage to follow-up care was successful. Most NYS EDs prescribe nPEP to appropriate patients but full implementation of guidelines remains incomplete.
Introduction
Nonoccupational post-exposure prophylaxis (nPEP) is an important component of the prevention strategies for HIV transmission and an increasingly acknowledged effective biomedical strategy in decreasing rates of new infection. New York State (NYS) first established nPEP guidelines in 1997, recommending prophylaxis following sexual assault. In 2004, the state expanded its guidelines and most recently updated them in 2013. New York State now recommends post-exposure prophylaxis (PEP) for significant risk exposures following sexual assault, sexual and needle-sharing activities, needlesticks outside of occupational settings, and trauma, including human bites. 1 The 2013 updated guidelines postdate the survey in this article, although the minimal changes made focused primarily on the suggested medication regimen.
A 2006 study demonstrated that NYS emergency departments (EDs) had inadequately implemented the state nPEP guidelines, especially for consensual sexual exposures. 2 This same work also demonstrated poor rates of linkage to care after the index visit. Linkage to follow-up care is essential for the success of nPEP to monitor medication compliance, to monitor for signs of seroconversion, and to provide risk-reduction counseling.
The NYS Department of Health (DOH) licenses and regulates all EDs in NYS. Providers in these facilities are expected to follow its guidelines or to develop a policy that justifies pursuing a different course. New York State DOH AIDS Institute guidelines recommend that EDs provide on-site starter packs of nPEP medication for rapid initiation of treatment, arrange for continuation of treatment, and develop a protocol for providing prevention and risk-reduction counseling to patients presenting with exposure from voluntary sexual activity or injection drug use. 1
In 2010, the NYS legislature amended its HIV testing law to require the offer of an HIV test to every individual between the ages of 13 and 64 be in any setting where primary care is delivered, including EDs (public health law Articles 21 and 27F, regulated by Part 63 of Title 10 of the New York State codes, rules, and regulation). In order to evaluate implementation of the testing law, we electronically surveyed every ED in NYS and have reported those results elsewhere. 3 As an additional part of the survey, we sought to determine current nPEP practices, protocols, and services in NYS EDs. This information would be useful as a comparison to both the previous 2006 study and other national data in the literature. Moreover, it would help guide targeted education, outreach efforts, and policy initiatives aimed at improving the quality of care provided to nPEP patients in NYS EDs.
Methods
Study Design and Study Population
An electronic survey (Supplementary Appendix 1) was posted to the Health Emergency Response Database System (HERDS) platform, a preexisting Web-based information network used by the NYS DOH to distribute surveys and other materials to EDs. An electronic announcement was then sent to all 191 ED directors in NYS requesting completion of the survey on the HERDS platform. Veterans’ Affairs hospitals and urgent care centers are not included in this system. The authors developed survey questions related to nPEP in consultation with members of the DOH staff experienced in survey development. We did not use a previously validated survey but based the instrument on a tool used in our previously published survey. 2 HIV and emergency medicine experts pretested the instrument for face validity. Response fields on the survey were not mandatory for any question and some questions allowed for more than one response. In cases where respondents answered a follow-up question (ie, one beginning with “if yes”) without responding to the original question, we eliminated these follow-up responses from the analysis and categorized the initial response as “no” in order to provide the most conservative estimates. No incentives were provided to respondents for their participation. The study was granted an exemption from the institutional review board of the NYS DOH.
Study Protocol
The survey was posted to the HERDS platform on March 12, 2012. Directors were given 7 days to complete the survey. Several rounds of follow-up calls and e-mails were made to facilities that had not completed the survey by the 7-day deadline. Surveys were accepted as late as May 22, 2012. Hospitals’ demographic information was automatically obtained through the preexisting HERDS database maintained by the DOH.
Data Analysis
Aggregate responses were partitioned based on several a priori categories for comparison. Emergency departments were classified as located in Designated AIDS Centers (DACs) or non-DACs according to NYS DOH certification. Designated AIDS Centers are hospitals that meet 17 standards required by the NYS DOH for providing optimal comprehensive care for patients with HIV/AIDS. 4 Sites were also divided into groups based on the prevalence of HIV and AIDS cases, excluding prisoners, in their Ryan White Region or borough, as previously defined in published NYS DOH surveillance data through December 2009: low prevalence was defined as fewer than 200 cases per 100 000 persons; medium prevalence, as 200 to 500 cases per 100 000 persons; and high prevalence, as 500 or more cases per 100 000 persons. 5
Results
Ninety-six percent (n = 184 of 191) of the EDs in NYS returned the survey. Of the 7 hospitals not responding, 5 were located in New York City (NYC) and 4 were DACs. In all, 3 were in high-prevalence areas, 3 were in medium-prevalence areas, and 1 was in a low-prevalence area.
Of responding EDs, 42% were located in NYC (n = 78 of 184) and 58% were outside NYC (n = 106 of 184). Of the EDs, 63% were in low-prevalence areas (n = 115 of 184), 14% were in medium-prevalence areas (n = 25 of 184), and 24% were in high-prevalence areas (n = 44 of 184). Of the EDs, 19% were in DACs (n = 35 of 184) and 81% were in non-DACs (n = 149 of 184).
Eighty-eight percent of the respondents (n = 161 of 184) reported evaluating any patient with a possible non-occupational exposure to HIV in accordance with NYS guidelines; all but 2 DACs (94%, n = 33 of 35) did so. Of the respondents, 8% (n = 15 of 184) evaluated patients at the clinician’s discretion and 3% (n = 5 of 184) evaluated patients only in the case of sexual assault. One (1%) site, a non-DAC in a high-prevalence area of NYC, reported that it did not evaluate patients for non-occupational exposures. Two (1%) EDs did not respond to the question. The specific breakdown of how EDs evaluated patients for non-occupational HIV exposure is presented in Table 1A.
Evaluation of Nonoccupational HIV Exposures.
Abbreviations: DAC, Designated AIDS Center; ED, emergency department; nPEP, nonoccupational post-exposure prophylaxis; NYC, New York City.
a Percentages do not sum to 100% due to rounding error.
Respondents were allowed to select more than 1 method for supplying antiretroviral drugs for nPEP and varied widely in their methods (Table 1B). Of the 181 hospitals that evaluated patients for non-occupational HIV exposure, most provided the patient with an nPEP starter pack (83%, n = 151) when indicated. Nine of these 151 actually provided a full 28-day prescription or the full supply of medication. One hospital reported providing the full 28-day course of nPEP without providing an nPEP starter pack, bringing the total number of EDs supplying nPEP in the ED (in the form of a starter pack and/or a full 28-day supply) to 152 (84%). Of the 181 hospitals that evaluated patients for non-occupational HIV exposure, 7 (4%) neither supplied antiretroviral drugs in the ED nor prescribed them; all 7 were hospitals outside the NYC metro area in low or medium HIV prevalence areas. Of the 152 EDs that reported supplying nPEP in the ED, almost all (96%, n = 146 of 152) reported providing the first dose of medication in the ED (Table 1C.)
Only 81 (44%) of the 184 responding EDs reported a mechanism to track how frequently the ED prescribed nPEP (Table 2A). Of those 81 sites, 39 (48%) EDs used an electronic health record or database to track nPEP prescriptions, 17 (21%) used manual tracking, and 18 (22%) used other methods (pharmacy logs, reports generated from an automated medication dispensing system, chart audits, or social work referrals). Of the 81 hospitals, 7 (9%) reported the capacity to track nPEP dispensation but did not do so. Hospitals in the NYC metro area, those in high-prevalence areas, and DACs were more likely to track the frequency of nPEP prescriptions using an electronic health record or database (Table 2B).
Mechanisms for Tracking nPEP.
Abbreviations: DAC, Designated AIDS Center; ED, emergency department; nPEP, nonoccupational post-exposure prophylaxis; NYC, New York City.
a Percentages do not sum to 100% due to rounding error.
Consistent with the NYS guidelines, 141 (77%) of the 184 responding EDs reported conducting sexually transmitted infection (STI) screening in all cases of nPEP evaluation. Seventy-one percent (n = 131 of 184) of EDs performed risk-reduction counseling, and 63% (n = 115 of 184) educated patients to immediately report symptoms suggestive of acute HIV seroconversion. Fifty-one percent (n = 93 of 184) consulted HIV providers for cases of nPEP. Designated AIDS Centers and hospitals in the NYC metro area were more likely to consult with an HIV “specialist” (Table 3).
Practices for Evaluating Nonoccupational HIV Exposures.
Abbreviations: DAC, Designated AIDS Center; ED, emergency department; nPEP, nonoccupational post-exposure prophylaxis; NYC, New York City.
Seventy-eight percent (n = 143 of 184) of the respondents had a linkage-to-care protocol in place for nPEP patients (Table 4A). However, only 22% (n = 41 of 184) followed up to determine whether patients were successfully linked to care (Table 4B). Nearly half (47%, n = 86 of 184) of the respondents provided some staff training in protocols for managing nPEP (Table 5A). More than half provided it on an ongoing basis (56%, n = 48 of 86) and 43% (n = 37 of 86) had provided a one-time training (Table 5B).
Linkage to Care.
Abbreviation: DAC, Designated AIDS Center; NYC, New York City.
a Percentages do not sum to 100% due to rounding error.
Staff Training for nPEP (178 Respondents).
Abbreviations: DAC, Designated AIDS Center; nPEP, nonoccupational pos-texposure prophylaxis; NYC, New York City.
a Percentages do not sum to 100% due to rounding error.
Discussion
New York State recommends nPEP for significant risk HIV exposures following sexual assault, consensual sexual activity, needle-sharing activities, needlesticks outside of occupational settings, and trauma, including human bites. The Centers for Disease Control and Prevention has recommended providing prophylactic medication following nonoccupational HIV exposures since 2005. 6 Nonetheless, prior research suggests that nPEP is not widely prescribed. A 2001 study of 600 ED providers attending a national conference found that approximately half had provided PEP to non–health care workers experiencing needlestick injuries or to sexual assault survivors; however, only 8% reported prescribing PEP following consensual sex. 7 A 2002 study found that just 59% of randomly selected ED providers had nPEP available in their ED, and only 39% worked at sites with written nPEP protocols. 8 Similar data from Massachusetts showed that fewer than half of EDs in that state had protocols (either formal or informal) in place for nPEP. 9 When evaluating the availability of nPEP in Los Angeles County in 2009, 38.9% of EDs offered PEP to patients including those with and without private insurance. 10 A 2012 to 2013 study found that 59.7% of HIV providers in the District of Columbia and 39.5% of providers in Miami had prescribed nPEP. 11 Data are similar for adolescent nonoccupational exposures with only one-third of pediatric infectious disease and pediatric ED physicians having prescribed nPEP. 12 When evaluating PEP from the perspective of cases as opposed to provider-based data, a retrospective analysis of Rhode Island EDs in 2008 showed that only 21% of eligible cases had PEP offered, and it was more likely in scenarios with health care workers in the occupational setting. 13
Considering the above-mentioned data, our finding that 88% (n = 161 of 184) of NYS EDs reported evaluating any presenting patient with possible nonoccupational exposure for HIV suggests that the use of nPEP is relatively robust in NYS. This practice is likely due to long-standing efforts of the NYS Department of Health AIDS Institute to promote its use through community education and the Clinical Education Initiative. These data are not case based and do not report the number of times in which nPEP was actually administered to eligible patients, which could be an area for further investigation. Although in NYS a significant number of EDs evaluated patients for nPEP at percentages higher than reported elsewhere in the country, there remains room for improvement. In our cohort, 5 (3%) EDs evaluated patients for nPEP only in the context of sexual assault, and a single ED reported not evaluating patients for nPEP patients. Furthermore, 4% of respondents that reported evaluation of patients for nPEP did not prescribe or supply medication.
The 2006 study on nPEP in NYS EDs found that with rates of nPEP initiation ranging from 71% to 87%, all aspects of the NYS guidelines were not widely implemented. 2 The data presented here are difficult to compare directly to data from the 2006 study because different questions were asked; however, full implementation remains inconsistent. For example, although guidelines indicate that the clinician should provide risk-reduction counseling, only 71% of EDs reported that providers did so, with DACs demonstrating no better performance than non-DACs. This counseling may occur more commonly in follow-up sessions with either HIV specialists or primary care physicians outside of the ED. Also, while the single person who responded might not have known of risk reduction specifically incorporated into departmental protocols, providers may have these conversations at the bedside. Similarly, the guidelines state that clinicians should educate patients about signs and symptoms of primary HIV infection; however, only 63% of EDs reported that patients were educated to immediately report symptoms suggestive of acute HIV seroconversion. Finally, although the guidelines recommend that clinicians perform assessments for sexually transmitted infections in patients who present with HIV risk exposures, only 77% of sites did so.
In the area of prescriptions and medication supply, guideline implementation is similarly inconsistent. NYS guidelines state that EDs should have starter packs of medication available on-site for rapid initiation of nPEP treatment, an important action since patients have complained of the inability to obtain their prescribed antivirals in a timely fashion. In the present study, only 83% of EDs supplied a starter pack when nPEP was initiated for any patient, and 4% neither supplied nor prescribed nPEP following an evaluation of these patients. Further assessment and outreach is warranted to elucidate what occurs during these patient encounters. Additionally, it would be interesting to pursue further questioning as to the availability of occupational PEP (oPEP) in those hospitals to see if discrepancies exist between practice patterns of oPEP and nPEP.
A direct comparison with the 2006 study on nPEP in NYS can be made in the area of follow-up for nPEP. In 2006, only 33% of EDs had a mechanism to determine whether follow-up occurred. In the present study, by contrast, 78% of responding EDs had a protocol for linkage to follow-up care. This represents a substantial improvement in the implementation of that aspect of the NYS guidelines that is equally important for adherence and success of nPEP regimens. Unfortunately, only 22% of EDs in our study actually followed up to determine whether referrals to care were achieved which suggests that some linkage is simply a passive referral to an HIV provider. Linkage to care and follow-up from the ED remains a challenge in many aspects of patient care and is not unique to HIV. 14 Prior research has demonstrated that consultation with a social worker significantly improved attendance for follow-up serology at 6 weeks for patients receiving nPEP. 15 Preliminary results from a study on regular telephone contact and short message service reminders for patients receiving nPEP to ensure follow-up are also encouraging. 16 However, a recent prospective observation of patients who received nPEP in 2 Boston EDs showed that only 54% of patients attended their first follow-up visit and 45.6% of those returned after the first visit. 17 These findings confirm the continued need to develop and strengthen protocols for successful follow-up from the ED.
Gaps in the full implementation of the NYS guidelines may result from a lack of provider and staff education. Efforts at education have so far included a Statewide Center of Excellence for PEP, HIV Testing and Diagnosis, which is funded by the NYS DOH and charged with, among other functions, providing resources to EDs for the implementation of nPEP. More recently the centers of excellence have expanded the focus to include patients with hepatitis C as well. A Web site (www.ceitraining.org), supported by the New York State Clinical Education Initiative, supports a mobile phone app with interactive case simulation modules and other provider resources. Any ED throughout the state may also receive in-person outreach, educational seminars, and technical assistance for protocol development and implementation. A 24-hour hotline is also available for clinicians to assist in the management of nPEP cases in real time. Funded prevention counseling programs also allow EDs to refer patients to agencies addressing sexual health, risk reduction, and evaluation for pre-exposure prophylaxis (PrEP). In order to provide financial assistance to patients without insurance or the ability to pay for nPEP medication, NYS now also has funded nPEP payment programs. Nonetheless, despite these education efforts, implementation of guidelines remains inconsistent, suggesting a need for further educational outreach through new avenues. Publication of successful models of implementation of nPEP and outreach methods in EDs around the country to ensure adherence to protocols would be beneficial in generating new ideas for education.
In this survey, only half of EDs had processes for staff training in nPEP, and of those, nearly half only offered a one-time training. It is critical for staff members, including triage nurses who have the first encounters with patients, to understand the availability and effectiveness of nPEP for high-risk exposures.
European studies suggest that the numbers of patients presenting for PEP evaluation is increasing. 18,19 With increased patient awareness in the United States and continued educational outreach programs, we will likely also see this upward trend in visits necessitating successful implementation of nPEP protocols. 20
The primary limitation of this study is that all data were self-reported; misunderstanding of questions may have affected the response in some cases. Additionally, not every respondent chose to answer every question. We also excluded responses to follow-up questions provided by respondents who had failed to answer the preceding question and as a result may present an overly conservative picture of NYS nPEP practices. However, the small number of nonresponders and their distribution across type and region suggest that this occurrence did not bias our findings.
A further limitation involves the knowledge base of respondents about nPEP protocols. We targeted ED directors through HERDS, and we assumed that respondents were aware of all protocols and if not would have researched answers prior to completing the survey. We did not separate adult and pediatric protocols in our survey. It is possible that a separate pediatric division of an ED may have a different protocol. Finally, differentiating between nonoccupational exposures following sexual assault when compared to other types of nonoccupational exposures may have provided a clearer picture of practices in the ED, given prior research that suggests these groups are sometimes treated differently. 7 More in-depth mixed qualitative–quantitative research would be useful to assess some of these issues.
Overall, our results suggest that the majority of NYS EDs prescribe nPEP to the appropriate population of patients but that full implementation of NYS guidelines for nPEP remains incomplete. Since 2006, there has also been substantial improvement in the area of linkage to care, although follow-up to ensure that patients have successfully linked remains limited. Continued education of providers about full implementation of nPEP protocols and enhanced targeted technical assistance may help increase and sustain this rate of improvement. With higher rates of full nPEP protocol compliance and dissemination of knowledge of nPEP, this effective prevention strategy will lead to decreased rates of new HIV infection for patients seeking timely evaluation in the ED.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
