Missed Opportunities for HIV Post-Exposure Prophylaxis

Background

Emergency Departments (ED) are frequently tasked with managing HIV exposures and initiating post exposure prophylaxis (PEP).  A survey of ED providers in early 2000 demonstrated that many were uncomfortable determining the need for PEP after non-occupational exposures, like sexual contact and injection drug use. For such cases, PEP management occurred 49-100% of the time. In 2005, the CDC released new guidelines delineating PEP for non-occupational cases. The incidence of HIV infections has remained stable in the US (50,000 cases per year) and some believe that this may, in part, be due to the underuse of PEP.

CDC 2005 Guidelines: PEP should be given if

• Exposure within 72 hours
• Exposure mechanism was high risk
  • Needle stick, mucous membrane exposure, needle sharing, vaginal or anal intercourse, blood exposure to open wound receptive oral intercourse, human bite that broke skin
• Body fluid known to transmit HIV
  • Blood, seminal/vaginal/rectal secretions/csf/synovial fluid/amniotic fluid
  • NOT urine, vomit, stool, saliva
• Source was known to be HIV positive or at high risk for HIV infection

Primary Results

Primary Results:

• 2,244 ED patients with ICD code blood or body fluid exposure; 272 excluded leaving 1,972 charts for analysis.
• 1,358 (68.9%) occupational and 614 (31.1%) non occupational
• Men 40.4% occupational group, 76.2% non occupational
• Of the non-occupational cohort, majority of exposures were from abandoned needle sticks (25.2%) and anal intercourse (22.5%)
• 36% occupational were fresh needle stick injuries (no fluid contaminant)
• Majority of non-occupational exposures (90.5%) and occupational exposures (76.7%) received baseline HIV test but few had subsequent testing (25.4% in occupational 6 mos, 35% non occupational)

Critical Results:

• Primary Outcome (PEP given difference occupational vs. non-occupational)
  • Group estimated there would be at least a 10% difference
  • Non-occupational 72.5% vs. Occupational 84.2% (Difference = 11.7% CI: 3.8 – 19.1%)
• Secondary Outcomes
  • Appropriate management was delivered in a similar number of low-risk exposures in the occupation (92.4%) and non-occupational (93.0%) groups
  • None of the occupational exposure patients who completed follow up HIV testing over 6 months seroconverted, while 4 of the non-occupational patients converted (2 of those patients never received the PEP)

Strengths

• First study to examine the difference in prophylaxis rates between occupational and non-occupational exposures
• Details about patients were extracted from chart by two trained medical residents who were blind to the study hypotheses
• Inter-rater reliability determined by random sampling of 10% of charts
• Baseline HIV testing and PEP medications were offered to patients free of charge which may increase compliance with guideline adherence
• HIV prevalence in Vancouver, Canada is similar to many North American Cities

Limitations

• Single center study
• Retrospective Chart Review
  • Only looked at one specific ICD code (did not capture diagnostic codes like needlestick, exposure to other disease, assault, rape, sexual abuse etc)
  • PEP may have been offered but not accepted and discussion may not have been documented
• Appropriateness of providing PEP determined by reviewers and thus involved both reviewer judgement and relies on completeness of the chart itself
• Reasons for no HIV testing unclear i.e. patients may have declined baseline HIV testing
• Follow up with the patients was poor (< 30% of the patients returned for follow up). While some of this may be due to the population in question, the fact that follow up care in the non-occupational group wasn’t provided for free likely influences this as well
• Unclear why patients seroconverted (were they actually sub-clinically positive during the first visit? Were they unable to receive their medications or did they not use them properly? Did they have subsequent exposures?)

Author's Conclusions

“For ED patients with blood or body fluid exposures, those with high-risk nonoccupational exposures were not given HIV prophylaxis nearly twice as often as those with high-risk occupational exposure. Although 6-month follow-up testing rates were low, 1.9% of high-risk nonoccupational exposure patients seroconverted.”

Our Conclusions

This retrospective, single center, chart review demonstrated that there is a significant difference between PEP in occupational and non-occupational patient cohorts. However the methodology utilized in this study introduces significant bias to the data making the application of it to clinical practice difficult at best.

Potential Impact To Current Practice

ED providers should be familiar with the CDC guidelines for offering PEP for both occupational and non-occupational body fluid exposures. Appropriate intervention in the ED has the potential to help limit spread of HIV within high-risk communities as well as among health-care workers.

Bottom Line

All patients who present to the ED after body fluid exposure, whether it be occupational or non-occupational, should be considered for PEP. Providers should use the 2005 CDC guidelines to determine which exposures are high-risk and who should be offered treatment.

Read More

Post-Exposure Prophylaxis Resources

CDC: Updated Guidelines for the Management of Occupational Exposures to HIV and Recommendations for Postexposure prophylaxis

San Francisco Needlestick Hotline: 888-448-4911