Access to post-exposure prophylaxis following sexual exposure for men who have sex with men in an Irish healthcare setting

Abstract

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

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 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

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 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

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 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 = 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 = <0.05). The frequency of HCP consulting with colleagues did not differ: mean 13 of 31 (41.9%) UPSI consultations and 7 of 24 (29.2%) CNSI consultations (p = 0.103). Similar numbers of ED respondents agreed to engage in discussion of the case by telephone – 26 of 30 (86.7%) UPSI consultations and 28 of 31 (90.3%) CNSI consultations (p = 0.544). For those who declined to engage in discussion, our patient was advised to attend sexual health services or general practitioner at next available opportunity (Table 1).

Table 1.

Comparison of responses to each scenario.

Comparison of responses	MSM	NSI	p Value
Time spent on call (Mean; minutes)	3.64	3.74	0.849
No. HCPs involved in call	1.94	1.29	<0.05
HCP – fellow HCP consultation	13/31 41.9%	7/24 29.2%	0.103
ED happy to engage in discussion on telephone	26/30 86.7%	28/31 90.3%	0.544

ED: emergency department; MSM: men who have sex with men; NSI: needle-stick injury; HCP: healthcare provider.

PEP knowledge

There was no difference in ED respondent’s knowledge of PEP and indications for use (classified as competent or non-competent). Of the 31 UPSI 14 (45.2%) and of the 30 CNSI 9 (30.0%) telephone call respondents were deemed as having a competent knowledge of PEP (p = 0.103). There was no difference in respondent’s knowledge of PEP availability within their ED; 8 of 23 (34.8%) UPSI respondents and 7 of 14 (50.0%) CNSI respondents knew where to access PEP medication (p = 0.146).

PEP administration

The proportion of ED respondents who stated PEP may be offered in either scenario did not differ – 7 of 24 (29.2%) UPSI respondents and 7 of 30 (23.3%) CNSI respondents (p = 0.944). There was a statistically significant difference in the number of EDs advising the patient to attend the department for further assessment and PEP. Only 7 of 31 (22.6%) UPSI consultations as compared to 15 of 31 (48.4%) NSI consultations were advised to attend the respondent’s ED following the telephone consultation (p = 0.034).

Management

We identified a statistically significant difference in respondents offering baseline serological testing in each scenario. Two of 9 (22%) UPSI cases and 18 of 24 (75%) CNSI cases were informed that they would receive testing for bloodborne infections during initial assessment (p = 0.006) (Table 2). We documented if appropriate advice was given to attend follow-up services and found just over half (16/31, 51.6%) of UPSI exposures were advised to attend infectious diseases/genitourinary medicine services

Table 2.

Comparison of PEP knowledge for each scenario.

Comparison of responses	MSM	NSI	p Value
Did ED have a competent knowledge of PEP?	14/31 45.2%	9/30 30.0%	0.103
ED awareness of PEP availability in department	8/23 34.8%	7/14 50.0%	0.146
ED offering PEP	7/24 29.2%	7/30 23.3%	0.944
Did ED tell patient to attend department?	7/31 29.2%	15/31 48.4%	0.034
Did ED offer baseline serological testing?	2/9 22.2%	18/24 75.0%	0.006

ED: emergency department; PEP: post-exposure prophylaxis.

Discussion

This is the first study to review access to PEPSE for MSM consulting EDs in the Republic of Ireland. MSM were as likely as CNSI to be advised regarding their situation via telephone (86.7% of UPSI vs. 90.3% of NSI) and received similar amounts of telephone consultation time from ED respondents. We demonstrated ED respondent tendency to offer PEP medication was similar in both situations (29.2% of MSM UPSI vs. 23.3% of CNSI), despite no evidence to support use in non-occupational CNSI.⁸ MSM were less likely to be advised to attend ED to receive PEP compared to CNSI, and are less likely to access PEP for a situation in which there is strong evidence for use. A deficit in care and appropriate follow up was also identified, with lower numbers of respondents offered baseline serological testing for UPSI than CNSI, and only 51.6% (16/31) of UPSI exposures were advised to attend genitourinary medicine services. Considering the high prevalence of undiagnosed HIV in the MSM community, this represents a missed opportunity to actively screen for HIV in a high-risk population. HIV-positive MSM unaware of their status are 3.5 times more likely to transmit HIV than HIV-positive MSM who knew of their diagnosis.²⁸ ED knowledge of PEP and indications for use were similar in both situations. We hypothesise factors including departmental pressures including staff availability, unawareness of PEP indications and unfamiliarity with sexual history taking. Lanier et al.²⁹ demonstrate less than half of healthcare providers conduct sexual history taking with patients.²⁹ We identified a disparity in access to PEP for MSM, representing missed opportunities to utilise a targeted intervention known to reduce HIV transmission in MSM. Possible reasons include poor knowledge of PEP indication, availability and administration for UPSI. As the majority of ED respondents were nursing staff it may represent an opportunity for PEP-related education of frontline staff members. Reasons for higher tendencies to recommend PEP for CNSI may stem from management of occupational NSI, which is frequently undertaken by EDs.³⁰ As PEP is ‘intended for use in emergency medical settings where a patient first presents… including needlestick or other sharps injury, sexual exposure… where there is a risk of transmission of infection, in particular blood borne viruses,’¹⁸ MSM should have access to PEP within EDs. While non-occupational CNSI represent a concern for patients and healthcare workers, it must be appreciated that MSM are a much higher risk group for HIV transmission. Irish data show that of a total 3254 patients accessing care with HIV in 2010–2011, 2898 (89.1%) could identify a mode of transmission. Of these, 50% were heterosexual, 25% were MSM and 21% were intravenous drug users. None identified sharps injuries in the community as a method of transmission.⁷ As previously discussed, MSM are the group most at risk for new HIV infection, and should be encouraged to seek PEP for high-risk sexual encounters. Rowley et al.³¹ demonstrated the effectiveness of PEP use in MSM, with 31 patients accessing PEP remaining HIV negative at 6-month follow-up,³¹ supporting use of PEP to reduce HIV transmission. If MSM are encouraged to seek PEP, access to medication is an essential component of this plan. Limitations of our study include a small sample size of hospitals (limited by the total number of hospitals within this jurisdiction), time pressure on individual department staff members, many of whom took calls whilst managing other responsibilities, leading to difficulty in completing the entire series of datasets per questionnaire. There were a variety of healthcare workers who offered advice. However, this study was not designed to assess individual healthcare personnel PEP knowledge but to assess the reality of an individual receiving the most appropriate advice in a defined at-risk situation. The authors also acknowledge that better study design may involve looking at whether PEP was offered or not for each situation, rather than comparison of two different situations.

In conclusion, this represents an inequality in access to a strongly indicated intervention for MSM exposed to HIV. Publication and dissemination of national PEP guidelines will aid appropriate use of PEP for frontline staff. This study also highlights missed opportunities for HIV screening in an at-risk population, where earlier detection could lead to better health outcomes for patients and help limit onward transmitted infection.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

References

Beyrer

Baral

van Griensven

. Global epidemiology of HIV infection in men who have sex with men. Lancet 2012; 380: 367–77.

Beyrer

Sullivan

Sanchez

. The increase in global HIV epidemics in MSM. AIDS 2013; 27: 2665–2678.

Koblin

Mayer

Eshleman

. Correlates of HIV acquisition in a cohort of Black men who have sex with men in the United States: HIV prevention trials network (HPTN) 061. PLoS One 2013; 8: e70413–e70413.

Koblin

Husnik

Colfax

. Risk factors for HIV infection among men who have sex with men. AIDS 2006; 20: 731–739.

Goodreau

Golden

. Biological and demographic causes of high HIV and sexually transmitted disease prevalence in men who have sex with men. Sex Transm Infect 2007; 83: 458–462.

UNAIDS. Global Report: UNAIDS Report on the Global AIDS epidemic 2012, http://www.unaids.org/en/media/unaids/%5D (2012, accessed 22 October 2013).

HIV in Ireland- 2012 Report. Published by the Health Services Executive (HSE) and Irish Health Protection and Surveillance (HPSC) Centre, June 2013.

Benn

Fisher

Kulasegaram

. UK guideline for the use of post-exposure prophylaxis for HIV following sexual exposure (2011). Int J STD AIDS 2011; 22: 695–708.

van Sighem

Jansen

Bezemer

. Increasing sexual risk behaviour among Dutch men who have sex with men: mathematical models versus prospective cohort data. AIDS 2012; 26: 1840–1843.

10.

Millett

Peterson

Flores

. Comparisons of disparities and risks of HIV infection in black and other men who have sex with men in Canada, UK, and USA: a meta-analysis. Lancet 2012; 380: 341–348.

11.

Kirby

Thornber-Dunwell

. High-risk drug practices tighten grip on London gay scene. Lancet 2013; 381: 101–102.

12.

Vermund

. Global HIV epidemiology: a guide for strategies in prevention and care. Curr HIV/AIDS Rep 2014; 11: 93–98.

13.

Johnson

Diaz

Flanders

. Behavioral interventions to reduce risk for sexual transmission of HIV among men who have sex with men. Cochrane Database Syst Rev 2008; (3): Cd001230–Cd001230.

14.

Cardo

Culver

Ciesielski

. A case-control study of HIV seroconversion in health care workers after percutaneous exposure. Centers for Disease Control and Prevention Needlestick Surveillance Group. N Engl J Med 1997; 337: 1485–1490.

15.

Centers for Disease Control and Prevention. Management of possible sexual, injecting-drug-use, or other nonoccupational exposure to HIV, including considerations related to antiretroviral therapy. Public Health Service statement. MMWR Recomm Rep 1998; 47: 1–14.

16.

Smith

. Antiretroviral postexposure prophylaxis after sexual, injection-drug use, or other nonoccupational exposure to HIV in the United States: recommendations from the US Department of Health and Human Services. MMWR Recomm Rep 2005; 54: 1–20.

17.

Health Services Executive (HSE) and Irish Health Protection and Surveillance (HPSC) Centre, Guidelines for the Emergency Management of Injuries. September 2012.

18.

Clutterbuck

Flowers

Barber

. UK national guideline on safer sex advice. Int J STD AIDS 2012; 23: 381–388.

19.

Joshi

. Post-exposure prophylaxis after sexual exposure (PEPSE) awareness in an HIV-positive cohort. Int J STD AIDS 2014; 25: 67–69.

20.

Sayer

Fisher

Nixon

. Will I? Won't I? Why do men who have sex with men present for post-exposure prophylaxis for sexual exposures?. Sex Transm Infect 2009; 85: 206–211.

21.

Mehta

Silvera

Bernstein

. Awareness of post-exposure HIV prophylaxis in high-risk men who have sex with men in New York City. Sex Transm Infect 2011; 87: 344–348.

22.

Fernandez-Balbuena

Belza

Castilla

. Awareness and use of nonoccupational HIV post-exposure prophylaxis among people receiving rapid HIV testing in Spain. HIV Med 2013; 14: 252–257.

23.

Roedling

Reeves

Copas

. Changes in the provision of post-exposure prophylaxis for HIV after sexual exposure following introduction of guidelines and publicity campaigns. Int J STD AIDS 2008; 19: 241–242.

24.

Canadian Paediatric Society. Needle stick injuries in the community. Paediatr Child Health 2008; 13: 205–218.

25.

Papenburg

Blais

Moore

. Pediatric injuries from needles discarded in the community: epidemiology and risk of seroconversion. Pediatrics 2008; 122: e487–e492.

26.

Thompson

Boughton

Dore

. Blood-borne viruses and their survival in the environment: is public concern about community needlestick exposures justified?. Aust N Z J Public Health 2003; 27: 602–607.

27.

Rutland

Sundaram

Mani

. The awareness of postexposure prophylaxis for HIV infection following sexual exposure in emergency departments in a regional HIV network. Int J STD AIDS 2010; 21: 636–637.

28.

Marks

Crepaz

Janssen

. Estimating sexual transmission of HIV from persons aware and unaware that they are infected with the virus in the USA. AIDS 2006; 20: 1447–1450.

29.

Lanier

Castellanos

Barrow

. Brief sexual histories and routine HIV/STD testing by medical providers. AIDS Patient Care STDS 2014; 28: 113–120.

30.

Zenner

Tomkins

Charlett

. HIV prone occupational exposures: epidemiology and factors associated with initiation of post-exposure prophylaxis. J Epidemiol Commun Health 2009; 63: 373–378.

31.

Rowley D, O’ Bara R, Quinlan M, et al. Audit of the use of post exposure prophylaxis following sexual exposure (PEPSE) in a community sexual health clinic for men who have sex with men. In: Oral presentation, society for the study of sexually transmitted diseases in Ireland, Autumn Meeting 2011, Dublin.