Pre-elective HIV postexposure prophylaxis clinic for medical students: design,protocol,uptake and effectiveness

Abstract

We sought to evaluate medical student need for HIV postexposure prophylaxis (PEP) prior to their elective and introduce a ‘Pilot PEP Clinic’. We undertook a survey of 388 medical students to assess their elective plans. All were offered an appointment in a clinic, assessed via a protocol and provided a PEP ‘starter-pack’ prescription if criteria were met. A follow-up questionnaire was sent to assess the acceptability of the clinic. The pre-elective questionnaire response rate was 232/388 (60%); 72/232 (31%) of respondents planned their elective in areas of high HIV prevalence and, of these, 32/72 (45%) attended the clinic. Of 32, 31 (97%) met the clinic protocol criteria and received a prescription for PEP. Of 32, 29 (90%) completed the follow-up questionnaire and every respondent rated the clinic as acceptable. The main concern was the cost of antiretroviral medications. We conclude that a ‘Pre-elective HIV PEP Clinic’ is an acceptable way to provide students with safe access to PEP prior to their elective.

Keywords

HIV medical elective postexposure prophylaxis PEP prevention

INTRODUCTION

Many medical, dental and nursing students choose to undertake their electives in developing countries that pose a high risk of HIV exposure. The elective period offers students a valuable learning opportunity; however, inexperience, the relatively high prevalence of HIV and lack of resources available to implement standard infection control increases the likelihood of exposure to blood and bodily fluids. The average risk of HIV exposure following a percutanous exposure to HIV-infected blood has been estimated at 0.3% and postexposure prophylaxis (PEP) with zidovudine has been shown to reduce the transmission of HIV by around 80%.¹

The Department of Health (DoH) guidelines from 2000 and 2004 specifically mention the responsibility of medical schools to students undertaking electives abroad and recommend the provision of a PEP starter pack for students travelling to countries where antiretroviral therapy is not commonly available.^2,3 In 2008 the updated guidance from the DoH stated that students should consider taking a PEP starter pack only if one is not available at the host institution, and this should be determined prior to departure.⁴

Several studies have found that students were embarking on their electives ‘unprepared and ill advised’.^1,2 In 1999 Gamester et al. surveyed medical students at one UK medical school returning from their electives. Many students (44%) had chosen to travel to areas of high HIV prevalence but had been unaware of this risk. An occupational exposure was reported by 3%; these were poorly managed and not followed up.⁵ In 2001 a questionnaire study of 140 Dundee medical students returning from their electives abroad found that a large number of students (37%) reported significant exposure to potentially infective fluids.⁶

A survey of UK medical schools found that the advice regarding HIV risk reduction and the provision of PEP varied considerably and called for more consistency and the provision of regularly updated, evidence-based guidelines for undertaking a safe elective.⁷ Again in 2002 another study showed that although many medical schools had updated their policies regarding HIV risk reduction and PEP, differences still existed between institutions.⁸

The aim of this study was to evaluate the needs of medical students in relation to HIV PEP prior to their elective at our UK medical and introduce a pre-elective PEP clinic for medical students to provide safe access to PEP in accordance with DoH guidance.

METHODS

Anonymous questionnaires were distributed to 388 fourth year medical students at our institution following submission of their elective project proposals. The questionnaire identified students’ plans for their elective including destination, chosen specialty, their perception of the HIV risk during the elective and their plans to take PEP. Areas were classified as high HIV prevalence where there was an average adult prevalence of HIV ≥0.5% based on the UNAIDS update 2007.⁹ North America was excluded from the high prevalence category as it was felt that PEP would be easily accessible.

A pilot PEP clinic for all local medical students to attend prior to their elective was established. Students were given an individual appointment with a genitourinary (GU) medicine consultant to discuss their elective plans, establishing the extent of HIV exposure and the need to take PEP. Detailed counselling and written information was provided with a prescription for a four-day ‘starter pack’ of antiretrovirals. Students paid cost price for their medication. A small medical kit including gloves, needles and syringes was also offered to all students attending the clinic regardless of whether a prescription was given.

Individual consent to be contacted for a follow-up questionnaire was obtained from clinic attendees and on their return from the elective, a detailed email questionnaire was sent out. This assessed the level of risk of clinical exposure to HIV, the use of PEP, the availability of PEP at host institutions and the suitability of the information, counselling and provision of PEP at the clinic.

RESULTS

Pre-elective medical student questionnaire

Of the 232 students responding to the pre-elective questionnaire, 72/232 (32%) planned to undertake their medical elective in an area defined as high HIV prevalence (Figure 1). We found that 70/72 (96%) students travelling to high prevalence areas felt they had received insufficient information from the medical school about their risk of HIV exposure. With respect to PEP, 33/72 (46%) of those going to high prevalence areas had planned to take a PEP starter pack with them and of these, only two students knew where to acquire one.

Figure 1

Elective destinations for the 2008 elective at our institution

Thirty-two students attended the clinic before the elective period and 29/32 (90%) responded to the postelective questionnaire. All but one of the students who attended the clinic took a prescription for a PEP starter pack (there was known availability at the host institution for the student not taking one).

Twenty of the respondents (66%) reported performing exposure-prone procedures during the elective placement which included arterial blood gases, cannulation and venepuncture. No student reported having to take PEP during the elective; however 28/29 were re-assured to have PEP with them. Of 29, 11 (38%) said they did more in hospital knowing that they had a supply of PEP and 18/29 would take PEP again (Table 1).

Table 1

Results of the post-elective questionnaire

Question	Stronglyagree	Agree	Notsure	Disagree
Enough information on when to take PEP?	18	10	1	0
Re-assured to have PEP with them on the elective?	24	4	1	0
Take PEP again?	16	4	4	5
Did more in hospital because of PEP?	5	6	6	11
Offer a clinic every year?	23	6	0	0

PEP = postexposure prophylaxis

Students were asked to rate how useful they found different aspects of the clinic and all students found the PEP clinic useful or very useful (Table 2). Overall, the clinic appears acceptable and all students agreed it should be offered every year. The main concern put forward by 16 of the 29 students (55%) was the cost of the drugs; some students suggested support from the medical school to subsidize the cost of the prescription would help improve the clinic for future years.

Table 2

Results of the post-elective follow-up questionnaire

Provision	Very useful	Useful	Not useful	Pointless
Individual advice from a consultant	17	11	1	0
PEP information leaflet	6	22	0	0
Medical kit provided	6	15	7	1
Overall clinic	23	6	0	0

PEP = postexposure prophylaxis

DISCUSSION

Our study demonstrates that areas of high HIV prevalence remain a popular choice of elective destination for students at our medical school and some students planning to visit such areas were unaware of the risks. Our pre-elective questionnaire results suggest that students at our medical school were still embarking on their electives without adequate preparation and sufficient advice regarding HIV risk and PEP.

We found difficulties in defining areas of high HIV prevalence and national prevalence can underestimate the level of HIV among hospital inpatients and therefore underestimate exposure that a student may experience in a hospital setting. We would therefore recommend that information regarding HIV risk and PEP should be offered to all students prior to the elective, perhaps in the form of an elective planning evening.

The increasing availability of antiretrovirals in resource poor settings may mean that HIV PEP is more easily accessible than in previous studies. However, antiretrovirals must be available without delay and it is unethical to place the burden of responsibility on institutions in resource-limited settings. The DoH guidance 2008 states that medical students should inform themselves of the HIV prevalence and the provision of PEP at their chosen destination, but that medical schools have a responsibility to provide advice about HIV risk reduction and PEP if required.⁴

Our innovative ‘Pre-elective HIV PEP Clinic’ provided a safe and effective means of providing advice on occupational exposure to HIV and PEP. None of the students reported a need to take PEP during the elective but the positive student feedback would support establishing the clinic as a long-term solution to the provision of occupational PEP for medical students, and could be used as a model for well-needed, regularly updated national guidelines in the future. The main concern among medical students who attended the clinic was the price of drugs. While it is not essential, considering all the other costs associated with a modern elective, discounting would certainly be welcomed by students.

Footnotes

ACKNOWLEDGEMENTS

Funding or competing interests: None.

Ethical approval: No ethical approval was required as the study was considered a service evaluation. Trust R&D approval was obtained.

Contributorship: LS and KS designed the questionnaires and analysed the data; SB supervised the study. LS wrote the manuscript with critical appraisal from KS and SB.

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