A review of HIV postexposure prophylaxis provision at a genitourinary medicine department

INTRODUCTION

Postexposure prophylaxis (PEP) administration after exposure to HIV, for the purposes of reducing HIV acquisition, is now accepted practice for both occupational ¹ and non-occupational scenarios. ^2,3

The Edinburgh genitourinary (GU) medicine department policy for HIV PEP provision is formed from combining British Association for Sexual Health and HIV (BASHH), ⁴ international World Health Organization (WHO) ⁵ and European guidelines ⁶ for PEP following various exposures. These guidelines provide clear indications for when PEP is recommended, should be considered or not recommended, depending on the circumstances surrounding the specific exposure.

We audited the management of patients attending the Edinburgh GU medicine clinic following possible exposure to HIV infection.

METHODS

Case-notes were reviewed of all patients who attended the GU medicine department between 1 January 2006 and 31 December 2008, and received a Scottish STI Surveillance System (STISS) code for HIV PEP advice or initiation. ⁷ We included patients even if they had been initially reviewed elsewhere (e.g. an emergency department) and directed to GU medicine for a decision on PEP continuation or discontinuation. Data were collected on patient demographics, details of the exposure and subsequent clinical management. The principal audit outcome measures (AOMs) used, as well as suggested targets and audit results are shown in Table 1. The AOMs include those suggested by BASHH guidelines, ⁴ as well as additional ones based on our clinic practice. However, we did not include HIV testing rates at six months post-PEP as an AOM, as only a three-month post-PEP HIV test is required by the Edinburgh clinic protocol (the 6-month test is optional).

For the purposes of the audit, we considered that guidelines had been followed if PEP was initiated for exposures where guidelines ‘recommended’ PEP, and not initiated for exposures where it was ‘not recommended’. For scenarios where guidelines stated PEP may be ‘considered’, both outcomes of PEP initiation and non-initiation were accepted. Whatever the exposure, if medical review was beyond 72 hours post-event, the guideline recommendation was taken to be PEP ‘not recommended’.

RESULTS

Over the audit period, 81 individuals attended the Edinburgh GU medicine department following 85 potential HIV exposure events; four individuals attended regarding two exposure events each. Of the 81 individuals, a majority were male (56, 69%), of white ethnicity (75, 93%) with a median age of 29 years (range 15–61).

Of the 85 exposure incidents, the source was a known HIV-positive individual in 38 (45%) cases. Twenty-three (27%) exposures occurred in a health-care occupational setting and 50 (59%) in a sexual context (including seven sexual assaults). The remaining 12 (14%) cases involved a variety of scenarios, including needle-stick injuries sustained outside health-care environments (e.g. by discarded needles in street or hotel room bins) and physical or bite injuries perpetrated by high-risk assailants. Of the 50 sexual exposures, 35 cases involved anal intercourse, nine cases involved vaginal intercourse and six cases involved oral sex alone. Forty-one of the sexual exposures received screening for other sexually transmitted infections within one month of initial presentation (usually performed >10 days post-sexual exposure at our service).

Table 2 shows the overall audit results. Baseline HIV testing was only performed in 38 (45%) of the 85 exposures. However, baseline testing rates improved for those presenting following sexual exposures (33 of 50, 66%); only one individual tested positive at baseline.

PEP was initiated in 65 (76%) cases. In 68 (80%) of the 85 exposures PEP initiation outcome tallied with (BASHH and Eurosurveillance) guideline recommendations for that specific scenario. ^4,6 Table 1 shows the breakdown of PEP initiation outcome versus guideline recommendations. A majority of the discrepancies (16 of 17) were due to low risk exposures being started on PEP: four cases where PEP was initiated outside GU medicine, two cases where PEP was started pending source testing and two cases due to patient wishes. In the remaining eight cases there was no obvious documented reason for the discrepant PEP decision. Of the 16 cases where PEP was initiated against guideline recommendations, it was discontinued within 72 hours in six.

PEP was not continued beyond the three-day starter pack in an additional three cases. In one case, baseline HIV testing was positive and in the remaining two cases, following the prescription of a three-day starter pack, it was unclear from the documentation whether these patients failed to reattend for the full course or attended elsewhere for this. No patients discontinued PEP within the initial 72 hours for toxicity reasons.

Where PEP was given, it was administered within the recommended audit target of 72 hours in all except four cases: in two cases the delay was due to the patient attendance being beyond 72 hours post-event and in the other two cases time to starting PEP was not documented. Of the 65 exposures where PEP was initiated, in all but three cases (where the regimen was not documented) a regimen containing dual nucleoside reverse transcriptase inhibitors plus a single protease inhibitor was prescribed.

Of the 56 individuals who continued PEP beyond 72 hours, a majority (53, 95%) were reviewed at least once during the treatment course, and had routine blood testing performed (BASHH recommends weekly reviews, but the departmental policy is a minimum of one review, with repeat assessments as required). Documentation regarding adherence was poor, with only 31 having this recorded in their notes. Where documented, 27 of 31 managed satisfactory adherence, with few or no missed doses. Of the remaining four patients, two had a substantial number of missed doses and two discontinued PEP prior to completion of the course because of side-effects. Thus (documented) satisfactory completion of four weeks of PEP with good adherence (27 of 56, 48%) fell far short of the recommended BASHH audit target of 75%.

Only 37 of the 56 individuals (66%) continued on PEP attended for follow-up HIV testing at three months. Of the 20 patients not initiated on PEP, 12 returned for follow-up HIV testing between three and six months; of these, seven were patients eligible for PEP but not initiated (see Table 2) and four of them returned for post-exposure testing. In both scenarios above, a reason for patient failure-to-attend (e.g. patient attended elsewhere for their follow-up test) was documented in only a small number of cases. None of the patients who returned for repeat testing had seroconverted for HIV.

DISCUSSION

Our audit revealed that the majority of individuals reviewed at the Edinburgh GU medicine department following potential exposure to HIV received a clinical decision on PEP in accordance with guideline recommendations, though the 90% BASHH audit standard was not reached. It is worth noting that in three of the cases where PEP was initiated unnecessarily, this decision was made outside the GU medicine department.

Just over three-quarters of the patients reviewed were initiated on PEP, compared with the low 17% demonstrated in an audit within the same department in 2001. ⁸ This might be related to increased clinician readiness to prescribe PEP as much as a change in the type (and therefore risk level) of exposures presenting to the department in comparison to 2001: 50 of the 85 exposures in the current audit were following a sexual exposure, compared with four of 76 exposures in the previous audit. This is likely due to better advertisement and awareness of PEPSE in some high sexual risk populations such as men who have sex with men.

It is disappointing that baseline HIV testing happened in only 45% of all patients, including only 66% of those presenting following sexual exposure – a potentially high-risk population in which BASHH recommends mandatory baseline testing. We plan to introduce a new clinic PEP initiation proforma that includes baseline HIV testing for sexual exposures.

More encouragingly, when PEP is now prescribed, it is using approved drug regimens and is usually initiated within 72 hours of exposure. Clinicians were less successful at documenting PEP adherence, with <50% of cases having such details documented. The new clinic PEP proforma will therefore also incorporate PEP adherence documentation.

In comparison, clinic HIV test performance at three months post-completion of PEP successfully surpassed the 60% audit target; a significant improvement from the 2001 audit.

In conclusion, this audit has demonstrated some areas for improvement in the management of HIV PEP at the Edinburgh GU medicine department, although generally the department is meeting or just falling short of a majority of the guideline targets.