Implementing a Comprehensive nPEP Program Improves Medical Treatment

Standardizing an emergency department protocol for non-occupational post-exposure prophylaxis (nPEP) for sexual assault patients caused an increase in nPEP administration, according to a paper published in HIV Medicine.

Investigators from the University of Arkansas for Medical Sciences retrospectively analyzed post-sexual assault patient evaluations in order to support and guide the creation and implementation of nPEP protocols. The investigators also wanted to increase the percentage of post-sexual assault patients who were correctly offered nPEP and subsequently given an appropriate prescription, they explained. The investigators collected pre-intervention data between July 2016 and June 2017 as well as post-intervention period data from July 2017 to June 2018.

The study authors wrote that sexual contact is the most common method of HIV transmission, and medical evaluations of sexual assault patients frequently occurs within an emergency department. However, the implementation of established nPEP guidelines varies among emergency departments, they added. There is also little to no follow up among this patient population and another barrier to obtaining information is that PEP management of occupational and non-occupational exposure is not always the same.

During the pre-intervention period, nPEP management was based on the individual emergency department provider’s knowledge, the study authors wrote. Prescriptions were provided on discharge and patients were not regularly scheduled for tele-health or in-person follow-up visits. The study authors also noted that infectious disease physicians, HIV providers, and HIV pharmacists were not involved, they said.

With that in mind, their nPEP program provided for baseline screening labs and appropriate prophylactic measures for hepatitis B, chlamydia, gonorrhea, syphilis, and Trichomonas vaginalis. The study authors added more details about the program including real-time collaboration between ED providers, sexual assault nurse examiners, and HIV pharmacists; an initial nPEP dose administered in the emergency department; an on-site specialty pharmacy, with prescriptions available to fill weekend gaps; regularly scheduled tele-health visits with an HIV pharmacist; and an in-clinic visit with an infectious disease physician scheduled while the patient remained in the emergency department for a 28-day follow-up visit.

A total 147 patients were included in the analysis, the study authors said, with 59 in the pre- and 88 in the post-intervention groups. The majority of these patients were female (90 percent) and the median age was 26 years. Nearly half were African American and half were white. The study authors added that the median time to emergency department presentation following assault was 12 hours, and 133 of the patients that presented were candidates for nPEP. The pre- and post-intervention groups did not have significant demographic or baseline characteristics, the study authors observed.

Once the nPEP program was introduced, HIV screening on initial presentation increased from 28 percent to 95 percent, the investigators determined. Plus, adherence to appropriate performance of laboratory evaluation and administration of hepatitis B vaccine also “greatly improved,” the study authors wrote. STI prophylaxis administration was consistent in the pre- and post-intervention groups.

The study authors found that nPEP was offered and ultimately prescribed to nPEP candidates more frequently in the post-intervention group compared to the pre-intervention group. Furthermore, nPEP prescriptions were more commonly deemed appropriate in the post-intervention period.

The investigators wrote that even while 28-day follow-up for patients prescribed the nPEP prescriptions were more frequently recommended by emergency department providers in the post-intervention period, patients rarely presented for these visits in both of the groups.

“Standardization of an nPEP emergency department protocol for sexual assault patients resulted in increased nPEP administration, appropriateness of prescription, screening for STIs, hepatitis B vaccination and scheduling 1 month follow-up care,” the study authors concluded. “However, the rate of confirmed medication dispensation and follow-up remained low. We recommend implementation of nPEP programs in emergency departments to improve medical treatment for sexual assault patients.”