Non-Occupational Post-Exposure Prophylaxis (nPEP) in Rural Areas – Does It Exist?

Nurses are on the front-lines of increasing access to health care and, as a nurse, my first priority is always the patient. A recent case demonstrates the importance of the role of nursing in providing needed services for patients. In this case, a young person was a victim of sexual assault resulting in HIV exposure. The MidAtlantic AETC had conducted training on post-exposure prophylaxis (PEP) and one of our participants in that training was responsible for making sure that the patient received nPEP. Despite all the training offered by the AETCs, many healthcare providers are not current with the recommendation to provide nPEP for all high-risk HIV-exposed patients as soon as possible within emergency departments (EDs) in the United States.

Subsequently, this case was brought to the attention of the AETC Rural Health Committee. An email was sent to Committee members asking if there was a good “nPEP” tool for rural ED clinicians but there seemed to be a scarcity of such tools according to committee members. 

At the next call, the Committee engaged in a discussion of the need for dissemination of information about nPEP to rural providers. Members indicated that other rural areas had similar gaps in nPEP uptake. For example, in a study of rural Georgia EDs, one of our Committee members, Harold Katner, found that 18% did not have an nPEP and STD policy, with only 9% of these EDs providing nPEP (Crow, Ahmed, Kumar, Katner, 2013). In this study, only 13% of hospitals reported consistently doing rapid HIV testing on patients seen for sexual assault. Furthermore, 18% provided no STD prophylaxis treatment. 

Members on the Committee identified a few of the recurrent reasons nPEP is not consistently recommended or provided, which included: 1) lack of referral sources post-nPEP; 2) ED clinicians are concerned about nPEP side effects; 3) erroneous assumption that rural areas "do not have a problem with HIV infection"; and, 4) turnover of clinicians in rural EDs making maintenance of clinical knowledge and practice uneven. The group decided to explore the possibility of developing an educational tool for clinical providers in rural areas to increase informed decision-making regarding nPEP, especially related to sexual assault and non-assaultive sexual exposure.   

The Rural Health Committee, comprised of members from across the continental United States, Alaska, and the U.S. Virgin Islands, reached out to the following groups for input and involvement in developing a toolkit: the International Association of Forensic Nurses, the National Center for Medical-Legal Partnership, and the National Network of STD/HIV Prevention Training Centers. Members of these organizations were all in agreement that an intervention is needed to increase nPEP use. They also provided input on approaches to use of the tool as well as content needed. After 5 months of conversations, email exchanges, edits, and additions, the toolkit was developed. It includes a pocket guide, a pen with a pull-out banner with information, a poster, and an infographic slide set.

The purpose of this toolkit is to provide guidance for a streamlined and efficient approach to prescribing nPEP and other post-sexual exposure treatments. Our hope is that it will help to increase the discussion and prescribing of nPEP to minimize HIV transmission to those with high-risk sexual exposure seeking treatment in healthcare facilities. 

 

Crow A, Ahmed T, Kumar R, Katner HP. Statewide Survey of Emergency Department Practice for Prophylaxis of Sexually Transmitted Infections in Rape Victims. Infectious Diseases Society of America, October 4, 2013, Session 137: Presentation 1138.

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