Putting PEP into practice

In the UK, in 2004, the Terrence Higgins Trust (THT) mounted an awareness-raising campaign about PEP directed at gay men.

Following the campaign, according to data from the 2005 Gay Men’s Sex Survey,¹ gay men in the UK in 2005 were almost twice as likely to be aware of PEP than they were in 2003 - an increase from 22% to 39%. Awareness of PEP significantly increased in every demographic subgroup and in every area of the country, although the rise was greatest in London and Brighton, the cities most targeted by THT’s campaign.

In the 2007 Gay Men’s Sex Survey, awareness of PEP had increased again, to 56.3%.²

The campaign also had a significant impact on the numbers of gay men seeking PEP, and the numbers of men being prescribed the drugs. In the UK, the proportion of gay men who had ever sought PEP increased significantly from 1.0% in 2003 to 1.4% in 2005 and had more than doubled to 3.4% in 2007, and the proportion who had ever actually taken PEP rose from 0.6% in 2003 to 1.2% in 2005 and 2.4% in 2007.

Seeking PEP and taking PEP rose in all demographic groups and in all areas and remained highest in London and Brighton, among men with higher numbers of sexual partners and those with higher incomes.

However, taking PEP was still rare even among the group most at risk from HIV in the UK. Although 7.5% of men not tested HIV positive said they thought they had been involved in sexual HIV exposure in the last year, only 16% of those who thought they had definitely been at risk had ever taken PEP.

A 2005 study by Sigma Research found that about one-in-six gay men who seek PEP after an HIV risk were turned away ‘inappropriately’. Sigma’s Catherine Dodds told the CHAPS conference³ that five out of 30 PEP seekers Sigma interviewed about their experiences were turned away when they sought PEP. Four of the five were denied it by A&E staff but a fifth was told flatly by a health adviser at a genitourinary medicine (GUM) clinic that ‘There was no such thing as PEP’.

In addition, three more men were turned away for PEP, but the refusals were probably appropriate as the men had not understood that they were at low risk.  There were also cases of people getting PEP inappropriately (for instance following oral sex without getting semen in the mouth).

However most gay men who sought PEP did so for good reasons. Four of the five who were turned away had had unsafe anal sex as the passive partner – in one case with someone known to be HIV-positive.

In general, however, both gay men’s awareness of PEP and their success in getting it has improved.

Another survey suggested doctors in the USA were also prescribing PEP inappropriately or misunderstood their own guidelines.⁴ The 13th Conference on Retroviruses and Opportunistic Infections (CROI) was told that the majority of calls to a helpline set up to advise doctors about non-occupational PEP against HIV were made too late. Fifty-five per cent of calls were made more than 24 hours after the patient’s exposure to HIV and 28% of them were made more than 72 hours after exposure. Only 32% were definitely made within 24 hours of the exposure.

Although the majority of calls were made by doctors, in the main they were not experienced in giving PEP. Nearly a third of calls were made from A&E departments.

Clinicians did appear to assess exposure risk reasonably accurately. Fifty-five per cent of calls were made about exposures deemed by the investigators to be ‘high risk’ and only 5% were low risk. In 30.4% of cases the source partner was known to have HIV.

A presentation from New York State at the 2006 Toronto International AIDS Conference had similar findings.⁵ PEP has been available in hospital emergency departments since December 2004 but New York guidelines state that the source partner must have HIV and that PEP will only be prescribed within 36 hours of exposure. A survey revealed that only 60% of hospitals have a protocol for prescribing PEP after what is called ‘voluntary sex’ (i.e. not sexual assault). PEP was prescribed two-thirds of the time after a report of sexual assault but only 43% of the time after voluntary sex. Thirty per cent of emergency departments, despite the state guidelines, did not prescribe PEP, only a third followed-up patients and only 23% reviewed seroconversion rates.

By 2010, a number of surveys from regional hospitals presented to the second BHIVA/BASHH conference in Manchester showed that increasing numbers of patients were seeking PEP following sexual exposure.

The studies showed that there was wide variation in the achievement of some standards, including variation in the number of patients given baseline HIV, STI and hepatitis B tests and in the number who attend for follow-up. Although adherence to prescription guidelines was improving, some patients were still being prescribed PEP when the likelihood of infection was low.

Several surveys attested to the increasing awareness and use of PEP amongst patients. Surveys from Belfast⁶ and Manchester⁷ found that requests for PEP had increased 2.5-fold in 2008/09 compared with previous years, with 8.8 requests per month at Central Manchester Hospital compared with 3.4 per month in 2007/08. The survey from Belfast found that about half of patients coming forward were gay men and this and a survey from Edinburgh⁸ reported that about 40% of partners were known to have HIV.

Some centres prescribed PEP in line with BASHH recommendations⁹ (99% was achieved in Manchester after standardised forms for assessing PEP were introduced), but in others some prescriptions were still inconsistent with guidelines. Nineteen per cent of prescriptions in Edinburgh were for non-recommended categories. Most centres prescribed over 90% of PEP within the 72-hour ‘window period’ but Belfast prescribed 17% of PEP later than this.

A survey of healthcare staff from emergency departments in Southampton and Portsmouth¹⁰ found that only 70% of staff had heard of PEP. Of those who had, 73% were aware it should be prescribed within 72 hours.

While 94% of them would correctly prescribe PEP to partners of known HIV-positive contacts, only 59% would prescribe it to a woman who came in saying she had had anal sex with a man from sub-Saharan Africa (recommended in the guidelines) while 39% would prescribe it to a man or woman who had had vaginal intercourse with a partner of unknown status (not recommended).

Completion of PEP and long-term follow-up almost never measured up to the BASHH targets, however. Whether patients completed their four-week course was frequently not documented, but completion rates amongst cases that were documented varied from 55% in Belfast to 32% in Manchester, against a BASHH target level of 75%.

Nonetheless 44% of patients in Manchester turned up for their three-month follow-up appointment and HIV test, so completion rates were probably higher. The BASHH target for three-month follow-up is 60%: three-month attendance figures in Belfast and Edinburgh were 35% and 54% respectively.

Testing people who presented for PEP for existing HIV infection was not universal. In Manchester 76% of patients were baseline-tested, rising to 95% by the end of the study period, but in Edinburgh only 44% were tested. One person tested positive at baseline in Edinburgh, as did one in Manchester, showing that pre-existing infections may be missed, and PEP unnecessarily prescribed, if baseline tests are not done.