Nonoccupational Postexposure Prophylaxis: High Attrition Rates

Sonia Nagy Chimienti, MD

Older age and self-payment were associated with failure to follow up after starting nPEP; women were less likely than men to complete the 28-day antiretroviral regimen.

Patients seeking nonoccupational postexposure prophylaxis (nPEP) following sexual or percutaneous HIV exposure often present to an emergency department (ED) for initial evaluation. Those deemed to have an exposure are provided with a few days of antiretroviral therapy (ART) and are directed to follow up in an ambulatory clinic setting within a week for further testing, counseling, and ART. Little is known about patient attendance at follow-up appointments or adherence to ART, but available data suggest adherence is poor.

In a prospective, observational study, researchers assessed frequency of follow-up among patients who received an initial supply of ART from EDs at either of two urban academic medical centers between July 2010 and June 2011. The initial follow-up appointment with an affiliated HIV clinic was scheduled for 3 to 6 days after the ED visit; additional visits were scheduled at 2 and 4 weeks and 3 and 6 months for appropriate counseling, laboratory testing for adverse reactions to ART, and screening for HIV and other sexually transmitted infections. nPEP medications were provided according to published guidelines. Individuals who did not present for the initial follow-up were contacted by telephone or mail before the anticipated completion of the ART starter pack.

Of the 180 individuals referred for nPEP follow-up (median age, 28 years; 66% women; 71% white, 14% black, 10% Hispanic), 57% had sexual exposures (72% nonconsensual; 22% involving men who have sex with men). Among the exposures that were nonsexual, 18% were related to intravenous drug use, 40% involved accidental needle sticks, and 42% were accidental mucous membrane or non-needle percutaneous exposures. Only 98 patients (54%) attended the first ambulatory nPEP follow-up visit, and only 43 (24%) of those for whom ART was recommended completed the 28-day course. In multivariate analysis, factors associated with failing to show up for the initial ambulatory clinic appointment were older age (adjusted odds ratio, 0.96; 95% confidence interval, 0.93–0.99) and lack of insurance/self-payment for services (aOR, 0.32; 95% CI, 0.11–0.97). Women were less likely than men to complete the prescribed 28-day ART regimen (aOR, 0.34; 95% CI, 0.15–0.79).

Citation(s):

Bogoch II et al. Patient attrition between the emergency department and clinic among individuals presenting for HIV nonoccupational postexposure prophylaxis. Clin Infect Dis 2014 Apr 10; [e-pub ahead of print].