Sexual Assault Survivors Who Get HIV Postexposure Prophylaxis Often Lost to Follow-up

By Linda Carroll

June 05, 2021

(Reuters Health) - While patients who have been sexually assaulted often welcome the post-exposure prophylaxis (PEP) medications offered in the emergency room, infectious disease clinic follow-up and documented completion of PEP tend to be low, a new study finds.

A retrospective analysis of data from more than 400 emergency department visits by sexual assault survivors found that among those who accepted the HIV-PEP, just 2.7% followed up with the infectious disease clinic within 28 days of starting the medication, and 19% returned to the emergency department for additional care within 28 days, according to the results published in the American Journal of Emergency Medicine.

"The biggest take-home message from this study is that sexual assault survivors at high risk for HIV have a high interest in HIV PEP, but there is a lot of work to be done bridging care to the outpatient setting," said the study's lead author, Dr. Stephen Liang, an associate professor of medicine and emergency medicine at Washington University School of Medicine in St. Louis.

"We do a really good job at providing acute care to survivors in the ED," Dr. Liang said. "But afterwards pulling all the pieces - medical care, psychosocial case management, victim assistance in navigating the legal system, financial assistance to pay for psychiatric counseling - together has been the biggest challenge."

To provide the best care for these patients, there needs to be better communication between medical providers and the entire network of multidisciplinary supports, Dr. Liang said.

To take a closer look at what happened to sexual assault survivors after they received HIV PEP in the ED, Dr. Liang and his colleagues performed a retrospective study of survivors who were evaluated and offered HIV PEP at the Barnes-Jewish Hospital ED between January 1, 2005 and January 1, 2018.

One barrier for sexual assault survivors who want to take HIV PEP is the high cost of the medication, but that problem was solved for the patients in the study because they were provided with a free 28-day supply of antiretroviral drugs, Dr. Liang noted.

The researchers' analysis was based on 423 ED visits by 415 unique patients whose median age was 25. The majority of the patients were female (95.5%) and nearly two-thirds (63.4%) were Black. Many were unemployed (66.3%) and uninsured (53.9%). Psychiatric comorbidities (38.8%) and substance abuse (23.6%) were common.

About 87% of the patients accepted HIV PEP (368 of 423 ED visits). Ten patients (2.7%) followed up with the infectious disease clinic within 28 days of starting HIV PEP, while 70 patients (19%) returned to the ED for care within 28 days.

Psychiatric comorbidity (Odds Ratio 2.48) and anal penetration (OR 2.02) were associated with greater likelihood of a repeat ED visit; female gender was associated with lower likelihood (OR 0.30) of repeat visit. Completion of HIV PEP was documented for 14 (3.3%) individuals.

Amanda Ringold was not surprised by the new findings.

"This is something I think every emergency department and every hospital system is dealing with," said Ringold, a nurse practitioner in the emergency department at the UPMC Magee-Women's Hospital. "A lot of people balk at the cost. I've actually been working on a project to start giving out the whole prescription, which costs us about $3,000."

"This paper is a carbon copy of what I've been going through and trying to fix," Ringold said, adding that it helps to read about others grappling with the same problem. "For example, I tried to follow 25 patients and was only able to follow-up with one."

Anyone can be a victim of assault, "but certain populations are more vulnerable, including those who are homeless, uninsured or have mental health issues," Ringold said. "Some may not have access to a phone. Or their phone is out of service. Or they have a new number."

The onus for reaching out needs to be on those who are taking care of these patients, Ringold said. "The patients just went through a big trauma and taking a medication every day is a reminder of something they want to forget," she added.

SOURCE: American Journal of Emergency Medicine, online June 1, 2021.