[Viva] Fwd: CATIE-News - Feasibility and sustainability of providing HIV prophylaxis (PEP) after sexual assault in Canada
Tami Starlight
tamistarlight at gmail.com
Thu Jan 26 14:15:43 PST 2012
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From: <mailing at mercury.catie.ca>
Date: Thu, Jan 26, 2012 at 11:02 AM
Subject: CATIE-News - Feasibility and sustainability of providing HIV
prophylaxis (PEP) after sexual assault in Canada
To: cosmictami at shaw.ca
*CATIE-News - Feasibility and sustainability of providing HIV prophylaxis
(PEP) after sexual assault in Canada*
Sexual assault in Canada
Sexual assault is a widespread human rights concern. According to
Statistics Canada, over 22,000 cases of sexual assault were reported to
police in 2010. However, this statistic likely underestimates the true
extent of sexual assault since it’s estimated that as many as 90% of sexual
assaults in Canada are not reported to police.
Sexual assault survivors may be at risk of sexually transmitted infections
including HIV. Furthermore, certain kinds of sexual assault can
significantly increase the risk of HIV transmission, such as multiple
perpetrators, multiple sex acts, anal sex, damage to the mucous membranes
and pre-existing sexually transmitted infections.
Post-exposure prophylaxis (PEP)
Sexual assault survivors may benefit from the use of post-exposure
prophylaxis to reduce their risk of becoming infected with HIV.
Post-exposure prophylaxis (PEP) is the use of anti-HIV drugs for 28
consecutive days after a known or suspected exposure to HIV, to reduce the
risk of infection. PEP must be started within 72 hours of a suspected
high-risk exposure to HIV.
In Canada, the use of PEP after occupational exposures (such as needlestick
injuries in the workplace) is considered the standard of care and is widely
used. On the other hand, PEP after non-occupational exposures (such as
consensual sex and sexual assault) is not widely available or accessed.
The Ontario HIV PEP Study
In Ontario there is a network of 35 Sexual Assault/Domestic Violence
Treatment Centres (SA/DVTCs) across the province. These hospital-based
centres provide assessment, counselling and treatment to approximately
3,000 sexual assault survivors every year.
In 2003, the Ontario Network of SA/DVTCs implemented a program, as part of
a study, to offer HIV risk counselling and free PEP to men, women and
children after sexual assault. The program involved the development of
guidelines, protocols, counselling tools and patient handouts, as well as
the training of staff. The purpose of the program was to evaluate the
feasibility and sustainability of a province-wide HIV PEP program. The
project was funded by a grant from the Ontario Women’s Health Council,
Ontario Ministry of Health and Long-Term Care between 2003 and 2005.
Of the 34 treatment centres in Ontario at the time, 24 participated in the
program. The other 10 centres were unable to participate because of
staffing and infrastructure barriers.
In addition to counselling and support for sexual assault, sexual assault
survivors who were at “high risk” or “unknown risk” of HIV infection (as
defined by the study investigators) and who sought care less than 72 hours
after the assault, were also offered PEP. The study considered survivors to
be at “high risk” if they had had survived assaults involving anal, oral or
vaginal sex by someone who was HIV-positive or from a high-risk group
(intravenous drug users, men who have sex with men, or persons from
countries where HIV is relatively common). If the HIV status of the
perpetrator was unknown and it was not known whether the perpetrator
belonged to a high-risk group, survivors who had experienced assaults
involving anal, oral or vaginal sex were considered at “unknown risk.”
The provision of PEP included HIV risk counselling, provision of PEP
medications, and five follow-up visits over the course of four weeks. The
purpose of the follow-up visits was to help people adhere to their
medication schedules and monitor side effects. The HIV medicines used were
as follows:
- AZT + 3TC (sold as a fixed-dose combination called Combivir)
- lopinavir-ritonavir (Kaletra)
Feasibility of the PEP program
Between September 2003 to January 2005, 1103 sexual assault survivors
sought care at participating treatment centres. The majority (97%) of
participants were female and the average age was 21 years.
Of the sexual assault survivors that sought care, 900 were eligible for PEP
and 798 were subsequently offered PEP. The majority, 91%, who were offered
PEP were at “unknown risk” of HIV infection, while the remaining 9% were
considered to be at high risk of infection.
Overall, PEP was started by 347 (44%) of the sexual assault survivors who
were offered PEP. PEP was declined by some for various reasons including:
- Lack of concern about HIV (63%)
- Anxiety about side effects (45%)
- Inability/unwillingness to follow the regimen or return for follow-up
(16%)
Those deemed to be at “high risk” were more than twice as likely to start
PEP. Other factors that predicted whether someone started PEP included:
- Younger age
- Encouragement from the healthcare provider
- Moderate to high level of anxiety about HIV infection (as assessed by
the healthcare provider)
- Assaults involving a stranger or multiple sex acts
Of the people who started PEP, 236 (68%) *did not* complete the full
course of medication and follow-up visits. Reasons for not completing PEP
included the following:
- Side effects (81%)
- Interference with usual routines (42%)
- Inability to take time from work, school or other commitments (22%)
Side effects were reported by 96% of those who took PEP and attended one
or more follow-up visits. The most common side effects included:
- Fatigue (59%)
- Nausea (50%)
- Diarrhea (23%)
- Headache (21%)
- Mood changes (20%)
- Vomiting (16%)
Overall, the study suggests that the implementation of a province-wide
program of HIV PEP for sexual assault survivors is feasible. However, the
study investigators concluded that “further research is needed to determine
how best to engage participants to return for ongoing monitoring and
support” and that “ongoing evaluation of strategies aimed at increasing PEP
completion rates is clearly necessary.”
Sustainability of the PEP program
Healthcare providers involved in the study, including administrators,
nurses, physicians, social workers,and pharmacists, were surveyed about the
sustainability of the PEP program. Of the 132 healthcare providers who
completed the survey (94 of whom were nurses), the majority (65%) believed
that universal offering of HIV PEP to SA/DVTC clients was sustainable at
their hospital on a long-term basis.
However, many of the healthcare providers who believed the program was
sustainable felt that several conditions would need to be met first. These
conditions were similar to the concerns raised by healthcare providers who *did
not* believe that the program was sustainable. From the survey and
supplementary interviews, the study investigators identified four major
areas of concern to the sustainability of the program once funding for the
program finished in 2005.
1. Resources
Healthcare providers were concerned about who would pay for the PEP
medications. They were also concerned about the additional staff time
required to maintain the program, including time required to track clients
to ensure follow-up.
2. Expertise
Healthcare providers were concerned about the lack of external supports to
ensure that the PEP protocols, tools and pamphlets remained up-to-date.
Questions were also raised about who would provide ongoing training to
staff.
3. Commitment
Healthcare providers were concerned about resistance from hospital
administration and other staff to providing PEP. For example, some of the
physicians and pharmacists involved in the study did not want to follow the
protocol and prescribe/dispense PEP because they believed the risks (such
as side effects) of taking the medications outweighed the benefits.
4. Accommodation
Healthcare providers were concerned about their inability to address
specific client and community needs. For example, some sexual assault
survivors were unable to return to the hospital for follow-up visits
because they lived too far away. Also, concerns were raised about the
appropriateness of the language level used in the client information
pamphlets.
The way forward
Several important actions have been taken based on the results of the HIV
PEP study. In 2006, the Ministry of Health and Long-Term Care agreed to pay
for PEP medications at all treatment centres in Ontario. In 2007, the
protocols and tools were adapted and orientation and training of staff
began. In 2008, a permanent HIV PEP Expert Group was established to review
and revise the drug regimen, protocols and tools on an ongoing basis.
As a result of these actions, PEP after sexual assault has become the
standard of care at all 35 SA/DVTCs across Ontario. In addition, the PEP
completion rates have increased from 32% between 2003-2005 to 40% between
2006-2010. Hopefully the best practices and lessons learned from this HIV
PEP study can be adapted to other provinces and territories in Canada.
*—James Wilton*
*Further reading*
CATIE fact sheet on post-exposure
prophylaxis<http://www.catie.ca/en/fact-sheets/prevention/post-exposure-prophylaxis-pep>
CATIE *Prevention in Focus* article on post-exposure
prophylaxis<http://www.catie.ca/en/pif/summer-2010/can-we-prevent-infection-hiv-after-exposure-world-post-exposure-prophylaxis-pep>
CATIE Programming Connection case study on the nPEP program run by *Clinique
l’actuel* in Montreal <http://www.catie.ca/en/pc/program/pep-program>
Health Initiative for Men (HiM) position paper on nPEP
<http://checkhimout.ca/assets/uploads/files/PEP_Paper_rev_web_copy.pdf>
References
1. Perreault S and Brennan S. 2010 “Criminal victimization in Canada,
2009.” *Juristat*. Vol. 30. no. 2. Statistics Canada Catalogue no.
85-002-X.
2. Brennan S and Dauvergne M. 2011 “Police-reported crime statistics in
Canada, 2010.” *Juristat*. Statistics Canada Catalogue no. 85-002-X.
3. Loutfy MR, Macdonald S, Myhr T et al. Prospective cohort study of HIV
post-exposure prophylaxis for sexual assault survivors. *Antiviral
Therapy*. 2008; 13(1):87–95.
4. Du Mont J, Macdonald S, Myhr T, Loutfy MR. Sustainability of an HIV
PEP Program for Sexual Assault Survivors: “Lessons Learned” from Health
Care Providers. *The Open AIDS Journal*. 2011;5:102–12.
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Miigwetch/Thank you/Merci
*Tami M. Starlight*
Vancouver, Canada
tamistarlight at gmail.com
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cosmictami (skype)
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