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The authors S Day et al1 should be commended on the performance of their department in the appropriate provision of post-exposure prophylaxis after sexual exposure (PEPSE) in accordance with BASHH
A co-ordinated post exposure prophylaxis (PEP) policy was introduced at St Mary’s Hospital, London in November 2002, comprising formal links between GUM, A&E and...
A co-ordinated post exposure prophylaxis (PEP) policy was introduced at St Mary’s Hospital, London in November 2002, comprising formal links between GUM, A&E and Occupational Health, and establishing a dedicated PEP
All patients given PEP following sexual or occupational exposures are followed up in this clinic. A retrospective notes audit3 of all clinic attendees was conducted over a 6 month period in 2003, comparing our service with outcome measures highlighted in national guidelines at the time.45
From June to November 2003, 48 patients attended. 54% had occupational exposures. Of the 46% with non-occupational exposures, 27% were sexually exposed (n=13).
Management of our PEPSE recipients has subsequently been compared with BASHH guidelines2.
85% presented for PEPSE via the GUM clinic, 15% via A&E. Demographics, sexual exposures, and attendance for follow up HIV tests, are presented in Table 1.
In 6 of the 13 sexual exposures, the partner was known to be HIV positive, 5 had untraceable partners of unknown serostatus, and in the final case the partner was traced and tested HIV negative on the day of exposure. This patient was not prescribed PEPSE.
PEPSE was in line with ‘recommended’ indications in 11 of the 12 remaining cases. One patient presented after receptive oral sex with a known HIV positive partner, and was concerned that he had bleeding gums. This fell in line with a ‘considered’ indication according to guidelines.
Hence 100% of PEPSE prescriptions fell within recommended guidelines2 (BASHH target 90%).
Time from exposure to first dose was not documented in 1 patient, the remainder received PEPSE within 72 hours (90% target); Range 13-54 hours, mean 28 hours.
100% of PEPSE recipients completed the full 28day course of standard PEP - Combivir, Nelfinavir at the time of audit, (75% target).
Our co-ordinated approach to the provision of PEP has enabled us to provide a successful service. PEPSE is easily accessible, appropriately prescribed, and high completion rates were observed, with no discontinuations related to adverse events. The high adherence rates may have been related to the continuity of seeing the same SpR in clinic
throughout the month of treatment. If appropriate, patients were also referred promptly to clinical psychology services (25% of our cohort) for further adherence support and discussion about sexual risk taking.
At the time of audit we saw comparatively few patients requiring PEPSE. Given recent media coverage, awareness of PEPSE amongst MSM in London has significantly increased – 12 patients requesting PEPSE at St Mary’s in the last 2 weeks alone.
The authors rightly suggest that a PEPSE follow up clinic and dedicated proforma would help ensure appropriate prescription, aid adherence and completion of PEPSE, and improve attendance rates for follow up serology. Certainly the success of our PEP Clinic concurs with this suggestion.
1. Post-exposure HIV prophylaxis following sexual exposure:a retrospective adduct against recent draft BASHH guidance. Day S et al. STI 2006;82:236-237
2. BASHH. United Kingdom guideline for the use of post-exposure prophylaxis for HIV following sexual exposure. Fisher M et al. Int J.STD&AIDS 2006;17:81-92
3. A co-ordinated approach to HIV Post Exposure Prophylaxis ensures appropriate and high completion rates. L. Sathia, C Collister, J Walsh. Post Presentation at 7th International Conference on Drug Therapy, Glasgow, Nov '04.
4. HIV Post exposure Prophylaxis - Guidance from the UK chief medical officers expert advisory group on AIDS Revised February 2004 - available at http://www.advisorybodies.doh.gov.uk/eaga/publications.htm
5. Clinical Effectiveness Group (British Association of Sexual Health and HIV) - United Kingdom Guideline for the use of Post-Exposure Prophylaxis for HIV following sexual Exposure available at: