Prescription of Postexposure Prophylaxis for HIV-1 in the Emergency Room: Correct Transmission Risk Assessment Remains Challenging.

Abstract

Limited data are available about the accuracy of postexposure prophylaxis (PEP) prescription in the emergency rooms. Here, we evaluated PEP prescription decision making with respect to the risk of sexual HIV transmission and the exposed person's fear vis-à-vis HIV. Using a risk assessment algorithm, we retrospectively evaluated the adequacy of PEP prescription for all persons presenting at the emergency room of the University Hospital Zurich after consensual sex from 2007 to 2013. We used logistic regression to identify factors that correlate with risk-concordant and risk-discordant decisions. We documented 975 persons with a total of 1051 visits for PEP: 83% were men, 71% were Swiss, and 37% were men who have sex with men. In 74% of visits, the decisions were concordant with the risk evaluation algorithm (22% discordant, 4% unknown). In 61% (644/1051) PEP was prescribed; however, in 12% (76/644) the prescriptions were without indication of HIV transmission risk and were attributed to the exposed person's request. Importantly, in 10% (101/1051) of all visits, there were potential risks but PEP was not prescribed, either because of physician's decision or exposed person's refusal. The presence of the source partner strongly correlated with appropriately withholding PEP (adjusted odds ratio for giving PEP 0.05; 95% confidence interval: 0.03 to 0.08). We found that 22% of PEP decisions were risk discordant because of exposed person's request, incorrect estimation of the sexual transmission risk by the physician, or exposed person's refusal to accept PEP. Emergency physicians may benefit from specialized risk assessment training and patients from education in HIV transmission risk awareness.