Improving Emergency Access to Human Immunodeficiency Virus Prophylaxis for Patients Evaluated After Sexual Assault

Abstract

Introduction: Patients evaluated after sexual assault may benefit from nonoccupational postexposure prophylaxis (nPEP) to prevent infection with HIV, yet multiple barriers may prohibit nPEP delivery. The IN-STEP (Integrating nPEP after Sexual Trauma in Emergency Practice) project was designed to improve access to HIV screening and prevention for patients evaluated in the emergency department (ED) of our academic hospital after a sexual assault. Methods: The IN-STEP team identified and addressed four key areas for improvement: (1) training of ED providers to perform nPEP assessments; (2) access to HIV testing in the ED; (3) provision of nPEP medications, using a patient-centered approach; and (4) continuity of care between the ED and follow-up sites in the community. Improvements were implemented using parallel plan-do-study-act cycles corresponding to these four key areas. Results: IN-STEP resulted in significant systems improvements in HIV screening, prevention, and continuity of care. This program not only improved the care of patients affected by sexual assault but also those evaluated for HIV due to other indications. Conclusions: Involvement of a multidisciplinary leadership team, clear delineation of a patient-centered project focus, and coordination across four parallel areas for improvement were useful for completing this complex effort.

Characteristics of acute sexual assault care in New England emergency departments

“…Also, especially as patients may not have PCPs, our findings dovetail with previous literature suggesting ED clinicians find unclear or inconsistent outpatient follow‐up to be a barrier to providing high‐quality care for this patient population. 19 …”

“…Also, especially as patients may not have PCPs, our findings dovetail with previous literature suggesting ED clinicians find unclear or inconsistent outpatient follow-up to be a barrier to providing high-quality care for this patient population. 19 Our study is also novel in its exploration of barriers to the provision of high-quality acute sexual assault care and solutions to overcome as participants pointed out, many of these solutions require increased funding, and mandating care without supporting it financially has not been successful. 20 Again, the telehealth provision of sexual assault forensic examiner resources represents one avenue to address barriers as well as incorporate solutions that emerged in our study while potentially minimizing costs.…”

SANE Knowledge of HIV nPEP

“…Upon further inquiry, a significant gap in the literature concerning SANE knowledge of HIV infection and HIV nPEP evidence-based practice guidelines was identified. Current literature on the topic of HIV nPEP for victims of sexual assault surrounds risk of exposure, patient adherence, access and barriers, current practices in various states and countries, and standardized order sets (Chacko et al, 2012; Djelaj et al, 2017; Draughon et al, 2014; Draughon et al, 2015; Draughon & Sheridan, 2012; Draughon-Moret et al, 2016; DuMont et al, 2011; Krause et al, 2014; Ortega et al, 2022; Saadatzadeh et al, 2021; Segovia et al, 2023; Shipeolu et al, 2020; Silva-Nash et al, 2022). Although SANE education topics are clearly outlined and include the topic of HIV transmission and prophylaxis (IAFN, 2018; USDOJ, 2018), the assessment and retention of knowledge after nurses complete SANE training may be lacking.…”