METHOD

A retrospective survey was carried out of managing physicians at all UK GUM clinics using self completed questionnaires inquiring about the period from January to December 1999.

RESULTS

Questionnaires were sent to 213 GUM clinics; 132 responded with a response rate of 62%.

Requests and prescriptions for NONOPEP

Table 1 shows that the number of requests and prescriptions for NONOPEP increased fourfold and sevenfold respectively in comparison with the 1997 survey. For this study period, 242 requests for NONOPEP were reported by 56 (42%) clinics. One hundred and forty five of the requests (60%) were made to nine clinics, six of which were located in the London area.

A larger proportion of people (54%) were prescribed NONOPEP in 1999, and there was also an increase in the proportion of clinics that received requests and prescribed NONOPEP. Of the 242 requests, NONOPEP was prescribed to 130 (54%) people by 39 (70%) of the clinics. These prescribing clinics received 83% (201/242) of all requests, prescribing PEP to 65% (130/201) of them. Sixty four per cent (n=83) of the prescriptions were given by six clinics, four which were located in the London area.

Forty five of the 56 clinics (80%) that had received NONOPEP requests gave a description of the reason for the last request. Most requests came from HIV serodiscordant couples who had either had unprotected sex (13 cases, 29%) or a condom breakage during sex (10 cases, 22%). Another nine requests were after sexual assaults and seven after needlestick injuries from discarded needles or assault with a needle. Other reasons, mostly with partners of unknown HIV status, made up the remaining six requests.

The time interval between exposure and request for NONOPEP was given for 141 requests. The majority of requests were made within 48 hours of exposure. The cumulative numbers (percentages) of requests received within 4, 12, 24, and 48 hours of exposure were nine (6%), 48 (34%), 85 (60%), and 116 (82%) respectively.

Physician opinion for justification of NONOPEP

One hundred and twenty four (94%) physicians responded regarding their opinions on the clinical scenarios justifying NONOPEP. The majority are likely to offer NONOPEP to male and female sexual assault victims of known HIV positive perpetrators (see table 2).

Management of NONOPEP

When asked about preferred NONOPEP treatment regimen, over 75% (95/123) of GUM physicians would prescribe the triple combination of AZT, 3TC, and indinavir. The majority (80%) stated that the length of treatment would be 4 weeks. Sixty one per cent of clinics would not offer PEP if more than 72 hours had elapsed.

DISCUSSION

The number of NONOPEP requests and prescriptions has increased from 1997 to 1999. This may reflect a combination of increasing public and physician awareness, risky sexual behaviour, and access to PEP. There is considerable variation in the practices and opinions of GUM clinics and physicians regarding NONOPEP for HIV with differences in opinion regarding the combination of drugs for PEP, the maximum time allowed to elapse from time of exposure, and whether NONOPEP was justified at all. This is not surprising, given the lack of specific guidelines—even where guidelines exist for the management of occupational exposure to HIV there is considerable variation in practice between hospitals.⁷

Most NONOPEP requests and prescriptions originated at London GUM clinics. This is in keeping with the higher population and prevalence of HIV in the area (63% of those living with diagnosed HIV in the United Kingdom are resident in London and 67% are treated there ⁸).

Of the clinics that received requests for NONOPEP, 36% of requests were following unprotected sexual intercourse (excluding condom breakages). This proportion is surprisingly low given the concern that NONOPEP is being adopted as a mode of HIV prevention.⁹ A recent study showed that the availability of PEP was not related to an increase in high risk sexual behaviour^9,10 but recommended that ongoing surveillance was important to monitor trends. The implementation of a NONOPEP surveillance system would also be useful to determine utilisation, effectiveness, side effects, and failures of therapy.

One of the limitations of the study was the fairly low (62%) response rate. The results may be subject to bias with more physicians having an interest in NONOPEP completing the questionnaires. In addition, the reasons given for NONOPEP requests were assessed in a limited and subjective manner, relying on the physician's description of the last encounter. The description of the last request only gives a snapshot view of the reasons, and it would be more useful to know the range of reasons. The collection of such data would be facilitated with the implementation of a surveillance system, collecting data such as the number and reasons for request, whether NONOPEP was given, and completion rates and side effects of therapy.

CONCLUSIONS

The variation in the practices and opinions among GUM physicians highlights the need to develop standard guidelines to facilitate the decision whether or not to prescribe NONOPEP. If this is not possible because of a lack of consensus, the development of a standard set of questions for clinicians to ask when NONOPEP is requested would be useful. (This is broadly in line with the policy CDC has recommended in the United States.¹¹) The decision on whether or not to prescribe NONOPEP is then made in consultation with the patient.