Prescription of post-exposure prophylaxis for HIV-1 in the emergency room: correct transmission risk assessment remains challenging

BACKGROUND: Limited data are available about the accuracy of 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. METHODS: 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. RESULTS: We documented 975 persons with a total of 1,051 visits for PEP: 83% were male, 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 OR for giving PEP 0.05 95% C.I. 0.03, 0.08). CONCLUSION: We found that 22% of PEP decisions were risk-discordant due to 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