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Anderson JC, Boakye MDS, Draughon Moret J. Patient and Provider Decision Making About HIV Postexposure Prophylaxis Following Sexual Violence: A Qualitative Analysis. J Assoc Nurses AIDS Care 2023; 34:566-581. [PMID: 37787738 PMCID: PMC10592041 DOI: 10.1097/jnc.0000000000000430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2023]
Abstract
ABSTRACT To explore patient and health care provider HIV postexposure prophylaxis (PEP) decision making following sexual assault, semistructured interviews regarding HIV PEP provision with 15 patients and 10 health care providers were conducted. A qualitative, descriptive, thematic analysis approach was used. Four themes were derived: (a) medical concerns; (b) emotional, trauma, and support factors; (c) daily medication management; and (d) ensuring access to HIV PEP. How participants described these themes and the importance placed on factors within each theme varied between the two groups. Altering provider communication so that HIV PEP discussions better align with patient decision-making factors (e.g., trauma and ability to take in information, how to manage side effects) could facilitate improvement in HIV PEP decision making following sexual assault for patients. High-level policy changes would improve HIV PEP access for sexual assault patients without necessitating the extraordinary efforts individual providers currently undertake.
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Affiliation(s)
- Jocelyn C Anderson
- Jocelyn C. Anderson, PhD, RN, SANE-A, is an Assistant Professor, Ross and Carol Nese College of Nursing, Pennsylvania State University, University Park, Pennsylvania, USA. Michelle D. S. Boakye, PhD, MPH, RN, is a Postdoctoral Fellow, Fitzpatrick College of Nursing, Villanova University, Villanova, Pennsylvania, USA. Jessica Draughon Moret, PhD, RN, is an Associate Clinical Professor, Betty Irene Moore School of Nursing at UC Davis, Sacramento, California, USA
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Draughon Moret J, Choe L, Anderson JC. Psychosocial Health Factors Among Men Reporting Recent Sexual Assault. JOURNAL OF FORENSIC NURSING 2023; 19:88-99. [PMID: 37205615 PMCID: PMC10220287 DOI: 10.1097/jfn.0000000000000428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2023]
Abstract
AIM The aim of this study was to describe psychosocial health factors in a community sample of men who sought care for sexual assault in the previous 3 months and who were recruited using Internet-based methods. METHODS The cross-sectional survey assessed factors related to HIV postexposure prophylaxis (PEP) uptake and adherence postsexual assault: HIV risk perception, HIV PEP self-efficacy, mental health symptoms, social responses to sexual assault disclosure, PEP costs, negative health habits, and social support. RESULTS There were 69 men in the sample. Participants reported high levels of perceived social support. A high proportion reported symptoms of depression ( n = 44, 64%) and posttraumatic stress disorder ( n = 48, 70%) consistent with cutoffs for clinical diagnoses. Just over a quarter of participants reported past 30-day illicit substance use ( n = 20, 29%), and 45 people (65%) reported weekly binge drinking (six or more drinks on one occasion). POTENTIAL IMPACT OF THIS WORK ON HEALTH EQUITY AND FORENSIC NURSING Men are underrepresented in sexual assault research and clinical care. We highlight similarities and differences between our sample and prior clinical samples and also outline needs for future research and interventions. CONCLUSIONS Men in our sample were highly fearful of acquiring HIV, initiated HIV PEP, and completed or were actively taking HIV PEP at the time of data collection despite high rates of mental health symptoms and physical side effects. These findings suggest that forensic nurses need not only to be prepared to provide comprehensive counseling and care to patients about HIV risk and prevention options but also to address the unique follow-up needs of this population.
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Affiliation(s)
| | - Lina Choe
- Ross and Carol Nese College of Nursing, Pennsylvania State University
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Scannell MJ, Rodgers RF, Molnar BE, Guthrie BJ. Factors Impacting HIV Postexposure Prophylaxis Among Sexually Assaulted Patients Presenting to Two Urban Emergency Departments. JOURNAL OF FORENSIC NURSING 2022; 18:204-213. [PMID: 35696421 DOI: 10.1097/jfn.0000000000000399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
INTRODUCTION Sexually assaulted patients who seek care in emergency departments are often recommended for nonoccupational HIV postexposure prophylaxis treatment. HIV postexposure prophylaxis is an effective method in preventing HIV transmission if the treatment is administered promptly and if a full 28-day course is completed. However, research has shown that only a fraction of patients who start the treatment will complete a 28-day course. Research is needed to explore factors that may be associated with compliance to postexposure prophylaxis so that interventions can be designed to address the factors that put patients at risk for noncompletion. METHODS A retrospective chart review was conducted examining 246 medical records of sexually assaulted female patients who presented to one of two urban hospitals. A number of patient and event-related factors were examined to determine whether they were associated with HIV postexposure prophylaxis adherence among patients presenting at an emergency room after a sexual assault. RESULTS Results revealed that five factors showed significant associations with sexually assaulted female patients completing HIV postexposure prophylaxis treatment. These factors include educational level, employment, health insurance, vaginal injuries, and tongue-mouth assaults. IMPLICATIONS FOR PRACTICE The results of this study represent a starting point from which to inform the development of targeted interventions such that those most at risk for nonadherence can receive additional support or services to improve HIV postexposure prophylaxis adherence.
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Affiliation(s)
- Meredith J Scannell
- Author Affiliations: Center for Clinical Investigation, Emergency Department, Brigham and Women's Hospital
| | | | - Beth E Molnar
- Institute for Health Equity & Social Justice Research, Bouvé College of Health Sciences, Northeastern University
| | - Barbara J Guthrie
- Yale School of Public Health, Department of Social and Behavioral Sciences
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Ortega B, Thayer J, Chen L, Steblin S, Mhaskar RS, Straub DM. nPEP protocol implementation and evaluation at a local US Crisis Center. AIDS Care 2022; 34:1268-1275. [PMID: 34338091 DOI: 10.1080/09540121.2021.1957079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Non-occupational Post-Exposure Prophylaxis for HIV (nPEP) is recommended by the CDC for isolated exposures that pose "substantial risk" for HIV transmission. To combat multiple barriers to nPEP utilization, a comprehensive program was developed through the local community sexual assault provider. The purpose of this study was to evaluate nPEP protocol implementation. A retrospective chart review was conducted of all sexual assault victims seen during a six-month period, and all patients who accepted nPEP were selected for follow-up phone interviews. 157 patients presented during the study period. Mean time to care was 32.4hrs, with 126/157 (80%) presenting ≤72hrs. 114/157 (73%) patients were offered nPEP by providers. 67/114 (59%) patients accepted, with the most common reason for declining being needing more time to decide. 10/13 (77%) patients able to be contacted reported completing nPEP, with side-effects cited as the most common noncompletion reason. 9 reported side effects and 4 received recommended follow-up HIV testing. 83/99 (84%) patients clearly eligible by chart review were offered nPEP, suggesting good adherence to CDC guidelines. Most patients contacted completed nPEP despite side-effects, suggesting good adherence. Our findings demonstrated multiple points status post-sexual assault to potentially improve the nPEP process.
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Affiliation(s)
- Briana Ortega
- Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | | | - Liwei Chen
- Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | | | - Rahul S Mhaskar
- Morsani College of Medicine, University of South Florida, Tampa, FL, USA
| | - Diane M Straub
- Morsani College of Medicine, University of South Florida, Tampa, FL, USA
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Saadatzadeh T, Salas NM, Walraven C, Sarangarm P, Crandall CS, Crook J, Sarangarm D, Yaple C, Stafford A, Wilson CG, Page K, Carvour ML. Improving Emergency Access to Human Immunodeficiency Virus Prophylaxis for Patients Evaluated After Sexual Assault. J Healthc Qual 2021; 43:82-91. [PMID: 32195742 PMCID: PMC7501159 DOI: 10.1097/jhq.0000000000000260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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.
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Draughon Moret JE, Sheridan DJ, Wenzel JA. "Reclaiming Control" Patient Acceptance and Adherence to HIV Post-Exposure Prophylaxis Following Sexual Assault. Glob Qual Nurs Res 2021; 8:23333936211046581. [PMID: 35187201 PMCID: PMC8851138 DOI: 10.1177/23333936211046581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 08/27/2021] [Indexed: 11/17/2022] Open
Abstract
Sexual assault is an irrefutable trauma; an insult to the autonomy of the person forced into sexual acts. Sexual assault sequelae range from physical injury and acute traumatic stress, to pregnancy and sexually transmitted infections, including human immunodeficiency virus (HIV). HIV post-exposure prophylaxis (HIV PEP) following sexual assault may decrease the likelihood of HIV transmission. Many patients seeking healthcare post-sexual assault either do not initiate HIV PEP or do not complete the 28-day medication regimen. In this qualitative interpretive description, we interviewed sexual assault patients (N=11) about HIV PEP discussions/reactions, attitudes and understanding related to HIV and PEP, and barriers and facilitators of HIV PEP acceptance and adherence. Participants described a process of losing and reclaiming control throughout post-assault care and follow-up; and how this affected HIV PEP-related decision-making. Most HIV PEP decisions were described as a process of reclaiming control over one outcome while simultaneously losing control of another.
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Affiliation(s)
- Jessica E Draughon Moret
- Faculty of the Betty Irene Moore School of Nursing in Sacramento, University of California Davis, Davis, CA, USA
| | - Daniel J Sheridan
- Faculty of the School of Nursing in Baltimore, Johns Hopkins University, Baltimore, MD, USA
| | - Jennifer A Wenzel
- Faculty of the School of Nursing in Baltimore, Johns Hopkins University, Baltimore, MD, USA
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Santa Maria DM, Breeden K, Drake SA, Narendorf SC, Barman-Adhikari A, Petering R, Hsu HT, Shelton J, Ferguson-Colvin K, Bender K. Gaps in Sexual Assault Health Care Among Homeless Young Adults. Am J Prev Med 2020; 58:191-198. [PMID: 31859174 PMCID: PMC11006393 DOI: 10.1016/j.amepre.2019.09.023] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 09/16/2019] [Accepted: 09/17/2019] [Indexed: 01/16/2023]
Abstract
INTRODUCTION Young adults experiencing homelessness are at increased risk for sexual assault. Receiving a post-sexual assault examination has important implications for HIV and unintended pregnancy prevention; yet, utilization is not well understood. In a population at elevated risk for HIV, unintended pregnancy, and sexual violence, identifying barriers and facilitators to post-sexual assault examination is imperative. METHODS As part of a large, multisite study to assess youth experiencing homelessness across 7 cities in the U.S, a cross-sectional survey was conducted between June 2016 and July 2017. Data were analyzed in 2019 to determine the prevalence and correlates of sexual violence and examine the correlates of post-sexual assault examination utilization. RESULTS Respondents (n=1,405), aged 18-26 years, were mainly youth of color (38% black, 17% Latinx) and identified as cisgender male (59%) and lesbian, gay, bisexual, or queer (29%). HIV risks were high: 23% of participants had engaged in trade sex, 32% had experienced sexual assault as a minor, and 39% had experienced sexual exploitation. Young adults reported high rates of sexual assault (22%) and forced sex (24%). Yet, only 29% of participants who were forced to have sex received a post-sexual assault examination. Latinx young adults were more likely than other races/ethnicities to receive post-assault care. Participants frequently said they did not get a post-sexual assault exam because they did not want to involve the legal system and did not think it was important. CONCLUSIONS Interventions are needed to increase use of preventive care after experiencing sexual assault among young adults experiencing homelessness.
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Affiliation(s)
- Diane M Santa Maria
- Cizik School of Nursing, University of Texas Health Science Center at Houston, Houston, Texas.
| | - Khara Breeden
- Texas County Forensic Nurse Examiners, Houston, Texas
| | - Stacy A Drake
- Cizik School of Nursing, University of Texas Health Science Center at Houston, Houston, Texas
| | - Sarah C Narendorf
- Graduate College of Social Work, University of Houston, Houston, Texas
| | | | - Robin Petering
- Suzanne Dworak-Peck School of Social Work, University of Southern California, Los Angeles, California
| | - Hsun-Ta Hsu
- School of Social Work, University of Missouri, Columbia, Missouri
| | - Jama Shelton
- Silberman School of Social Work at Hunter College, New York, New York
| | | | - Kimberly Bender
- Graduate School of Social Work, University of Denver, Denver, Colorado
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Djelaj V, Patterson D, Romero CM. A Qualitative Exploration of Sexual Assault Patients' Barriers to Accessing and Completing HIV Prophylaxis. JOURNAL OF FORENSIC NURSING 2017; 13:45-51. [PMID: 28525428 DOI: 10.1097/jfn.0000000000000153] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Sexual assault patients may encounter barriers when accessing, accepting, and completing nonoccupational postexposure prophylaxis (nPEP), such as lacking insurance or an understanding of nPEP. However, less is known about how sexual assault forensic examiner (SAFE) programs' protocols, approaches to discussing nPEP, and community resources may influence nPEP completion. Utilizing a qualitative case study framework, we conducted semistructured interviews with 10 SAFEs from an urban SAFE program in which emergency department physicians write prescriptions for nPEP before sending patients to the SAFE program. The participants identified barriers encountered by their patients, ranging from emergency department providers inconsistently offering prescriptions for the correct medication, to difficulty locating a local pharmacy stocking nPEP. The SAFEs also expressed concern that uninsured patients had to complete additional steps to access nPEP, while feeling overwhelmed by the immediacy of their assaults. Several participants raised concern that patients' emotional distress and fear of acquiring HIV may impede their ability to comprehend information and access nPEP. Participants also noted that the 28-day nPEP regimen might be a daily reminder for patients of the sexual assault. The SAFEs identified multiple strategies for discussing HIV and nPEP with these patients. Implications of the SAFE's role in reducing barriers are discussed.
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Affiliation(s)
- Valentina Djelaj
- Author Affiliations: School of Social Work, Wayne State University
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Seña AC, Hsu KK, Kellogg N, Girardet R, Christian CW, Linden J, Griffith W, Marchant A, Jenny C, Hammerschlag MR. Sexual Assault and Sexually Transmitted Infections in Adults, Adolescents, and Children. Clin Infect Dis 2016; 61 Suppl 8:S856-64. [PMID: 26602623 DOI: 10.1093/cid/civ786] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Survivors of sexual assault are at risk for acquiring sexually transmitted infections (STIs). We conducted literature reviews and invited experts to assist in updating the sexual assault section for the 2015 Centers for Disease Control and Prevention sexually transmitted diseases (STD) treatment guidelines. New recommendations for STI management among adult and adolescent sexual assault survivors include use of nucleic acid amplification tests (NAATs) for detection of Trichomonas vaginalis by vaginal swabs; NAATs for detection of Neisseria gonorrhoeae and Chlamydia trachomatis from pharyngeal and rectal specimens among patients with a history of exposure or suspected extragenital contact after sexual assault; empiric therapy for gonorrhea, chlamydia, and trichomoniasis based on updated treatment regimens; vaccinations for human papillomavirus (HPV) among previously unvaccinated patients aged 9-26 years; and consideration for human immunodeficiency virus (HIV) nonoccupational postexposure prophylaxis using an algorithm to assess the timing and characteristics of the exposure. For child sexual assault (CSA) survivors, recommendations include targeted diagnostic testing with increased use of NAATs when appropriate; routine follow-up visits within 6 months after the last known sexual abuse; and use of HPV vaccination in accordance with national immunization guidelines as a preventive measure in the post-sexual assault care setting. For CSA patients, NAATs are considered to be acceptable for identification of gonococcal and chlamydial infections from urine samples, but are not recommended for extragenital testing due to the potential detection of nongonococcal Neisseria species. Several research questions were identified regarding the prevalence, detection, and management of STI/HIV infections among adult, adolescent, and pediatric sexual assault survivors.
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Affiliation(s)
- Arlene C Seña
- Institute for Global Health and Infectious Diseases, Department of Medicine, University of North Carolina at Chapel Hill
| | - Katherine K Hsu
- Division of STD Prevention, Bureau of Infectious Diseases, Massachusetts Department of Public Health, Jamaica Plain
| | - Nancy Kellogg
- Division of Child Abuse Pediatrics, Department of Pediatrics, University of Texas Health Science Center at San Antonio
| | - Rebecca Girardet
- Division of Child Protection Pediatrics, Department of Pediatrics, University of Texas Health Science Center at Houston
| | - Cindy W Christian
- Child Abuse and Neglect Prevention, Children's Hospital of Philadelphia, Pennsylvania
| | - Judith Linden
- Department of Emergency Medicine, Boston Medical Center and Boston University School of Medicine, Massachusetts Massachusetts Sexual Assault Nurse Examiner Program, Massachusetts Department of Public Health, Boston
| | - William Griffith
- Women's Emergency Services, Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center, Dallas
| | - Anne Marchant
- Massachusetts Sexual Assault Nurse Examiner Program, Massachusetts Department of Public Health, Boston
| | - Carole Jenny
- Division of General Pediatrics, Department of Pediatrics, University of Washington, Seattle
| | - Margaret R Hammerschlag
- Division of Pediatric Infectious Diseases, Department of Pediatrics, State University of New York Downstate Medical Center, Brooklyn
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Nonoccupational Postexposure Human Immunodeficiency Virus Prophylaxis: Acceptance Following Sexual Assault. Nurs Res 2016; 65:47-54. [PMID: 26657480 DOI: 10.1097/nnr.0000000000000122] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Nonoccupational postexposure prophylaxis (nPEP) for HIV following sexual assault may decrease the likelihood of HIV transmission. OBJECTIVE The purpose of this exploratory chart review study was to examine factors associated with patients accepting post-sexual assault nPEP at three forensic nurse examiner programs in urban settings. METHODS Forensic nursing charts of patients presenting for acute sexual assault care were reviewed as part of a mixed-methods study. RESULTS Patients assaulted by more than one or an unknown number of assailants were over 12 times more likely to accept the offer of nPEP (adjusted odds ratio [aOR] = 12.66, 95% CI [2.77, 57.82]). In cases where no condom was used (aOR = 8.57, 95% CI [1.59, 46.10]) or when any injury to the anus or genitalia was noted (aOR = 4.10, 95% CI [1.57, 10.75]), patients were more likely to accept nPEP. Patients with any injury to the face or head were less likely to initiate nPEP (aOR = 0.32, 95% CI [0.11, 0.97]). DISCUSSION This study is an important first step in understanding factors associated with nPEP acceptance after sexual assault.
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Beekmann SE, Henderson DK. Prevention of human immunodeficiency virus and AIDS: postexposure prophylaxis (including health care workers). Infect Dis Clin North Am 2014; 28:601-13. [PMID: 25287589 DOI: 10.1016/j.idc.2014.08.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Postexposure prophylaxis (PEP), which is designed to prevent human immunodeficiency virus (HIV) infection after an exposure, is one of several strategies for HIV prevention. PEP was first used after occupational HIV exposures in the late 1980s, with the Centers for Disease Control and Prevention issuing the first set of guidelines that included considerations regarding the use of antiretroviral agents for PEP after occupational HIV exposures in 1990. Use of PEP has been extended to nonoccupational exposures, including after sexual contact or injection-drug use. This article provides a rationale for PEP, assessment of the need for PEP, and details of its implementation.
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Affiliation(s)
- Susan E Beekmann
- Department of Internal Medicine, The University of Iowa College of Medicine, Infectious Diseases SW34-J GH, Iowa City, IA 52242, USA
| | - David K Henderson
- Clinical Center, National Institutes of Health, Bethesda, Building 10-CRC, Rm 6-2551, MD 20892, USA.
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Draughon JE, Hauda WE, Price B, Rotolo S, Austin KW, Sheridan DJ. Factors Associated With Forensic Nurses Offering HIV nPEP Status Post Sexual Assault. West J Nurs Res 2014; 37:1194-213. [PMID: 24733232 DOI: 10.1177/0193945914530192] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Nonoccupational, postexposure prophylaxis (nPEP) for human immunodeficiency virus (HIV) is offered inconsistently to patients who have been sexually assaulted. This may be due to Forensic Nurse Examiner (FNE) programs utilizing diverse nPEP protocols and HIV risk assessment algorithms. This study examines factors associated with FNEs offering nPEP to patients following sexual assault at two FNE programs in urban settings. Offering nPEP is mostly driven by site-specific protocol. At Site 1, in addition to open anal or open genital wounds, the presence of injury to the head or face was associated with FNEs offering nPEP (adjusted odds ratio [AOR] 64.15, 95% confidence interval [CI] = [2.12, 1942.37]). At Site 2, patients assaulted by someone of Other race/ethnicity (non-White, non-African American) were 86% less likely to be offered nPEP (AOR 0.14, 95% CI = [.03, .72]) than patients assaulted by Whites. In addition to following site-specific protocols, future research should further explore the mechanisms influencing clinician decision making.
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Affiliation(s)
| | | | - Bonnie Price
- Bon Secours St. Mary's Hospital, Richmond, VA, USA
| | - Sue Rotolo
- Dr. Rotolo Forensic Consulting, Leesburg, VA, USA
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