Post-exposure prophylaxis (PEP) is a proven way to prevent HIV transmission after a possible exposure. Though access to PEP has been spotty, a dial-in hotline program in New York City has helped qualified patients access PEP at their local pharmacies, raising the possibility that remote screening methods could be an important way to bolster PEP use.
A detailed analysis of the New York PEP hotline program was presented at IDWeek 2018 in San Francisco by Allison Glaser, M.D., an infectious disease specialist with the Icahn School of Medicine at Mount Sinai Hospital in New York.
Notably, Glaser and her colleagues found that the hotline improved access to PEP among New Yorkers who needed it.
Even though the Centers for Disease Control and Prevention endorsed PEP in 2005, New Yorkers had reported trouble accessing it in local emergency rooms.
Time is of the essence, as PEP's effectiveness dwindles with every passing hour after a potential HIV exposure, and it can only be taken within 72 hours of exposure to be effective. In 2010, the PEP hotline was initiated with a grant from the NYC Health and Hospital Corporation. In 2015, Mount Sinai Hospital was awarded a grant from the NYC Department of Health and Mental Health to continue the PEP hotline program, to bring it to scale to help concerned New Yorkers get access to PEP as soon as possible, and to study the effectiveness of such a program.
Here's how the hotline worked: Most patients learned about the hotline by doing an internet search for what to do after a possible HIV exposure. If they called the hotline during business hours, they spoke to a trained patient navigator who would help them schedule a same-day appointment. If they called after business hours, an on-call provider would write an immediate prescription for a PEP starter pack, which patients could pick up free of charge at a local pharmacy.
To assess the effectiveness of the hotline program, Glaser and her colleagues looked at the demographics and outcomes for 1,278 callers over the course of one year. Notably, they found that 96% of callers who were prescribed PEP over the phone went to the pharmacy to pick up their prescription starter packs. Researchers found that people who called the hotline were less likely to start treatment if they were asked to come into a clinic for screening prior to picking up a prescription.
"This analysis indicates that access to PEP improved with an immediate prescription over the phone," said Glaser. When Glaser and her colleagues crunched the numbers, they found that the chances of a patient accessing PEP was 1.6 times greater if they were given a prescription over the phone rather than directed to visit a clinic.
PEP is more complex than the morning after pill for contraception, sometimes called Plan B. Instead of a one-time pill, patients take medication every day for four weeks. That's why, as part of the 24/7 hotline program, all patients were asked to visit a clinic either within a few days of picking up their starter pack or prior to starting PEP. Visiting a clinic in person also gives providers an opportunity to test for other sexually transmitted infections.
The vast majority of people who called into the hotline were gay or bisexual cisgender men. Their average age was 30 years old. In terms of race and ethnicity, callers were 40% white, 17% black, 11% Asian, and 29% Hispanic, with the remainder of ethnicities unknown or "other."
On average, people called the hotline about 31 hours after their potential HIV exposure, and nearly all exposures were from sex rather than sharing needles or workplace contact. Seventy-three percent of callers reported anal sex, 21% reported vaginal sex, 63% reported condomless sex, and 29% said the condom had failed.
Reassuringly, 90% of callers showed up for their follow-up appointments, and 19% opted to start on pre-exposure prophylaxis (PrEP).
Glaser also sought to identify possible patterns or links between the callers' backgrounds and the type of HIV exposures they reported. Overall, she found that younger patients (between the ages of 18 and 29) were more likely to have condomless sex and receptive anal sex, as well as less likely to report sex with a sex worker.
Women were more likely to say they had been raped, as well as more likely to say that they didn't know the HIV status of their partner. Male callers were more likely to know their sex partner's status.
"Compared to LGBTQ callers, more straight callers reported condom failure, vaginal sex, and not knowing their sexual partner's HIV status, and sex with a sex worker," said Glaser. "When looking at substance use, more males and white callers reported alcohol or drugs at the time of exposure."
Glaser also spoke about the potential to expand this hotline model to other cities and communities, noting that after-hours calls were a significant time burden for the on-call clinician. Overall, only a third of calls were placed during business hours.
"Night times and weekends are definitely the times when people are most sexually active," said Glaser. "So, it did end up being a lot of work for one infectious disease fellow on call."