Risks when the index’s HIV status is unknown | Right Decisions

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PEP after sexual exposure - information for clinicians
Risks when the index’s HIV status is unknown

Announcements and latest updates

Welcome to the Right Decision Service (RDS) newsletter for August 2024.

Contingency planning for RDS outages

Following the recent RDS outages, Tactuum and the RDS team have been reviewing the learning from these incidents. We are committed to doing all we can to ensure a positive outcome by strengthening the RDS to make it fully robust and clinically resilient for the future.

We would like to invite you to a webinar on 26^th September 3-4 pm on national and local contingency planning for future RDS outages. Tactuum and the RDS team will speak about our business continuity plans and the national contingency arrangements we are putting in place. This will also be a space to share local contingency plans, ideas and existing good practice. We would also like to gather your views on who we should send communications to in the event of future outages.

I have sent a meeting request for this date to all editors – please accept or decline to indicate attendance, and please forward on to relevant contacts. You can also contact Olivia.graham@nhs.scot directly to register your interest in participating.

2.National IV fluid prescribing calculator

This UK CA marked calculator is now live at https://righdecisions.scot.nhs.uk/ivfluids . It has been developed by a multiprofessional steering group of leads in IV fluids management, as part of the wider Modernising Patient Pathways Programme within the Centre for Sustainable Delivery. It aims to address a known cause of clinical error in hospital settings, and we hope it will be especially useful to the new junior doctors who started in August.

Please do spread the word about this new calculator and get in touch with any questions.

New toolkits

The following toolkits are now live;

Gender identity healthcare: adults and young people standards. (https://rightdecisions.scot.nhs.uk/genderidentity ) Note that this toolkit includes self-evaluation forms for each standard. A Scottish Government launch of these standards, together with the toolkit and NES educational resources, is planned for 3^rd September.
Care Inspectorate staffing method framework.
Vascular surgery pathways from the Modernising Patient Pathways Programme within the Centre for Sustainable Healthcare Delivery.

Updated guidance on current and future Medical Device Regulations

We have updated and simplified this guidance within our standard operating procedures. We have clarified the guidance on how to determine whether an RDS tool is a medical device, and have provided an interactive powerpoint slideset to steer you through the process.

Guide to six stages of RDS toolkit development

We have developed a guide to support editors and toolkit leads through the process of scoping, designing, delivering, quality assuring and implementing a new RDS toolkit. We hope this will help in project planning and in building shared understanding of responsibilities throughout the full development process. The guide emphasises that the project does not end with launch of the new toolkit. Implementation, communication and evaluation are ongoing activities throughout the lifetime of the toolkit.

Training sessions for new editors (also serve as refresher sessions for existing editors) will take place on the following dates:

Thursday 5 September 1-2 pm
Wednesday 24 September 4-5 pm
Friday 27 September 12-1 pm

To book a place, please contact Olivia.graham@nhs.scot, providing your name, organisation, job role, and level of experience with RDS editing (none, a little, moderate, extensive.)

7 Evaluation projects

Dr Stephen Biggart from NHS Lothian has kindly shared with us the results of a recent survey of use of the Edinburgh Royal Infirmary of Edinburgh Anaesthesia toolkit. This shows that the majority of consultants are using it weekly or monthly, mainly to access clinical protocols, with a secondary purpose being education and training purposes. They tend to find information by navigating by specialty rather than keyword searching, and had some useful recommendations for future development, such as access to quick reference guidance.

We’d really appreciate you sharing any other local evaluations of RDS in this way – it all helps to build the evidence base for impact.

If you have any questions about the content of this newsletter, please contact his.decisionsupport@nhs.scot If you would prefer not to receive future newsletters, please email Olivia.graham@nhs.scot and ask to be removed from the circulation list.

With kind regards

Right Decision Service team

Healthcare Improvement Scotland

National guidelines tell us the chance of people having HIV with a detectable viral load. Some people have a higher chance than others for example men who have sex with men, people who have come to live in the UK from countries where HIV is a lot more common (particularly sub Saharan Africa) and some people who inject drugs.

For example a man who has sex with men in England is thought to have around a 1 in 43 chance of having HIV with a detectable viral load. For heterosexual men and women in the UK who are not of Black African ethnicity the chance is about 1 in 5,000 and 1 in 10,000. For heterosexual men and women in the UK who are Black African ethnicity the chance is about 1 in 172 and 1 in 114.

If it is not known if the index has HIV but is either

from a country of high prevalence particularly sub Saharan Africa - country specific HIV prevalence can be found within the UNAIDS epidemic and response data
a man who has sex with men
a person who injects drugs from high risk countries particularly Eastern Europe and Central Asia – HIV prevalence within people who inject drugs is available from the UNAIDS key populations data.

and

if the patient received anal sex without a condom (or the condom burst/came off) PEP is normally recommended
If the patient gave (insertive) anal sex or received vaginal sex without a condom (or the condom burst/came off) then the following factors should be taken into account:
- breaches in the mucosal barrier such as genital ulcer disease or trauma following sexual assault or first intercourse
- multiple episodes of exposure within a short period of time eg group sex
- sexually transmitted infection in either partner
- more detailed knowledge of local HIV prevalence within the index case population

PEP may then be considered for insertive anal sex but is generally not recommended and is likely to be rarely given for receptive vaginal sex unless there are clear specific extenuating factors which increase the risk.

PEP is not recommended when the exposure is insertive vaginal sex

Proactive attempts should be made to establish the HIV status of the index partner whilst not delaying PEP.