Documents reveal details on n-PEP policy delays

LANSING — A policy to provide access to people who have been exposed to HIV to anti-retroviral medications has been stalled in the Michigan Department of Community Health’s legal department for months, documents obtained by Michigan Messenger show.

The use of anti-retroviral medications to prevent HIV infection in non-occupational exposures is called non-occupational post exposure prophylaxis (n-PEP). The Centers for Disease Control and Prevention in Atlanta has offered guidance on n-PEP since 2005, but a Michigan Messenger investigation in 2009 revealed that Michigan had no such policy to follow. Shortly after that story appeared a top MDCH official said a policy would be in place “early” in 2010. However, as Michigan Messenger reported in November, the state still did not have a policy in place.

James McCurtis, a spokesperson for MDCH, told Messenger at the time that the proposed policy was being reviewed by the legal department. But documents obtained through the state’s Freedom of Information Act show that the policy was forwarded to Deborah Garcia Luna, an attorney at MDCH, in August.

But numerous calls and emails to Luna from agency leaders were ignored, leading Robert Barrie to write on Dec. 3 to Debra Szwejda, then director of the HIV AIDS Prevention and Intervention Section, “I’m sorry she hasn’t got back to me, I can’t tell you how frustrating this has been for me. I cannot imagine why after two months I haven’t heard anything at all.”

Luna sent an e-mail to Barrie an hour later with draft changes to the document. Prior to that, Luna’s last communication to Barrie, based on the released e-mails, was October 12, when she informed Barrie she was acting Freedom of Information Act coordinator for the department and expected to get back to the document the following week.

On Dec. 16, Barrie forwarded Luna a new, more detailed policy draft. There were no further communications between Luna and Barrie released in the Freedom of Information Act request released to Messenger.

Documents released by the department show that department officials began meeting about the new policy three days after Michigan Messenger’s story on n-PEP policies first appeared. From that point, officials met a total of 10 times on the policy. Those meetings and discussions included Amna Osman, director of the Division of Health, Wellness and Disease Control and HAPIS Manager Deb Szwejda.

Even with all the focus on the document by health department staff, advocates are criticizing the policy draft as unclear.

“It’s unclear and often bounces between n-PEP and PEP,” says Mark Peterson, a spokesperson for Michigan Positive Action Coalition. The two ideas Peterson is reference are related to occupational exposure such as needle sticks which is called PEP and exposures to the virus as a result of consensual sexual behavior, sexual assault or intravenous drug use. PEP has been used in health care settings since 1987 when the FDA approved the use of AZT to treat the virus.

In both situations, doctors prescribe a 28 day course of anti-retroviral medications for the person exposed. The course of medications has to be started with in 72 hours of exposure, with success rates decreasing as the time between exposure and commencement of medication. As Michigan Messenger reported, too often n-PEP is denied or delayed by medical professionals either out of ignorance of the medication protocols or moral judgments about the source of exposure.

Messenger also found that access to n-PEP varies by location. Southeast Michigan hospitals are more likely to prescribe the medications than are other locations in the state.

The release of the documents and the lengthy delays in finishing the policy led groups that represent the lesbian, gay, bisexual and transgender community to issue calls for the department to speed up the policy development and approval process.

Emily Dievendorf, policy director for Equality Michigan, released the following statement:

Unfortunately, as the MDCH has neglected to take the necessary immediate action this important issue required, our position hasn’t changed since we released our initial statement: Equality Michigan can find no rationale or justification for the lack of a uniform protocol regarding the availability and distribution of n-PEP existing in our state. Since the CDC released their procedural recommendations in 2005, there has been a template available for the State of Michigan to use in the creation of its own n-PEP policy. While EqMI understood that creating and releasing a policy tailored to Michigan would not happen over night, bureaucracy within the Michigan Department of Community Health could not have been so tangled as to excuse a five year delay in educating Michigan health facilities about their role in using n-PEP for HIV prevention. This lack of communication translates to a lack of application that could have shielded countless individuals from HIV, ultimately saving lives.

The Michigan Department of Community Health, in absence of its own policy, had a responsibility to alert health officials and facilities to the CDC’s recommendations for the use of n-PEP. We appreciate the commitment the MDCH made to have a policy in place by early 2010, but that deadline has long since passed. For just 2009, the MDCH reported 820 new HIV diagnoses in Michigan. Equality Michigan calls on the MDCH to cut through the red tape. We need to finish what the CDC started almost 5 years ago, quickly, so that new statistics reflect Michigan’s continued commitment to the prevention of HIV and to the survival of our residents

The National Gay and Lesbian Task Force, which issued a call in November for MDCH to get the new policy out, also weighed in on the new information and the continued delays.

“The LGBT community has long fought against government inaction on HIV/AIDS. We want policies that will help prevent the spread of HIV to be implemented as quickly and safely as possible to protect all individuals regardless of sexual orientation or gender identity,” says Darlene Nipper, deputy executive director of the National Gay and Lesbian Task Force. “A year-long delay in implementing a policy modeled after a CDC recommendation made public years ago is completely unacceptable and the Michigan Department of Community Health should move immediately to implement the policy.”

MDCH officials say they are moving with all due diligence on the policy.

“We currently have a draft document. It is under review as we work to determine the best way to present that information to providers,” said Kelly Niebel, acting spokesperson for MDCH. “We want to make sure we do so in a manner that is most beneficial to providers and in sync with CDC guidelines.”

As for a time frame, Niebel says that is not set in stone yet.

“We should have something pretty well solidified in the next couple of months.” Niebel said.