Fact Sheet: Post-Exposure Prevention (PEP) after rape

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Fact Sheet - PEP especially after rape

What Is Post-Exposure Prevention (PEP) - especially after rape

Why PEP now?

There is still no cure for AIDS. Prevention remains the most effective way

to halt the epidemic. The best way to avoid HIV infection is to avoid expos

ure in the first place through sexual abstinence, having only uninfected sex

partners, consistent condom use, injection drug use abstinence, and consistent

use of sterile injection equipment.

However, recently we have learned a lot about treating HIV and understanding

the progression of HIV disease. Protease inhibitors used in combination with

other HIV drugs have been extremely effective in reducing the levels of

HIV in the blood and restoring health to many patients. For HIV-uninfected

persons who are exposed to HIV, there may be a window of opportunity in

the first few hours or days after exposure in which these highly active

drugs may prevent HIV infection.

A study of health care workers showed that treatment with AZT after needles

tick exposure to HIV-infected blood reduced the odds of HIV infection by 81

%. 3,4 The study was not designed to test the efficacy of AZT for post-exposure

treatment and has some limitations. Following consultations,the findings from

this study and other data led the Centers for Disease Control and Prevention

(CDC) to recommend post-exposure prevention (more commonly known as

post-exposure treatment, post-exposure prophylaxis or (PEP) for some health care

workers who are accidentally exposed toHIV-infected body fluids.

Since PEP is recommended for health care workers, it is only logical that

PEP be considered for people exposed to HIV through sex or injection drug

use, especially since these are more common sources of HIV infection.

What are components of PEP?

There are no federal recommendations governing PEP for sexual or injection

drug use exposure although the CDC is currently studying the matter. Many

physicians and clinics across the country currently offer PEP in widely varying

forms. 5 Most forms of PEP involve providing one or several anti-HIV drugs

within 72 hours of possible exposure. These drugs are then taken for a 4-6-week

period.

Before PEP is implemented, a thorough risk assessment should be conducted to

determine a patient's level and frequency of risk-taking, as well as the

HIV status of the patient's partner. Patients should be informed of the

potential side effects and difficulty taking the drugs and should be assisted to

develop strategies to successfully take the drugs as prescribed.

Partner notification and counseling can be part of a PEP program.

One of the potential advantages of PEP is the opportunity to reach and counsel

people at high risk for HIV. PEP programs should include a behavioral counseling

component to help patients develop skills for avoiding

future exposure to HIV and to deal with the fear of becoming infected.

Referrals to HIV prevention, substance abuse, medical, mental health and

housing programs should also be included to help patients address important

risk factors.

Unprotected sexual intercourse can result not only in HIV infection, but in

other sexually transmitted diseases (STDs) and unintended pregnancy.

PEP programs should offer testing and treatment for other STDs and testing for

pregnancy. STD infection has been shown to increase the risk of HIV transmission

2- to 5-fold, and treating STDs is an effective HIV prevention

intervention.

Does PEP work?

No one knows for sure. The idea of providing potent anti-HIV drugs to prevent

infection makes sense biologically, but some people believe the study of health

care workers and AZT is not definitive, and there have been no studies on PEP

for sexual or injection exposure. The potency of the new anti-HIV drugs,

however, is a compelling, if unproven, reason to offer PEP treatment after

exposure to a life threatening disease.

What are disadvantages of PEP?

One of the biggest fears about PEP is that people will return to unsafe sex

ual and drug using practices if they believe that PEP will prevent them fro

m becoming infected. There is some evidence that treatment advances, including

PEP, may be leading to increasing incidence of unsafe sex in the US.

For example, rates of gonorrhea among men who have sex with men have recent

ly increased for the first time since the early 1980s. Another fear is that

misuse of PEP drug therapies may cause a person to develop a resistant strain of

HIV. If PEP drug therapy is unsuccessful and a person does develop a

drug-resistant virus, the new anti-HIV drugs may not be as effective for

treating that person. This can occur not only with PEP,

but with any combination therapy treatment.

PEP regimens can be both complicated and prohibitively expensive to follow.

PEP drugs need to be taken at specific times of the day on a regular schedule.

About one-third of the health care workers who received PEP never finished the

regimen because of difficulty taking the drugs. Side effects of the drugs can

be severe and debilitating, and long-term effects are still unknown. A typical

dosage for four weeks can cost $600-1,000 including the medicine, blood tests

and clinic visits.

Prescribing PEP can be a complicated decision for clinicians, and should be

done on an individual basis. Many believe that a person with single case of

unprotected sexual- or needle-related exposure to an HIV+ partner would be a

good candidate for PEP. However, many people worry that providing PEP repeatedly

to a person with ongoing high-risk behavior may cause

disinhibition for unsafe sex and could also be toxic.

What programs exist?

San Francisco, CA has recently implemented a project to determine the

safety and feasibility of PEP. The study offers intensive behavioral

counseling, HIV testing and anti-HIV medication to persons who have been exposed

within the last 72 hours. The project will not look at the effectiveness of

PEP; rather it will look at whether participants comply with treatments, if

there are significant side effects, and if clients change their risk behavior

following the exposure.

Internationally, many countries are moving ahead with PEP. In France,

the Secretary of State for Health announced in August that PEP would be

made available to all accidental exposures to HIV, whether occupational,

sexual or injection. In London, England, PEP is available through clinics and

private physicians. In British Columbia, Canada, PEP is available in

emergency rooms for patients with possible exposure.

How can PEP help?

PEP can help strengthen HIV prevention strategies by serving as a

bridge between prevention and treatment, similar to STD prevention.

Traditional STD prevention includes education, testing, early treatment,

counseling, partner notification and follow-up. In San Francisco, one PEP

program is located in an STD clinic. Many people have advocated the integration

of HIV and STD strategies. PEP is a step in that direction.

No one expects PEP to be 100% effective. No prevention tool is 100% effective

for any medical condition, whether it be HIV, unwanted pregnancy or cancer. The

best prevention effort requires a " myriad of imperfect, cumulatively effective "

12 interventions. A comprehensive HIV prevention strategy uses many elements to

protect as many people at risk for HIV as possible. PEP offers the opportunity

to expand the range of prevention activities, thereby expanding the possibility

of saving lives.

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Says who?

1. Centers for Disease Control and Prevention. Backgrounder: CDC-

sponsored external consultants meeting on post-exposure therapy (PET) for

non-occupational exposures to HIV. Fact sheet prepared by the CDC.

July 1997.

2. Deeks SG, M, Holodniy M, et al. HIV-1 protease inhibitors: a

review for clinicians. Journal of the American Medical Association.

1997;277:145 -153.

3. Centers for Disease Control and Prevention. Case-control study of

HIV seroconversion in health-care workers after percutaneous exposures to

HIV-infected blood-France, United Kingdom, and United States, January

1988-August 1994. Morbidity and Mortality Weekly Report. 1995;44:929-933.

4. Cardo DM, Culver DH, Ciesielski CA, et al. A case-control study of

HIV seroconversion in health care workers after percutaneous exposure. New

England Journal of Medicine. 1997;337:1485-1490.

5. Zuger A. `Morning after' treatment for AIDS. The New York Times.

June 10, 1997.

6. Katz MH, Gerberding JL. Postexposure treatment of people exposed

to the human immunodeficiency virus through sexual contact or injection-drug

use. New England Journal of Medicine. 1997;336:1097-1100.

7. Wasserheit JN. Epidemiological synergy. Interrelationships between

human immunodeficiency virus infection and other sexually transmitted

diseases. Sexually Transmitted Diseases. 1992;19:61-77.

8. DK. Postexposure treatment of HIV-taking some risks for

safety's sake. New England Journals of Medicine. 1997;337:1542.

9. Dilley JW, Woods WJ, McFarland W. Are advances in treatment

changing views abou high-risk sex? (letter). New England Journal of Medicine.

1997;337 :501-502.

10. Centers for Disease Control and Prevention. Gonorrhea among men

who have sex with men-selected sexually transmitted diseases clinics, 1993-

1996. Morbidity and Mortality Weekly Report. 1997;46:889-892.

11. Perlman D. Morning-after HIV experiment starts in SF. San

Francisco Chronicle. October 14, 1997.

12. Cates W. Contraception, unintended pregnancies, and sexually

transmitted diseases: why isn't a simple solution possible? American Journal of

Epidemiology. 1996;143:311-318.

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Prepared by Pamela DeCarlo*, J. Coates, PhD* *CAPS, UCSF

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Rproduction of this text is encouraged; however, copies may not be sold, a

nd the Center for AIDS Prevention Studies at the University of California S

an Franciso should be cited as the source of this information. For addition

al copies of this and other HIV Prevention Fact Sheets, please call the Nat

ional AIDS Clearinghouse at 800/458-5231. Comments and questions about this

Fact Sheet may be e-mailed to FactsSheetM@p... A9 December 1997, University of

California