Questions about PEP

[Guest guest]

Dear Forum

PEP drugs do work, and the time limit and combination of drugs are all fine, but

doctors can suspect HIV transmission in case they are doing a surgical procedure

on a PLHA and they accidentally expose themselves. Similar drugs are used in

PPTCT to prevent vertical transmission. But the situation is different with

others:

1. How do we know we could have contracted the disease if it is through the

sexual route? Do we suspect we would have it each time there is unsafe sex

practiced? Impossible.

2. What about becoming drug resistant in case of using PEP eac time there is an

exposure? Doctors must be facing this problem already.

3. What about the cost of these drugs?

So, we feel there is no infringement of human rights here as no one can be sure

they have contracted the virus within the stipulated 72 hours.

Shah Rukh

E-mail<plha@...>

[Guest guest]

Hi to the Forum and in particular to Shah Rukh,

It is excellent that we are raising real questions in this forum. Real from

the perspective of the unifected in particular. I am always interested in

people's comments about why would I get a test because why would I want to

know my status?

And of course the real reason is because if you find out before your immune

system is 'stuffed', to use an aussie phrase, you can extend the quantity

and quality of your life. I can think of no better reason if anyone has had

a risk exposure that they should get tested after about a month.

The point that was being made in No. 1 is a comment about whether PEP can be

used as a morning after pill like in preventing a pregnancy after

unprotected intercourse when you thought she was on the pill but she tells

you afterwards that she hasn't been taking them or when the coitus

interuptus didn't work. Or when unprotected intercourse is a way of life.

PEP is definately not applicable for those incidents.

Where sex is concerned the most often time that PEP is prescribed is for an

accident, like the condom broke, or a crime, I was raped and he didn't use a

condom, or in the course of para medical activities where an ambulance

driver or a police officer damaged the effective skin barrier in the course

of their duties. And of course in stick or scalpel accidents or even

splashes where eye contact might occur in large quantity of infected body

fluid.

The next comment arises out of a perception of stopping and starting that

might result in drug resistance developing. Drug resistance develops when

you forget doses and the concentrations drop low enough for the medicine to

be ineffective and for the virus to learn how to neutralise the normal

protective qualities.

Stopping and starting medicine is possible without drug resistance

developing, provided of course it hasn't already developed) by doing what we

call an STI.

Here is another example of an instance where an acronym can be dangerous.

We say that you have to go through an STI.

If the patient thinks it means you have to get a sexually transmissable

infection (STI) then we have been badly misleading.

In this context we say you need to go through an STI ( a structured

treatment interruption)

In this process we might decide to stop a treatment program. The drugs are

working but either the client can't tolerate the side effects, or he is

having to have some other medical procedure which will be adversely affected

by the ARV's or the patient might just want to go on a drug holiday but

doesn't want to develop resistance, so that when things get better, he might

be able to start again.

Maybe he will be going somewhere where meds are not able to be safely

carried or used.

In this instance to stop resistance developing we examine the life of the

respective drug medicines in the body. Maybe one of the drugs in a triple

combination will have a longer effective life in the body so we would stop

that one first and then stop the other two when they will all exit the body

at the same time. In that process resistance doesn't have a chance to

develop because the concentrations just stop all together at once. That is

what happens of course with PEP in any of the above examples. It stops in

the right sequence so as to be gone before there is any chance of resistance

developing.

One of the problems India faces in this regard of course is that all three

drugs are administered simultaneously in one pill and unless the three drugs

were available separately (which of course they are) you could not structure

a treatment interruption as effectively.

It is unlikely that multiple use of PEP would occur in ordinary

circumstances. It is available as a medicine of right in our country subject

to an assessment of the risk exposure which must be done of course within 72

hours.

Sexual assault clinics would be knowing about them and knowing how

the patient can start and be briefed on the likely side effects. There is no

graphical instance where PEP has been abused in any of the dispensing

jurisdictions. I have heard people say that they never want to go through

another PEP treatment initiative but I'm never sure whether the anxiety is

about the effect of the drugs or the fear of the possible infection that

makes their experiences worse than folk who take them every day of their

lives and notice nothing of any consequence.

The last point that was raised was a point about cost. How much does it cost

to care for someone who becomes infected? What is the value of a life,

whether it be a crime victim, someone who was accidently exposed sexually, a

doctor or a public servant or allied health professional?

How much did they cost to train? How important is their continued good health?

I have some idea of what a lifetime of treatment costs and compared to a

once only PEP treatment, properly administered and correctly adherred to, it

should be seen as an investment not a cost. I know of no person in my

country who had a PEP treatment who ever sero converted. I can imagine that

some were probably not even infected in the first place. But better to be

safe than sorry.

I hoped that this will be useful as part of the understanding of how we

effectively manage HIV so that new infections disappear within a generation.

Of course it is only one small part of the learning strategy. We still need

to teach people about good safe sex or we are just chasing our tails. In

other writing I have underscored the only three behavioural ways that HIV

can be transmitted and what people need to be taught is to learn to play

safely where sex is concerned without taking any one of the risk behaviours

that cause transmission. At present we can hardly even mention the word

'sex' without a whole segment of the population falling off their perches.

That must change if we have any hope for the next sexually active generation

to say nothing of the 950 million members of the present population who are

so far still uninfected.

Since half of india's population is under 30 years of age when virility and

hormonal development peaks we need to start now not later.

Geoffrey

E-mail: <gheaviside@...>