The morning after

It’s no morning-after pill, but when facing the possibility of HIV exposure, PEP is the only game going.

“There’s no good study proving it works,” says Ed Lee, director of the Hassle Free Clinic, on using post-exposure prophylaxis (PEP) outside the workplace. “It may work, it may not, but it’s the best chance you’ve got.”

PEP is a treatment that decreases the chance of HIV infection through the combined use of anti-retroviral medicines. It sounds like a miraculous safety net, but it is a prevention that comes with conditions: there is a limited time period after exposure for it to be effective, it is not a surefire guarantee against infection and, outside of occupational exposure situation, it can be difficult to get access to.

Initially, PEP was only available for occupational exposures – mainly health workers, but also firefighters, police officers, paramedics, sanitation workers, and foreign aid workers – basically anyone who could be exposed to HIV in the workplace. The few studies that have been done on PEP have focussed on occupational treatment, which tends to be administered immediately after exposure. The US Public Health Service Guidelines For The Management Of Occupational Exposures cite a study finding the rate of infection is reduced by 81 percent in these cases.

But PEP is being used more and more in other situations. It may be given to newborns when the mother is HIV-positive or in cases of sexual assault. Less frequently, PEP is used after accidental needle exposure outside of the workplace, condom breakage or sex without a condom. There have been no studies done on PEP treatment in these non-occupational situations.

Lee says a proper study would require a large population base who are at risk and need PEP to follow the four-week treatment and then avoid any risky activity for another three months in order to get accurate results.

The treatment includes a four-week regime, a combination of anti-retroviral medicines, with the possible addition of a protease inhibitor to strengthen the dose. The individual drugs that make up the treatment – azidodeoxythymidine (AZT), lamivudine (3TC) and indinavir – are the same ones used to treat persons infected with HIV/AIDS and are already available in Canada.

The main problem is finding out about PEP. Many doctors don’t make the connection between the treatment used for occupational exposure versus sexual exposure – or are not familiar with HIV/ AIDS medicines. When a person is in need of PEP, there’s no time to waste on tracking it down.

Health Canada’s website indicates that PEP treatment needs to be administered within an hour or two after exposure to HIV, although Canadian AIDS Treatment Information Exchange (CATIE) says that it can still be effective up to 72 hours after exposure – but the sooner the better.

Agencies including the AIDS Committee Of Toronto (ACT), Health Canada and the Ontario Ministry Of Health And Long-term Care were unable to provide information about PEP treatment and its availability.

“I’ve never taken a call about PEP so I did a Google search on it,” says Katherine Saunders, a media relations officer for Health Canada.

Although Health Canada does have PEP information on its website, it’s linked through a section on HIV and women, sex and violence. Neither Health Canada nor the Ontario Ministry Of Health And Long-term Care could say whether PEP was readily accessible to the public, saying that it is something that individual physicians and their patients deal with.

The official word from ACT is that there needs to be more dialogue about the appropriateness and availability of PEP between healthcare providers and AIDS service organizations.

“The feeling was, we don’t have enough on it to talk about it,” says ACT’s communications coordinator Tyler Stiem. “Our line is that if you go to emergency after sexual assault or unprotected sex you can apparently get PEP, so that includes a condom break.”

Hassle Free Clinic, which does not offer PEP, also recommends going to a hospital’s emergency ward or family physician.

“The medication needs to be followed, so it’s important that the doctor who prescribes it follows it,” says Lee. “We do episodic as opposed to ongoing [treatment].”

Many private practices or hospitals do not have training about the pros and cons of PEP.

“I think people who know about it, it’s on their radar, they’ve asked,” says Lee. “But I don’t know about other people. I’m not sure whose role it should be. I think people who provide treatment information, it would be good if they had information.”

One explanation for the lack of information is that some people believe it is premature to offer PEP, as there is not enough research to substantiate its effectiveness, particularly with regard to non-occupational exposure.

“There have not been public awareness campaigns on post-exposure prophylaxis AIDS treatment on a national level,” says Paige Raymond Kovach at Health Canada.

There is also concern that widespread non-occupational use of PEP may undermine prevention efforts and reduce safer sex and safer drug-using practices. Both CATIE and Health Canada’s website make this case, and this is why medical practitioners challenge the myth that PEP is a “morning-after pill” for HIV. Aside from the fact that it is a treatment that lasts 28 days instead of one, it also offers no guarantees and has more serious side effects.

“If you talk to anyone who’s taken PEP, it’s not fun,” says Lee. “It’s fairly nasty medication.

“It’s available and expensive and ultimately, if it’s a one-off thing and a condom break occurs and your partner is HIV-positive or unknown, then it’s a good idea. If someone repeatedly doesn’t use condoms, this isn’t for them.”

* For more information about post-exposure prophylaxis go to Hc-sc.gc.ca/hppb/hiv_aids/you/-sex_violence/prophylaxis.html or call the US Centers For Disease Control And Prevention which has a PEP hotline at 1-888-448-4911.