Pep.chapsonline.org.uk

As drug-resistant HIV strains become
What would need to change
more common it will increasingly
if PEP for sexual exposure
1. HIV Post-Exposure Prophylaxis: Guidance from
impact on PEP’s effectiveness and
was to become more widely
the UK Chief Medical Officers’ Expert Advisory
Group on AIDS (Dept of Health guidelines on PEP
the need for resistance-testing of
available?
for occupational exposure; revised February 2004); ‘source’ individuals.
available at: www.advisorybodies.doh.gov.uk/eaga/ prophylaxisguidancefeb04.pdf (includes details of Won’t demand for PEP
drugs prescribed for PEP and side effects).
2. Guidelines for PEP following sexual exposure will
be available from the British Association for Sexual Health & HIV and its web site www.bashh.org outside populations seen as ‘high risk’.
3. Of 702 individuals in a Californian study receiving
PEP following possible sexual or IV drug-use • It is important that community
exposure 7 people (or 1%) went on to become based organisations both “sell”
infected. All 7 were gay men receiving PEP and advocate for the BASHH
following receptive anal intercourse (average timebetween exposure and first PEP dose was 45.5 guidelines. The CHAPS partnership
hours). Two of the men had poor adherence to PEP, can play a crucial role in this.
that of another was 'fair'. All 7 had unprotected anal intercourse in the 6 months prior to receiving • As part of a national programme
PEP. Between PEP starting and their sero- on PEP, mass media adverts and
conversion one reported additional high risk small media leaflets will be made
behaviour with a known HIV positive partner and 2 available. There will also be
did so with partners of unknown status. Roland ME
et al. Seroconversion following non-occupational
telephone and website-based
Post-exposure prophylaxis. Eleventh Conference
information provision.
on Retroviruses & Opportunistic Infections, San • There is a clear need for training
and development around PEP
4. Details of cohort studies of people receiving PEP
Where will the money
after sexual exposure can be found in HIV & AIDS
for PEP come from?
following sexual exposure and/or
Treatment Directory December 2002, National
the BASHH guidelines, for GUM
AIDS Manual, London pp 139-140.
practitioners, GPs, A&E departments
5. Katz M et al. Post-exposure treatment of people
and people delivering or involved
exposed to the human immunodeficiency virus
in the day-to-day implementation
through sexual contact or injection-drug use.
New England Journal of Medicine 336:1097- of HIV prevention interventions to
6. Vittinghoff E et al. Per-contact risk of human
• The CHAPS national programme
immunodeficiency virus transmission between
on PEP must be targeted at both
male sexual partners. American Journal of
high prevalence areas and high-
Will people become
risk subgroups of homosexually
7. Sick leave and loss of production due to side effects
is another factor and one Canadian study of PEP repeat users of PEP?
active men.
involving protease inhibitors estimated this added cost to be equivalent to the cost of the PEP drugs.
McLeod et al. Absenteeism adds significant cost
to HIV needlestick prophylaxis. XIV International
AIDS Conference, Barcelona, abstract TuPeE5167, 2002.
PEP, a (short-term) multi-agency specialist 8. For a cost-effectiveness analysis of the San
Francisco PEP programme see Steven D. Pinkerton et al Cost-effectiveness of Postexposure
Prophylaxis After Sexual or Injection-Drug
Exposure to Human Immunodeficiency Virus,
Archives of Internal Medicine 2004 164:46-54(http:// archinte. ama-assn.org/ cgi/ content/abstract/164/1/46).
9. Harrison LH et al. Post-sexual exposure
February 2004.
chemoprophylaxis (PEP) for HIV: a prospective
cohort study of behavioural impact. Eighth
Conference on Retroviruses and Opportunistic
Contributors: David Reid, Sigma Research, Infections, Chicago, abstract 225, 2001.
Julian Meldrum, Gay Men’s and Living Well 10. Preliminary data from the 2003 National Gay
with HIV teams at Terrence Higgins Trust, London.
Men’s Sex Survey, London, Sigma Research.
Terrence Higgins Trust 52-54 Grays Inn Road, London WC1X 8JU
Tel: 020 7831 0330 Fax: 020 7816 4552 Email: [email protected]
Website: www.tht.org.uk Helpline: 020 7242 1010 12 noon – 10pm daily
Terrence Higgins Trust is a registered charity no. 288527 Company Reg. no.1778149.
Registered in England. A company limited by guarantee
PEP: Post Exposure Prophylaxis
following sexual exposure to HIV
Post Exposure Prophylaxis (PEP) has been available to health workers exposed to HIV for many years; it
has been far less available to people exposed sexually. This briefing, primarily for sexual health promotion
workers, focuses on PEP following sexual exposure. It does not address PEP for health workers following
occupational exposure (e.g. needlestick injury or contact with blood), nor does it go into detail about drugs
prescribed for PEP. Information on these are signposted at the end of the briefing.
The first UK guidelines for PEP following sexual exposure are in development, with publication by the British Association for Sexual Health & HIV (BASHH) due in 2004 and available through the association’s web site www.bashh.org
What is PEP?
What PEP involves
possible side effects, can be found in the from 2004. Until the BASHH guidelines (2) and establish infection in the body.
following sexual exposure. It is believed or, if it does, to what extent. There are the least effective, frequently duotherapy after occupational exposure despite being times given to prevent infection following exposure after sex or IV drug taking.
those taking PEP after sexual exposure (3) How might it work?
established HIV infection may be adequate infection but is given as PEP. This mirrors detection in the blood. For PEP to prevent during this ‘window of opportunity’.
• Drugs prescribed.
delay in giving PEP the less likely it is to • Length of time between
exposure and start of PEP.
• Levels of adherence to PEP.
• Different types of exposure
(occupational or a variety
ineffective if administered later than 24 of sexual exposures).
‘source’ of infection is often unknown.
PEP’s effectiveness follow-up HIV tests offer PEP later than 24 to 48 hours.
The research
Does PEP work?
PEP in occupational settings from 2004 (1) based on ‘biological plausibility’ - i.e. it for babies born to infected women.
The risk of HIV
being passed on
exposure is not yet governed by nationally conversions among those completing PEP.
clinicians follow at their discretion, not reliable conclusions on PEP’s effectiveness. effective (and to what degree) is based on: • Biological plausibility
before the arrival of viral load-reducing (what can be expected to occur
treatments, the likelihood of transmission in the absence of firm data).
• ‘Has the person presented soon
• Existing cohort studies
enough after exposure for PEP
of people taking PEP.
to work?’
viral load it is believed the likelihood of • Studies of PEP in primates.
• ‘Was the ‘source’ HIV positive?’
• Expert opinion.
If the ‘source’ is identified as HIV positive, • Data on PEP from other settings
(e.g. use with new-born babies
of HIV-infected women).
Side effects of PEP
‘source’s’ virus strain. If the ‘source’ is uninfected, PEP is not given or is stopped.
• Insertive and receptive vaginal sex
(unless accompanied by trauma).
retroviral drugs for established infection.
• Insertive anal sex.
status of the ‘source’ individual may • Insertive or receptive oral sex.
However, factors such as viral load, skin insufficient time to produce effects such as heart disease, diabetes, liver problems the level of risk involved in each sex act.
• ‘Does the candidate for PEP have
HIV already?’
• Receptive anal sex - PEP
recommended.
lipodystrophy and serious liver damage.
• Oral sex (including receptive or
with ejaculation into the mouth)
- PEP not recommended.
• Insertive anal or insertive and
receptive vaginal sex - somewhere
considered when assessing PEP eligibility; between ‘recommended’ and ‘not
recommended’.
• Type of sex act and whether
‘insertive’ or ‘receptive’
(vaginal, anal, oral).
• Whether ejaculation
protease inhibitors are used) discontinue into the body occurred.
• Whether physical trauma (e.g.
bleeding) or violence (e.g. rape)
Under what circumstances
occurred.
of this. If the ‘source’ is of unknown is PEP given?
• Will the person be able to adhere
to 28 days of anti-retroviral
therapy and possible side effects?
only considered for receptive anal sex.
• Will the person consent to HIV
testing before PEP starts and for
follow-up tests at 1, 3 and 6
months?
How does someone get PEP?
Key factors remain how likely the ‘source’ that a ‘source’ is infected are low enough to make PEP seem not cost effective.
• ‘Yes’ 70.8%
• ‘Maybe’ 27.2%
• ‘No’ 2%
about PEP than those with low levels.
in the mainstream, gay and HIV press.
• Finding a clinic/clinician within
the necessary time period.
• Knowing which clinics/clinicians
are most likely to prescribe PEP.
• Knowing risk factors that make a
Will PEP use lead to
clinician more likely to prescribe PEP.
more drug resistant HIV?
If PEP is effective, the HIV entering the Does PEP encourage
exists cannot become drug-resistant.
willingness to say those things (truthful more sexual risk-taking?
PEP access increases sexual risk-taking.(9) these drugs. But after PEP the anti-viral more persuasive than ‘I had a casual sex taking among those who have had PEP.
no ‘memory’ behind that would interfere know.’ As with accessing health care in Is PEP cost-effective?
interventions with potential for reducing anti-retroviral treatment may also result 1) If the person given PEP already
has HIV. PEP may not be sufficient
Who knows about PEP?
therapy to suppress viral reproduction,
potentially allowing the virus to
develop resistance to the drugs used
in the PEP combination.
2) If PEP fails to prevent an infection.
Then the virus has encountered the
drugs, survived and may develop
• 0.7% have tried to get PEP
resistance. This is possible if someone
• 0.4% report taking it
does not complete the PEP course
rate the vast majority of those receiving • 4.8% know someone who has
or does not take PEP as instructed.
received it.
Alternately, if the strain of HIV
entering the body is already resistant
to any of the drugs in the PEP
• 3.1% had tried to get it
combination, PEP is more likely to
• 2.1% report taking it
fail and the person will be infected
• 22.9% know someone who has
with this drug-resistant strain.
received it.

Source: http://www.pep.chapsonline.org.uk/pdf/chaps_pep_briefing_sheet.pdf