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
for occupational exposure; revised February 2004);
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).
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’.
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
. Seroconversion following non-occupational
telephone and website-based
on Retroviruses & Opportunistic Infections, San
• There is a clear need for training
and development around PEP
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
Sick leave and loss of production due to side effects
is another factor and one Canadian study of PEP
repeat users of PEP?
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
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
chemoprophylaxis (PEP) for HIV: a prospective
cohort study of behavioural impact.
Conference on Retroviruses and Opportunistic
David Reid, Sigma Research,
Infections, Chicago, abstract 225, 2001.
Julian Meldrum, Gay Men’s and Living Well
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:
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.
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.
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
• Receptive anal sex - PEP
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
• 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
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
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.
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.
Clinical Rounds in Functional and Nutritional Medicine David M. Brady, ND, DC, CCN, DACBN (Food Intolerance) Introduction: This is the fifth in a series of Clinical Rounds , which will be appearing as a part of ND News & Review . In these Clinical Rounds real case studies from my practice will be presented. It is my aim to present interesting cases, which will f
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