Editor's note: This article concerns Post-Exposure Prophylaxis, or PEP, a treatment for individuals who may have been exposed to HIV. In early April we will discuss PrEP, or Pre-Exposure Prophylaxis, an experimental treatment for men who are likely to be exposed to HIV at some point in the future. We invite RealJock readers to check back for more on this important gay men's health topic.
You may have heard about PEP, or Post-Exposure Prophylaxis. It is often referred to as the gay man's morning-after pill. But is that accurate? And how well does PEP really work? Well. Let's imagine a scenario. Let's suppose you went out last night and had a few drinks and met a cute guy. And let's say you screwed up (pun intended), and had unprotected sex, and that you have reason to suspect that your partner was HIV positive. You've got two options. One: bury your head in the sand and pretend it never happened, thus effectively rolling the dice with your own HIV status. Or, two: take a course of medication that may reduce your risk of getting HIV by more than 80 percent. Yes, really. Any gay man should know about post-exposure prophylaxis, or PEP, and the issues surrounding it. And that's why we spoke to Dr. Raphael Landovitz, MD, an Assistant Professor in the Division of Infectious Diseases at the Center for Clinical AIDS Research & Education at the University of California, Los Angeles, who is a leading expert conducting research on PEP. He tells us that PEP is a powerful option—if you can get it.
What is PEP?
PEP stands for Post-Exposure Prophylaxis. It's essentially an after-the-fact treatment for potential HIV exposure due to unsafe sex. It is a cocktail of AIDS medications administered within a short window of a potential exposure, over a period of time (more on that below). And, though it is a recent hot topic of conversation, it is actually an idea that has been around for quite a while. "Back in the eighties," Landovitz recounts, "when hospital workers got exposed, say in an accidental needle-stick, they started PEP by taking AZT, a first-generation HIV drug." So this practical hospital solution effectively formed a real-life experiment. The results? Landovitz goes on: "One study published in 1997 in The New England Journal of Medicine showed that even though there was no single protocol—that is, different intervals elapsed after the exposure, and the amount of blood exposure was different in each case, and all the medical personnel were treated for different lengths of time—well, despite all these inconsistencies, the people who got AZT had an 81 percent lower risk of infection." That is, obviously, a hugely significant effect.
In fact, PEP may be even more effective than that original study suggests. At the time, Landovitz says, AZT was the standard drug used; now doctors use a mixture of two or three drugs and, he says, since the newer combinations have not been studied for efficacy in this context, there is a distinct possibility that they are even more effective than AZT was a decade ago. In short: PEP is potentially extremely powerful intervention, and a possible way to ameliorate a moment of weakness or a one-time mistake.
The one-night mistake is exactly the context in which PEP is typically used. "Most of the people I prescribe this for," Landovitz says, "are one-time slip-ups. It's guys who got drunk or used crystal meth and had sex. Or guys in a relationship where one is positive and the other isn’t, and a condom broke. Really, the prevalence of HIV in the MSM [men who have sex with men] community is high enough that PEP is probably worth doing even if you don't know the status of that one-time partner. The same thought process would be true if you have had sex with, or shared needles with an IV drug user, or a sex worker." Beyond that, however, Landovitz points out that, "It's a difficult issue to risk-stratify, given the problems of access to that so-called ‘source’ person—they’re often not around to be tested, so there are many unknowns." Did this all sound too good to be true? That's because, for now, it is. Here are some of the problems with PEP.
PEP appears to have the potential to revolutionize HIV/AIDS prevention, by providing a post-exposure intervention. There are, however, some substantial obstacles to the widespread use of PEP that threaten to keep this option out of the reach of the average person.
- Recognizing the need: Guys who go out and have unprotected sex often don't know the status of their partner for the night. In the event of a slip-up, this leads to what Landovitz calls "a complicated decision tree." How do you calculate your risk in the absence of information? Likewise, people need to be educated in the existence of PEP and know to go in search of it. You will not find it easy to acquire it easily and quickly when you need it. For more on that, read on.
- Getting access: Let's assume you decide you have reason to make use of PEP. Now you need a doctor—and not just any doctor. As Landovitz points out, you need "a doctor who knows what to do, how to do it, and is comfortable prescribing it." Not just that, but you need to get in to see this doctor fast. Landovitz says, "Animal studies suggest that the sooner you give the meds the more likely you are to be able to stop the infection. And most guidelines estimate the window at 72 hours. After 72 hours, it's probably not worth doing." Time is of the essence.
- Footing the bill: PEP is no simple morning-after pill. "Again," Landovitz says, "animal studies for length of treatment suggest you need to take PEP for 28 days. So it's not as 'simple' as the morning-after pill for pregnancy." Not by a long shot. Landovitz estimates the monthly cost of these medications at over 1,000 dollars if not covered by insurance, and even with insurance, co-pays for medications can be upwards of 45 dollars per prescription.
Researching PEP Access
Landovitz summarizes the situation of PEP thusly: "The CDC [Centers for Disease Control] and DHHS [Department of Health and Human Services] endorse the use of this intervention technology in high risk settings, as do state agencies including the California state Office of AIDS. Even the World Health Organization (WHO) has written on this treatment endorsing its use, but many doctors and patients don't know about it, and there are huge roadblocks to accessing it." Landovitz is not happy with the current state of affairs with regards to access and implementation: "I don’t know exactly how to solve this, but I believe there is a responsibility of Public Health and policy makers to assure access to a intervention that has over 80 percent efficacy. And while there hasn’t been a lot of interest, we’re making some slow but important advances."
How much interest? Try this. Landovitz's research in Los Angeles has focused on access to PEP, given the complex health provision system in LA, which covers not only a public (county) and private health-care system, but a sprawling geography that includes a huge number of different communities (from African-American to Latino to more traditionally “gay-identified” West Hollywood), many with different norms, customs, and even languages. So, Landovitz ran a study surveying 213 health care provision sites to see if they knew about PEP, whether they would provide it, and, if they would, whether they would offer it to the uninsured. The results were, well, depressing.
Of the 213 sites surveyed, Landovitz says, "Only 117 would actually talk to us at all. And of those, only 17 sites said that they would offer PEP at all. Of those 17, only seven would be willing or able to provide PEP to an uninsured person." That's a miniscule eight percent of the sites who would aid the uninsured and, Landovitz says, "They were mostly emergency rooms at hospitals, where the wait is long, care is not individual, and where in LA, most emergency rooms, and especially those in the county system are already overwhelmed. So, we've seen patients turned away on the grounds of 'this is not an appropriate use of the ER.'" In other words, some of those emergency rooms say they will prescribe PEP, but actually getting it may be another story.
But let's suppose you are fortunate enough to get into one of these emergency rooms and get a prescription. Well, Landovitz says, that often only puts you back at the starting line. "Often emergency rooms will only give a three or four-day starter package, and leave people on their own to find the rest of the 28 days of treatment. So again, you need a doctor, a prescription, insurance—and, in California, to qualify for the state ADAP (AIDS drug-assistance program), you need to already be HIV+!" This is the height of frustration.
In order to address the problems of access, Landovitz is part of a group that recently received funding for a one-year pilot program to deliver PEP at community-based sites in Los Angeles, hopefully beginning in July of this year. At that point, he hopes to have two PEP-administering locations. "As of right now," he says, however, "the PEP situation in general is really frustrating, and many of us are trying desperately to think creatively about how to get education and access to the right individuals."
We (and Landovitz) wish there were better news on this. The existence of PEP is a potentially extremely potent weapon in the war on HIV/AIDS, but it’s really not new—it’s more of “Cinderella’s Ugly Stepsister of HIV prevention,” says Landovitz, “It’s not sexy, it’s not new, so the interest is disappointingly sparse. We’re banging the drum pretty loudly in Los Angeles. We’re very excited about our community-based PEP delivery program which is hopefully going live this summer. Stay tuned.” Unfortunately, until access is substantially improved, PEP is likely to remain largely a secret weapon, available only to the privileged, or to people who can get to one of the rare public programs in a tiny number of urban centers. If you have a liking for public health advocacy, this is an issue that is worth some of your time and energy.