Preventive therapy rising for sexual exposures
Article provides how-to for providers
With dozens of general interest articles and an unofficial set of guidelines published, postexposure prophylaxis (PEP) for sexual exposure to HIV will become more prevalent, with or without federal guidelines, say AIDS experts who are studying the impact of the controversial therapy.
"Things are moving ahead, CDC or no CDC," says Kenneth Mayer, MD, director of the AIDS program at Brown University in Providence, RI, and one of a handful of AIDS researchers involved in studying the issue. "We did a provider survey in New England, and the general message was that not many providers have yet prescribed PEP, but many think they will over the next several years."
So far, there appear to have been more articles written on PEP, the most recent in the March issue of POZ, than there are patients who have been given PEP therapy. One of the first public health agencies to offer PEP has been the San Francisco Department of Public Health. In the Feb. 15th issue of the Annals of Internal Medicine, Mitchell Katz, MD, the department’s AIDS director, and Julie Gerberding, MD, MPH, director of HIV counseling and testing services at San Francisco General Hospital, published the first detailed guidance for offering PEP after sexual exposure.1
The guidelines come on the heels of the CDC’s recommendation that postexposure prophylaxis should be offered to health care workers with occupational HIV exposure — a change in stance that has acted as a catalyst for expanding preventive therapy to other exposures as well. The CDC sponsored a two-day consultants’ meeting last summer to receive input on PEP for sexual exposure. (See AIDS Alert, September 1997, pp. 97-102.) For numerous reasons, most importantly the lack of data on whether preventive therapy works with sexual exposure and concerns that such therapy would undermine safe-sex messages, the CDC has not endorsed PEP for non-occupational exposures. The agency has published a summary of the meeting on its Web site (see meeting summary in AIDS Guide for Health Care Workers, inserted in this issue), but CDC officials have said in advisory committee meetings that the CDC will publish a statement on the practice that will be limited to describing the pros and cons of PEP. (See AIDS Alert, September 1997, pp. 97-100.)
The Annals article walks clinicians through the complex requirements and issues surrounding PEP, from assessing exposure risk to choosing the appropriate therapy. One of the benefits of providing patients the opportunity for PEP is that it brings people at high risk of infection into the health care system, providing the opportunity for physician counseling on how to reduce future exposures, the authors note.
More than a year after encountering his first opportunity to use PEP (a woman had been raped by a man believed to be HIV-positive), Mayer is involved with the Massachusetts Department of Health in developing a model program for PEP at Fenway Community Health Center, which has been receiving about one call a week concerning PEP, and at Lawrence General Hospital, which has a rape crisis center and a strong outreach program for Latinos.
"We hope to have two really different places in Massachusetts, each developing expertise to be a referral center for PEP," he explains.
The program will include community education about safe-sex practices as a way of assessing whether the availability of PEP can avoid the much-feared lapse into high-risk behavior. When patients come to the center they will be asked to provide information about why they are seeking PEP, which will help determine who is most likely to use preventive therapy for sexual exposures, Mayer adds.
Another study involving HIVNET, a federally supported HIV prevention network of research centers, will conduct a randomized study of men who have sex with men. Half will receive intensive health education messages around PEP and have 24-hour access to health providers well-versed in PEP, while the other half will receive routine pre- and post-test HIV counseling with six-month follow-up meetings. The study aims to assess how different education protocols influence PEP and risk-taking behaviors.
1. Katz M, Gerberding J. The care of persons with recent sexual exposure to HIV. Ann Intern Med 1998; 306:306-311.