Research shows a need for post-exposure advice
May help reach those who need counseling
A San Francisco study of a telephone hotline for people who may have been exposed to HIV through nonoccupational risk behavior shows that there is a reasonable demand for post-exposure prophylaxis (PEP).
For purposes of a randomized PEP counseling study, investigators monitored a PEP telephone and counseling line that received nearly 1,000 calls within a 15-month period.1
Advertisements for the study hotline were targeted to venues that men who have sex with men (MSM) frequent, including organizations that provide medical services, says Michelle Roland, MD, assistant professor of medicine at the University of California, San Francisco (UCSF) Positive Health Program at San Francisco General Hospital.
Callers who were able to meet with study staff could participate in the study. While the study offered counseling and HIV prevention, as well as PEP prescriptions, the majority of callers who had qualified and agreed to participate in the study received a PEP prescription. The prescription often was provided by telephone because the caller was unable to meet with the study staff on the same day that the call was made, she says.
"We provided PEP in conjunction with [two or five] sessions of risk-reduction counseling because one of the biggest concerns about PEP is that people might rely on a secondary biomedical intervention and be less diligent about primary prevention, and we really want to help people stay safer in the future," Roland says.
The PEP intervention targeted MSM who are at high risk for HIV infection through advertising directed specifically to this audience, she says. "We did outreach to organizations that provide medical services to [MSM]; and as a result of that targeted outreach, we definitely were able to access the kind of people we thought would be most likely to benefit from PEP."
"What was important to me . . . is we were able to provide a service through our studies over the years, and the time to continue to do these studies is coming to an end in San Francisco," Roland adds. "So there’s going to be a vacuum created when we stop doing these studies."
The study concluded that the majority of exposures from callers to the study line merited PEP prescriptions and providing PEP may help reach high-risk people for prevention counseling.1
A national PEP service could provide technical assistance to health care providers, but it would take local PEP interventions targeting at-risk populations to replicate the services and success of the San Francisco intervention, Roland says.
Considerations in starting a PEP intervention service include the following:
- "How will you provide rapid access? Will you have a telephone number, drop-in service?" Roland asks.
- What criteria will you develop to determine eligibility based on potential exposure to HIV?
- What kind of medical monitoring will be necessary, such as HIV, hepatitis, and sexually transmitted disease testing?
- How will a partnership be formed with local mental health services?
- What comprehensive prevention and risk-reduction counseling and education will be provided?
"You can’t make PEP too easy — where someone can come in and do whatever they want and then take pills without getting any counseling," Roland says. "This is a serious thing — not a morning-after pill. Our goal is to keep people HIV negative now — but also in the future, so the bigger issues need to be addressed."
- How much will the PEP program cost, and how will it be funded?
It’s estimated that a 28-day course of antiretrovirals for a single exposure to HIV could cost between $600 and $1,000.2
The San Francisco PEP study prescribed Combivir for 90% of the PEP cases, Roland says. The cost is a drawback to making PEP readily available because the actual risk of becoming infected with HIV after a single episode of penile-anal sexual exposure is estimated to be very low, from 0.1% to 3%.2,3
Roland and co-investigators began to study PEP services after the 1996 health care worker study was published and occupational guidelines were changed. "The first question we tried to tackle was should we do an efficacy study, and that was problematic because we didn’t think a randomized control study would be ethical, so instead we did a feasibility study.
"We showed that people with high-risk exposures sought the PEP and had a lot of symptomatic side effects, such as fatigue, nausea, and headache, but no lab abnormalities," she says. "They adhered well, and there was a reduction in self-reported risk behavior at six and twelve months."
Although the earlier study did not attempt to analyze the efficacy of PEP, investigators noted that there were no new HIV infections within the first six months following the PEP consultation, and in the second six months, there were four seroconversions, all related to ongoing exposures, Roland says.
References
1. Roland M, Coates T, Robillard H, et al. Demand for a Nonoccupational post-exposure prophylaxis telephone study referral line exceeds resources. Presented at the 10th Conference on Retroviruses and Opportunistic Infections, Boston; February 2003. Poster 905.
2. Management of possible sexual, injecting-drug use, or other nonoccupational exposure to HIV, including considerations related to antiretroviral therapy. MMWR 1998; 47(RR-17):1-12.
3. Mastro TD, de Vincenzi I. Probabilities of sexual HIV-1 transmission. AIDS 1996; 10(suppl A):S75-S82.
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