by Michael Harney June, 2014
PrEP or PEP: Each a step in HIV prevention. They are points of discussion in terms of the before or after. Pre-Exposure Prophylaxis or Post-Exposure Prophylaxis; how does one decide?
Recent release by the Centers for Disease Control and Prevention (CDC) of guidelines in English and Spanish for PrEP implementation in the United accompanied by promotional materials to explain how PrEP is to be used, is intended to create increased uptake of PrEP among the variety of tools to prevent HIV infection in various segments of our population. The CDC guidelines are based on “findings from several large national and international clinical trials” at 11 sites in six countries.
Populations mentioned in the guidelines include gay and bisexual men, heterosexual men and women, and injection drug users. One study – iPrEx http://start.truvada.com/hcp/iprex-study# — included male to female transgender persons who have sex with men, but due to insufficient data, CDC does not include them in its guidelines. Logic and common sense, though, could lead a medical provider to extend PrEP to this population – if there is insurance or other coverage of the price, which exceeds $15,000 a year!
The bullet points about PrEP state that it’s a way to help prevent HIV with a pill – which must be taken every day to be most effective; and that people who are at substantial risk for HIV should talk to their doctor about PrEP. Future options being studied include long-acting nanoparticles injected monthly or every 3 months, similar to some forms of birth control.
Truvada® is the brand name of the Gilead Pharmaceuticals product currently being used for pre-exposure prophylaxis. By itself it cannot effectively treat an established HIV infection. For that, one or two additional antiretroviral medications are used in a standard regiment to suppress viral replication.
However, Truvada taken correctly and consistently each day by an HIV-negative person creates a chemical barrier in case a condom breaks and exposure to sexual fluid occurs; or if a syringe and needle are shared between two or more people (never recommended); or in general if there is exposure to semen, vaginal fluid, or blood in a sexual encounter or sexual assault. Long-term safety of PrEP for HIV-uninfected women after fetal (during pregnancy) or infant (during breastfeeding) exposure is not yet determined.
PrEP may be one of several options to help protect an HIV-negative male or female partner in a heterosexual HIV-discordant couple attempting to conceive, but this has not been formally studied, according to the U.S. Public Health Service Clinical Provider’s Supplement to the CDC PrEP Guidelines.
With few reported side-effects, there is potential for halting a “next-generation” of people getting infected with HIV, by adding PrEP to prevention methods already in use.
Though, implementation is not without controversy.
Here is a link to the statements in Slate Magazine made by both long-time AIDS activist Larry Kramer and another ACT-UP* veteran Peter Staley whose views differ on this subject:
Ask your doctor if PrEP is right for you. It is the “before” piece of this discussion.
PEP, on the other hand, for occupational (oPEP) as well as non-occupational exposure (nPEP) to HIV, is the “after” and has been an option for much longer. But its use against HIV must be implemented no more than 72 hours (3 days) after being exposed to the virus – and the sooner the better. PEP is analogous to the “morning after pill” but is taken as a combination of antiretroviral medications over a period of 30 days after significant exposure to HIV.
Access is becoming easier, particularly if one has healthcare insurance and has a primary care provider who may be reached soon after exposure to HIV. Thanks to U.S. Occupational Safety and Health Administration (OSHA) regulations https://www.osha.gov/OshDoc/data_BloodborneFacts/bbfact04.pdf , protocols for oPEP in healthcare settings are generally in place and make post-exposure prophylaxis less difficult to obtain.
Guidelines for PEP are found at the CDC’s website too.
HIV/STD and Hepatitis prevention utilize multiple tools from the toolbox. As with any task involving tools, different ones work best in different situations. Each of us has to learn how to properly use the tools that we currently have on-hand.
Both PrEP and PEP will be topics in multiple breakout and plenary sessions at the upcoming 20th International AIDS Conference to be held July 20-25, 2014 in Melbourne, Australia, the second largest city on that continent.
Make a note on your calendar to visit www.aids2014.org where you’ll find a promotional video beginning with greetings from the Australian Prime Minister, Tony Abbott, then Franҫoise Barré-Sinoussi, International Chair of AIDS 2014, and Sharon Lewin, Local Co-chair of AIDS 2014. Or, plan to follow daily highlights of the conference that week at www.kff.org .
Michael Harney, the Rubberman, is at firstname.lastname@example.org or 828-252-7489 ext. 311. ______________________
*AIDS Coalition To Unleash Power http://www.thebody.com/content/art14001.html