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Post-Exposure Treament: Painting the Right Picture

Posted Jul 21 2008 10:18am

The current issue of Mother Jones includesan article by Justine Sharrock on post-exposure prophylaxis. “Post-exposure prophylaxis,” or PEP, is the technical term for preventing HIV infection AFTER a person may have been exposed to the virus. As noted in the Mother Jones article, PEP typically involves a month-long regimen of HIV meds started within 72 hours (3 days) after a potential exposure to HIV.

Although I applaud Mother Jones for helping to raise awareness about this important prevention approach, I do have some serious reservations about the information in the article.

My first concern is with the article’s title: “The HIV Morning-After Pill.” Although early in the article Justine Sharrock describes PEP as a month-long drug regimen, it isn’t clear that this is the “morning-after pill” the title referred to. It can be very confusing for people to read about a “morning-after pill” without an immediate, explicit clarification that PEP actually involves many pills taken over the course of a month.

I was also disappointed that Sharrock cited the experience of a man (“Danny”) who received PEP in 2000 rather than describing a more recent PEP experience. A lot has changed in both HIV treatment and PEP during the 8 years since Danny received PEP. For one thing, although Danny was treated with a two-drug regimen, the CDC’s PEP recommendations call for a three-drug regimen.

In addition, Sharrock describes the PEP meds as “toxic” and says Danny suffered “debilitating nausea and fatigue” during his month-long regimen. Even in 2000, I wouldn’t have described the typical side effects of the then-available meds in those extreme terms. In 2008, there are newer, very-well-tolerated HIV meds and regimens. So I don’t think it’s helpful to focus on the toxicities of old regimens now. In fact, focusing on severe drug toxicities could have the undesirable effect of discouraging people from using PEP.

I also don’t think that Sharrock got things quite right in her description of how the HIV drugs work. Basically, all of the available HIV meds are designed to interfere with the life cycle of the virus and keep it from making new copies of itself. Since PEP involves giving people HIV meds soon after a possible exposure to the virus, the goal is to shut down the growth of any HIV before it has a chance to become established in the body.

Finally, I don’t think that the availability of PEP is really quite as limited as Sharrock describes. As she notes, since 2005, the CDC has recommended the appropriate use of PEP for high-risk non-occupational exposures to HIV. (Such exposures would include unprotected anal or vaginal sex, condom breakage or slippage, sexual assault, and the sharing of injection-drug equipment.) So I would expect that many doctors, hospitals, and clinics follow the CDC guidelines and make PEP available to their patients - even in states that don’t have official policies in place endorsing non-occupational PEP.

In closing, I’d like to comment briefly on what I believe is a major shortcoming of the CDC non-occupational PEP guidelines: They don’t reflect the significant advances in HIV treatment that have occurred in the 3+ years since the guidelines were issued in January 2005.

When treating people with HIV, many doctors rely on the latest treatment guidelines issued by the US Department of Health and Human Services (DHHS). The DHHS HIV treatment guidelines for adults and adolescents are generally updated at least once a year.

Unfortunately, the HIV drugs listed in CDC’s 2005 nPEP recommendations reflect DHHS’s now-obsolete 2004 guidelines for HIV treatment. For example, the list of “preferred regimens” in the nPEP guidelines is missing some drugs that are now included among the preferred regimens in DHHS 2008 treatment guidelines. Conversely, the nPEP guidelines also include as preferred regimens some combinations that are no longer favored in DHHS’s current guidelines.

So I think there’s good reason to argue that the list of preferred regimens in the official nPEP guidelines is out of date and should be revised as soon as possible. To avoid the need for continuous updating, any revised CDC PEP guidelines could simply recommend that doctors review the latest DHHS treatment guidelines when choosing a PEP regimen with their patients.

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