Policy on Post Exposure Prophylaxis (PEP) in non occupational HIV exposure

[Guest guest]

Need a national policy on Post Exposure Prophylaxis (PEP) in non

occupational exposure to HIV

Joe

Director-general of the Armed Forces Medical Services, Surgeon Vice

Admiral V K Singh's statement " ... If a person having unprotected sex

is put on ARV drugs within 24 hours of getting infected, the virus

can be killed, " (1) appears to be misleading interpretation of the

scope of Antiretroviral Post Exposure Prophylaxis (PEP) policy. Such

a misguided policy will have serious consequences on HIV prevention

and care efforts within the uniformed services and in the general

population. This statement indicates the urgency of the need for a

national policy on Post Exposure Prophylaxis (PEP) in non

occupational exposure to HIV (nPEP)

The provision of antiretroviral drugs to prevent HIV infection after

unanticipated sexual or injection-drug-use exposure might be

beneficial (2). In the Indian context, PEP is mostly used to prevent

HIV infection in occupational settings such as to prevent infection

among a health care provider after an accidental exposure to infected

blood or blood products. There is no official policy of PEP as such

in India, so one has to rely on global standards and best practices

to examine the merit of promoting PEP for each person having

unprotected sex.

Although, the benefits of a PEP regime after an exposure to HIV were

known earlier, promoting the use of PEP to prevent HIV in non

occupational exposure such as an protected sexual penetration is

contentious. A demand for nPEP is occurring in hospital emergency

departments in developing countries, but the diversity of practice

patterns suggests the need for evidence-based practice guidelines (3).

One of the most important aspect of CDC recommendation on PEP in non

occupational exposure is, the use of Nonoccupational Postexposure

Prophylaxis (nPEP) must be case by case basis under the supervision

of a trained physician.

The U.S. Department of Health and Human Services (DHHS) Working Group

on nPEP made the following recommendations for the United States of

America,

" For persons seeking care <72 hours after nonoccupational exposure to

blood, genital secretions, or other potentially infectious body

fluids of a person known to be HIV infected, when that exposure

represents a substantial risk for transmission, a 28-day course of

highly active antiretroviral therapy (HAART) is recommended.

Antiretroviral medications should be initiated as soon as possible

after exposure.

For persons seeking care <72 hours after nonoccupational exposure to

blood, genital secretions, or other potentially infectious body

fluids of a person of unknown HIV status, when such exposure would

represent a substantial risk for transmission if the source were HIV

infected, no recommendations are made for the use of nPEP. Clinicians

should evaluate risks and benefits of nPEP on a case-by-case basis.

For persons with exposure histories that represent no substantial

risk for HIV transmission or who seek care >72 hours after exposure,

DHHS does not recommend the use of nPEP.

Clinicians might consider prescribing nPEP for exposures conferring a

serious risk for transmission, even if the person seeks care >72

hours after exposure if, in their judgment, the diminished potential

benefit of nPEP outweighs the risks for transmission and adverse

events. For all exposures, other health risks resulting from the

exposure should be considered and prophylaxis administered when

indicated. Risk-reduction counseling and indicated intervention

services should be provided to reduce the risk for recurrent

exposures " .

Promoting the use of PEP after each sexual exposure has possible

policy and program implication which would undermine an effective HIV

prevention response. Such a policy could decrease in risk-reduction

behaviours resulting from a perception that `AIDS treatment' is

available, like any other sexually transmitted diseases. A PEP

treatment regime also could present serious adverse health effects

from antiretroviral treatment in otherwise healthy persons(4), (5)

(Data on the health consequences of a PEP treatment in a health

person is hard to come by) and potential in crease of the pool of

ARV resistant

virus through poor adherence to an nPEP course. Promoting the use of

PEP after each `at risk exposure' has further difficulties. Will such

a facility available after each and every episode of `at risk

behaviours'? A person could have a multiple episodes of at risk

behaviour at any given time.

" From a purely economic standpoint, PEP should be restricted to

partners of infected persons (e.g., serodiscordant couples), to

patients reporting unprotected receptive anal intercourse (including

condom breakage), and possibly to cases where there is a substantial

likelihood that the partner is infected. Providing PEP to all who

request it does not appear to be an economically efficient use of

limited HIV prevention and treatment resources " (6).

nPEP is an important tool for prevention HIV infection. However, to

maximise the effectiveness of nPEP, a concerted effort is necessary

to develop a national policy on the use of PEP in non occupational

exposure. Such a policy would definitely be helpful not only for

`Jawans' but for women (children and men) who are sexually assaulted

and at the risk of HIV infection as well. A policy vacuum is

contributing to several unavoidable HIV infections in India.

Health care providers must understand, there is no single `magic

bullet' to deal with the challenges of HIV infection. Respecting

individual rights, confidentiality and access to appropriate

information and services, promoting the use of condom and safer

sexual practices and creating an environment where safer sexual

practices could be practiced are far more effective than promoting

the use of PEP after each `at risk' behaviours.

References

(1) Siddhartha D Kashyap, [24 Nov, 2006. Times News Network] Report

sexcapades: Army. http://timesofindia .indiatimes.

com/Report_sexcapades_ Army/articleshow /

548219.cms

(2) Antiretroviral Postexposure Prophylaxis After Sexual, Injection-

Drug Use, or Other Nonoccupational Exposure to HIV in the United

States Recommendations from the U.S. Department of Health and Human

Services January 21, 2005 / 54(RR02);1-20 CDC MMWR

(3) Kunches, Laureen M; Meehan, Thera M; Boutwell, C; McGuire,

Flatley (2001) Survey of Nonoccupational HIV Postexposure

Prophylaxis in Hospital Emergency Departments. JAIDS Journal of

Acquired Immune Deficiency Syndromes. 26(3):263-265, March 1, 2001.

(4) JM Parkin , M , J , S El-Gadi, G Forster

and AJ Pinching (2000) Tolerability and side-effects of post-

exposure prophylaxis for HIV infection. The Lancet 2000; 355:722-723.

DOI:10.1016/S0140-6736(99)05005-9

(5) Christian Rabaud, Sibylle Bevilacqua, Isabelle Beguinot,

Véronique Dorvaux, Hélène Schuhmacher, Thierry May, and Philippe

Canton (2001) Tolerability of Postexposure Prophylaxis with

Zidovudine, Lamivudine, and Nelfinavir for Human Immunodeficiency

Virus Infection. Clinical Infectious Diseases 2001;32:1494-1495

(6) Pinkerton, D; Holtgrave, R Bloom, Frederick R (1998)

Cost-effectiveness of post-exposure prophylaxis following sexual

exposure to HIV. AIDS. 12(9):1067-1078, June 1998.