What You Should Know About . . . PEP! (The "Morning After" Pill)

A couple of months ago, my co-worker took a phone call from a person who was desperate to find a place to get the "morning after" pill for free after having unprotected sex 72 hours ago. It took several questions to figure out that the caller was not interested in the birth control version of the "morning after" pill, but what is referred to as PEP -- post exposure prophylaxis.

PEP is the standard of care for a health care worker who has been exposed to an HIV risk situation such as being stuck by a needle used on an HIV-positive patient. The medicine given seeks to attack the virus after it attaches to a lymph cell but before it has a chance to burrow into the nucleus and begin reproducing. Although historically used for health care workers, many cities are now offering this intervention to persons who may have been exposed to HIV through sex or drug use. The data shows that there was a 79% reduction in the odds of infection in health care workers who received PEP. Because of this, many HIV activists are beginning to ask if PEP should be offered to the general population as a prevention effort.

Okay, back to the story. My co-worker did the best he could to figure out what to do to help this caller, but unfortunately Atlanta does not offer PEP in a clinic-like setting for free. The caller quickly called back (and got me) to voice his anger at why Atlanta did not offer this service. I could not explain why Atlanta did not offer this, but felt the caller just needed someone to listen. As the caller spoke, I remember thinking, "What the hell were you thinking 72 hours ago?" I mean, even if we had free PEP available, I was afraid that the referral would be too late. I did call a private doctor's office who said that they would see the caller; however, he would need to come in that very second! The office worker also explained that there would be a charge, as well as the necessity for the person to completely adhere to the medication regimen. The cost could range anywhere from $600 - $2500 (with few insurance carriers willing to pay), as well as the possibility that side effects may be experienced (nausea, headaches, etc.).

I am glad that the caller called us because up until recently, I only thought about PEP in reference to nurses who get needle sticks in hospitals. They get a needle stick, call employee health for assessment, and if appropriate, start the protocol for antiretrovirals. A recent U.S. Centers for Disease Control statement on the management of nonoccupational exposures to HIV concluded that since no data exist regarding the efficacy of nonoccupational exposure, recommendations for or against its use cannot yet be made. To collect needed information, the National Nonoccupational HIV Postexposure Prophylaxis Registry has been created. In the meantime, however, some clinics and physician offices have started offering PEP for non-occupational exposures. Some charge and some do not.

Before we get into details, I want to talk about what really happens when someone wants to start taking PEP after a sexual or drug using exposure. First of all, it is not a "morning after" pill! You do not just take one pill the morning after! (Okay, I feel better.) This is what happens: First, you must call the doctor or clinic, between 24 to 72 hours after the exposure (the earlier the better). Then the following will most likely occur.

These are the guidelines for PEP after sexual and drug exposures to HIV developed at San Francisco Department of Public Health/ San Francisco General Hospital:

Consider post-exposure prophylaxis if conditions 1,2,3,4, and 5 are met:
1. High risk exposures. (In descending order of risk.)
   1. Unprotected receptive anal intercourse
   2. Sharing needles or drug paraphernalia
   3. Unprotected receptive vaginal intercourse
   4. Unprotected insertive vaginal intercourse
   5. Unprotected insertive anal intercourse
   6. Unprotected receptive fellatio with ejaculation
2. Partner is known to be HIV-infected, or in an HIV-risk group. (They used "group," not me!)
   1. Gay/bisexual man
   2. Injection drug use
   3. Sex worker
   4. Patient was raped
3. Exposure is an isolated event (e.g. broken condom), or patient intends to avoid future exposures through safer sex and clean needle use.
4. Patient presents for care within 72 hours of exposure.
5. Patient desires treatment and agrees to adhere to the treatment regimen.

If a decision is made to treat the patient, treat for 28 days with a two-drug antiretroviral regimen. The following are treatment regimens that may be offered:

Standard Treatment Regimen
(use as default regimen when no other information about the source partner is available)


• Zidovudine (AZT/ZDV) 200mg. PO tid or 300mg PO bid, PLUS
• Lamivudine (3TC) 150mg. PO bid

Alternate Regimen 1
(when partner is taking AZT and ddI, and resistance is suspected)


• Stavudine (d4T) 40mg PO bid, PLUS
• Lamivudine (3TC) 150mg. PO bid

Alternate Regimen 2
(when partner is taking AZT and 3TC, and resistance is suspected)


• Stavudine (d4T) 40mg. PO bid, PLUS
• Didanosine (ddI) 200mg. PO bid (if >60kg), or 125mg. PO bid (if < 60 kg)

With any of the above regimens the physician may:


1. Consider adding a protease inhibitor (nelfinavir 750mg. PO tid or indinavir 800mg PO q8h) if the source partner has a high viral load (>50,000), has advanced HIV disease, or has recently (e.g. in the past 30 days) been treated with one or both the nucleoside analogues in the above 3 treatment options, AND
2. The following are recommended baseline laboratory studies for exposed individuals:
   1. HIV-antibody
   2. Hepatitis virus antibody
   3. Hepatitis C virus antibody
   4. Gonorrhea, syphilis, chlamydia (if appropriate)
   5. Pregnancy test (if appropriate)
   6. Complete blood count
   7. Liver function tests
   8. Renal function tests

The source partner (if the partner information is available) evaluation will ask questions regarding the following topics:


1. If partner's current HIV status is unknown:
   1. HIV risk behaviors of partner (e.g. injection drug use)
   2. Prior HIV antibody test results
   3. Perform partner HIV testing and stop PEP if partner is not infected
2. If partner is known to be HIV infected:
   1. Clinical stage of HIV infection
   2. Quantitative HIV titer (viral load)
   3. Antiretroviral treatment history (past 30 days is most relevant)

HIV risk reduction counseling for all patients:


1. Educate the patient about modes of HIV transmission and the relative risks of transmission with different behaviors (e.g. anal intercourse is riskier than oral sex).
2. Discuss specific HIV risk behaviors relevant to the individual patient, including circumstances contributing to recent exposure (e.g. substance use).
3. Assess the patient's readiness to change HIV risk behaviors.
4. Strengthen the patient's skills to reduce HIV risk (e.g. proper use of condoms, communication with partners about condom use).
5. Negotiate a realistic and incremental risk reduction plan that focuses on the steps the patient will take to reduce their HIV risk.
6. Refer the patient to ongoing prevention programs to help them avoid risky behavior.

Follow-up evaluation:


1. If patient is found to be HIV-positive on baseline evaluation, change from PEP to optimal treatment for infected persons depending on stage of infection (i.e primary HIV infection, long standing HIV infection).
2. Assess side effects of antiretroviral treatment at two and four weeks (if post-exposure prophylaxis prescribed).
   1. Complete blood count
   2. Liver function tests
   3. Amylase (if didanosine or indinavir is used)
   4. Urinalysis (if indinavir is used)
   5. Glucose (if protease inhibitors are used)
3. Assess HIV risk behavior during interval since prior visit.
4. Reinforce prevention messages.
5. Assess adherence with medication.
6. Test for HIV-antibodies at six weeks, twelve weeks and six months.
7. Assess symptoms and signs of primary HIV infection.

Clearly this is not a "morning after" pill. Again, there is no research to show that PEP works for non-occupational exposure; however, "they" are currently gathering data. PEP can be quite expensive if you are not in a city that offers this service for free -- it can cost anywhere from $600.00 to $2,500.00. A package of condoms costs less.

National Resources

Whitman-Walker Clinic
Washington, DC
202-332-AIDS
PEP offered

Fenway Community Health Center
Boston
617-927-6450
PEP offered

San Francisco City Clinic
415-514-4PEP
PEP offered

Beth Israel Medical Center
New York City
212-420-2000
PEP offered

Howard Brown Health Center
Chicago
773-388-1600
PEP offered

HIV/AIDS Treatment Information Service
1-800-HIV-0440

National AIDS Hotline
1-800-342-AIDS

National HIV PEP Registry
(Providers only)
1-877-HIV-1PEP

Local Resources

AIDS Survival Project
404-874-7926
(Call for physicians who are willing to provide PEP.)