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:
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)
Alternate Regimen 2
(when partner is taking AZT and 3TC, and resistance is suspected)
With any of the above regimens the physician may:
The source partner (if the partner information is available) evaluation will ask questions regarding the following topics:
HIV risk reduction counseling for all patients:
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.
Fenway Community Health Center
San Francisco City Clinic
Beth Israel Medical Center
New York City
Howard Brown Health Center
HIV/AIDS Treatment Information Service
National AIDS Hotline
National HIV PEP Registry
AIDS Survival Project
(Call for physicians who are willing to provide PEP.)