2005-05-25-Do After-Exposure HIV Drugs Up Risky Sex?

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2005-05-25-Do After-Exposure HIV Drugs Up Risky Sex?


Debate Grows Over Promoting Treatment to Prevent HIV Infection

 

Powerful AIDS drugs can prevent HIV infection if taken soon after exposure. But should this fact be publicized?

No, say John Richens, FRCP, of London's Center for Sexual Health and HIV Research, and colleagues. In the journal Sexually Transmitted Infections, they argue that promoting this treatment will increase risky sex among men who have sex with men. Doctors refer to the treatment as post-exposure prophylaxis or PEP.

"When you promote PEP, it will have effects on behavior," Richens tells WebMD. "Making it widely available will alter people's perception of risk. We already are concerned about the rising trends in risky sexual behavior. Promoting PEP is not going to make people feel more at risk, but safer, and this may affect their behaviors."

There's no evidence for that, counters an accompanying editorial by Martin Fisher, FRCP, of Brighton and Sussex University Hospitals in England.

"Providing PEP may well act as a 'wake-up call' and have a beneficial effect on behavior rather than a deleterious one," Fisher writes.

That's what U.S. PEP expert Michelle Roland, MD, calls "the PEP moment." Roland is assistant professor of medicine at the University of California, San Francisco, and a physician for the Positive Health Program at San Francisco General Hospital.

"PEP gives us a time to intervene when a person is most receptive to a health message. It is the PEP moment," Roland tells WebMD. "It is amazing when people acknowledge to themselves that the behavior they just engaged in is not congruent with their own comfort level for risk. And so now we have the opportunity to support them to be safer."

PEP No Remedy for Unsafe Sex

If you think PEP is a morning-after pill, you're wrong. PEP means a full 28 days of treatment with a combination of AIDS drugs. Especially early in treatment, these drugs can cause very unpleasant side effects. Yet missing a dose isn't an option.

Who qualifies for PEP? Last January, the U.S. CDC put out guidelines. They stress that PEP is not the same as HIV/AIDS prevention, says guidelines co-author Lisa A. Grohskopf, MD, MPH, a medical officer for the CDC's National Center for HIV, STD, & TB Prevention.

"PEP is not to be considered a substitute for any other methods -- abstinence, mutual monogamy, consistent condom use, or use of clean injection equipment by those who cannot yet stop intravenous drug use," Grohskopf tells WebMD. "Those are really the first-line defenses. PEP is not a substitute. It is considered a safety net when those measures fail."

Even then, PEP only works if taken within 72 hours of exposure. The CDC recommends PEP for people who have had unprotected sex with a person known to have HIV infection. For those who have unprotected sex with a person whose HIV status is unknown, it's a tough call.

"When the source person's HIV status is unknown, it has to be a case-by-case decision based on what is known about the exposure and what is known about the source person," Grohskopf says.

Does PEP Increase Unsafe Sex?

Individualized counseling, Grohskopf and Roland say, is an essential part of PEP.

"There is no 'one size fits all' to PEP," Roland says. "Some people need more counseling than others. Some need referrals to mental health or substance abuse interventions."

All this may be very helpful for individual patients, Richens says. But he says putting out the message that PEP is available will have a social cost.

"The climate of fear about HIV is disappearing as treatment improves," he says. "If you are concerned over the fact that risky behavior is increasing among men who have sex with men, you have got to make people more apprehensive about the situation, not less. And PEP gives reassurance. So it is not going to counter these trends toward increasing risky behavior."

Roland disagrees. She points to several studies that find no increase in unsafe sex among people who have used PEP. And she notes that rates of sexually transmitted diseases do not increase when PEP becomes available in a community.

"All of the studies I am aware of, looking at those who received PEP and those who have knowledge of PEP, suggest there is not an increase in risk behavior," she says.



 

SOURCES: Richens, J. Sexually Transmitted Diseases, May 2005; online edition. Fisher, M. Sexually Transmitted Diseases, May 2005; online edition. Smith, D.K. CDC MMWR, Recommendations and Reports, Jan. 21, 2005; vol 54. John Richens, FRCP, Center for Sexual Health and HIV Research, London. Martin Fisher, FRCP, Brighton and Sussex University Hospitals, England. Michelle Roland, MD, assistant professor of medicine, University of California, San Francisco; Positive Health Program, San Francisco General Hospital. Lisa A. Grohskopf, MD, MPH, medical officer, National Center for HIV, STD, & TB Prevention, CDC, Atlanta.

 


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