Drugs Taken After Possible HIV Exposures May Prevent Transmission, But Questions Remain About Efficacy, Cost
Providing antiretroviral drugs shortly after possible HIV exposure through needlesticks can reduce health care workers' odds of contracting the virus, but whether the treatment should be provided to those exposed to HIV through sexual contact remains a question, the Los Angeles Times reports. Approximately 81% of health care workers who took a post-exposure prophylaxis regimen -- an "aggressive" 28-day course of drugs begun within 72 hours of exposure to HIV -- remained HIV-negative, according to several studies. Most Americans have "no qualms" about offering the treatment to health workers who risked possible infection "in the line of duty," and many are "much more inclined" to offer the drug regimen to victims of sexual assault. However, the idea of providing the therapy to those who were possibly exposed through consensual sex is more "controversial" and has lead to a "vigorous debate" among policy makers and AIDS activists, the Times reports.
Catch-22 of Greater Awareness
Many people do not know about the treatment and finding access to the drugs can be "difficult." But some people are able to locate places that offer the treatment through AIDS hotlines, advertisements in gay magazines or Internet sites, and some may even attempt to formulate their own version of the therapy using medications obtained from HIV-positive friends. Many public health officials worry that "growing publicity [about the regimen] ... might encourage reckless behavior among young people." Chuck Henry, director of Los Angeles County's Office of AIDS Programs and Policies, said greater awareness and availability of the treatment could provide people with a "false sense of security." He also questioned the wisdom of spending public money on a "still-unproved treatment" that costs between $800 and $1,000 per patient, instead of on other programs to "encourage" HIV prevention. However, Debra Johnson, a nurse practitioner at the University of Southern California Medical Center's AIDS Clinic, one of three California sites conducting studies of post-exposure prophylaxis, said it is important to provide anyone who may have been exposed to HIV with the treatment. "Is one any more deserving than another? I don't think so," she said. Dawn Smith, an epidemiologist with the CDC, which is currently debating PEP guidelines, said it is "important to 'get away from the concept of the innocent and the guilty.'" If health officials want to use PEP to "significantly" reduce the number of new HIV infections in the country "it needs to be given in a less emotional and more rational form," she added. The CDC is pondering whether to "remain neutral" on PEP use, or tell physicians that "there may be some situations where it is probably reasonable to suggest" treatment, Smith said.
Post-exposure prophylaxis is "not a simple morning-after option," according to Dr. Michelle Roland, the chief investigator for another PEP study being conducted by the University of California-San Francisco and San Francisco General Hospital. Unlike emergency contraception, which can prevent pregnancy when taken within 72 hours of unprotected sex, PEP drug regimens are "far more complicated," lasting four weeks and often causing side effects such as nausea, headache and fatigue and sometimes liver damage and anemia. Roland acknowledged that many health care workers do not finish the treatment, which usually consists of Combivir, a combination of zidovudine and lamivudine, sometimes combined with a protease inhibitor such as Crixivan or Viracept. In addition, the rise of drug-resistant strains of HIV makes tailoring the treatment even more "important," according to Dr. Gary Cohan of Pacific Oaks Medical Group, the nation's largest HIV practice.
Paying for Prophylaxis
Although many people pay for the treatment regimen out-of-pocket, some health plans, such as Blue Cross of California and Kaiser Permanente of Southern California, cover PEP. Dr. Mark Katz, Kaiser's regional HIV/AIDS coordinator, said that the HMO has been working to educate doctors about PEP and has established a system whereby infectious disease specialists are on call at all of its southern California medical centers to aid emergency room doctors who may not be familiar with the treatment. He estimated that Kaiser centers see a "few dozen" people who qualify for the treatment a year, at a cost of $30,000 to $40,000 to the HMO, a price "worth it to avoid any bad press or litigation," Katz said. Katz added that for every person who seeks PEP within the recommended 72 hours after exposure, "dozens" do not because they are unaware of the treatment (Allen, Los Angeles Times, 8/6).