How Can People Access Pep
The Canadian PEP guidelines recommend that PEP should be readily available in places where it is likely to be needed urgently. These include emergency departments, sexual health clinics and other clinics serving populations at increased risk of HIV.
The decision to provide PEP lies with the healthcare provider and is made on a case-by-case basis. Many healthcare providers are unaware of non-occupational PEP or may be unwilling to prescribe it. The Canadian guidelines outline practical advice for physicians providing PEP, including how to assess risk in people who present for PEP, how to provide monitoring and follow-up, and recommended drug regimens.
People starting PEP may be offered a starter pack of pills, so that PEP can be started right away, along with a prescription that needs to be filled to receive the full 28-day course of medications. Most emergency departments will have PEP starter packs available.
Anti-HIV drugs are expensive: a month-long course of PEP can cost $900 or more, depending on the drugs used. Although occupational PEP is normally covered by workplace insurance, coverage for non-occupational PEP varies across Canada. Non-occupational PEP medications are covered by some private and public health insurance plans; coverage varies depending on the province or territory and the type of exposure.
We thank Dr. Isaac Bogoch, Toronto General Hospital Research Institute, for expert review.
Does Pep Cause Side Effects
PEP is safe, but the HIV medicines used for PEP may cause side effects like nausea in some people. In almost all cases, these side effects can be treated and arent life-threatening.
If you are taking PEP, talk to your health care provider if you have any side effect that bothers you or that does not go away.
PEP medicines may also interact with other medicines that a person is taking . For this reason, its important to tell your health care provider about any other medicines that you take.
How Do I Access Pep
If you think you have been exposed to HIV, do not wait for an appointment to see a GP. Call the PEP info line at the Victorian HIV Prevention Service for guidance and information about where to find your closest PEP provider.
Your PEP provider will ask you a series of questions to determine your risk and whether PEP is appropriate.
PEP is available from the emergency department of most public hospitals, sexual health clinics and some other general practice clinics which specialise in sexual health.
If the exposure happens after hours, emergency departments are often the best place to go to make sure you start PEP as soon as possible.
PEP is widely available in Victoria and further information can be found at:
Get yourself tested for STIs, and treated if necessary, by your local GP .
PEP is not a morning-after pill that makes it easy and safe to have sex without a condom. You must take the medication every day for 28 days for PEP to work.
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Who Should Use It
PEP should be used by anyone who has had a very recent single exposure to the HIV virus. The most common high-risk situations are within the occupational context, such as an inadvertent needlestick at the hospital, or the nonoccupational context, such as sexual exposure or injection drug use.
PEP is only intended for emergencies and should not be used if you are regularly exposed to HIV.
Other groups that may need PEP are:
- Those who have been sexually assaulted
- Those who are unclear if a sexual partner has or had been exposed to HIV
- Anyone who engages in needle sharing;
Of note, if you are pregnant and have been exposed to HIV, your doctor will prescribe PEP with raltegravir instead of dolutegravir to limit the risk of birth defects.
How Do You Know If You Need Pep
PEP may be right for you if you are HIV-negative or dont know your HIV status, and you think you may have been exposed to HIV in the last 72 hours:
- During sex
- Through shared needles, syringes, or other equipment used to inject drugs, or
- Through sexual assault
Contact your health care provider immediately or go to an emergency room or urgent care clinic right away.
Your health care provider or emergency room doctor will evaluate you, help you decide whether PEP is right for you, and work with you to determine which medicines to take for PEP.
In addition, if you are a health care worker, you may be prescribed PEP after a possible exposure to HIV at work, such as from a needlestick injury.
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Exposure To Hiv Is An Emergency
An HIV exposure is a medical emergency and rapid initiation of PEPideally within 2 hours and no later than 72 hours post exposureis essential to prevent infection. Therefore, this Committee encourages emergency departments, outpatient clinics, and urgent care centers to train triage staff to assign high priority to patients who report a potential exposure. In deciding whether to continue PEP beyond the first emergency dose, care providers must balance the benefits and risks. PEP can be discontinued later in the evaluation process if indicated.
|NEW YORK STATE LAW: Minor Consent|
Baseline Testing Of Exposed Individuals
|Table 1: Baseline Testing Based on Age of Exposed Individual and Type of Exposure|
Delaney KP, Hanson DL, Masciotra S, et al. Time until emergence of HIV test reactivity following infection with HIV-1: Implications for interpreting test results and retesting after exposure. Clin Infect Dis 2017;64:53-59.
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Factors That May Impact Local Applicability
The safety of antiretroviral medications used for PEP, including the occurrence of serious adverse effects from use by people without HIV infection, use during pregnancy, and potential selection for drug-resistant strains of virus, have been explored and discussed in guidelines . Further information and alternative drug regimen recommendations are also provided . These topics, however, are outside the scope of this review.
The availability of certain antiretroviral medications remains limited and costly in low- and middle-income countries . Antiretroviral medications are also expensive in high-income countries . Identifying budgetary, human resource, infrastructure, and health system requirements within the local context are important for decision-makers to consider in the implementation of PEP programs .
Moreover, the achievement of global and national commitments requires timely and equitable delivery of HIV treatment and prevention . Addressing barriers to access, particularly those faced by populations that are marginalized or criminalized, will be critical for decision-makers .
Sexual Assault Exposure Risk
Statistics on sexual assault in the United States show high rates of attempted or completed rape among several populations, including cisgender women, men, children, and transgender individuals:
- 21.3% of women reported attempted or completed rape in their lifetime, with the first assault occurring :
- Before age 18 years in 43.2%
- Between the ages of 11 and 17 years in 30.5%
- At age 10 or younger in 12.7%
Risk of HIV infection: Increased risk of infection in cases of sexual assault has been associated with trauma at the site of exposure and absence of barrier protection:
PEP is the only proven method of reducing HIV acquisition after exposure, and it should be offered in cases of sexual assault. There are published reports of HIV seroconversion following sexual assault .
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Figure : Occupational Hiv Exposure: Pep And Exposure Management When Reported Within 72 Hours
Lead author: Elliot DeHaan, MD, with the Medical Care Criteria Committee, June 2020
In many cases of non-occupational exposure, the source is not available for testing. The HIV status of the source should not be the focus of the initial evaluation; determination of whether the exposure warrants PEP and, when indicated, prompt initiation of PEP, should be the focus.
Is Pep Right For Me
If you have had a potential exposure to HIV within the last 72 hours, then PEP might be right for you. The sooner you start PEP, the more effective it is.
PEP can be used after a potential exposure to HIV through sexual or injection drug use activities. This can include having unprotected sex , having a condom break during sex or sharing equipment used to inject drugs.
PEP can also be used after a potential exposure to HIV at work, such as when a healthcare worker or emergency responder has an accidental needle-stick injury.
A doctor or nurse practitioner will help you determine if you should start PEP, based on the nature of your exposure. Its important to be honest about your potential exposure so the healthcare provider can properly assess your risk.; PEP is usually only recommended if the potential exposure carries a high or moderate chance of passing HIV.
PEP can be used by people of all genders. Experts believe that PEP can effectively prevent HIV in trans people and that the drugs in PEP are unlikely to interfere with the hormones that some trans people take; however, this has not been well studied.;
PEP can be taken by pregnant people safely. Tell your doctor if you are pregnant or planning to have a baby so they can prescribe a drug combination that is safe for you. Breastfeeding is not recommended while taking PEP.
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Are There Any Other Hiv Prevention Options
There are many easy and effective ways to prevent HIV. Other than PEP, HIV transmission can also be prevented by:
- Using condoms with water or silicone-based lubricant during anal or vaginal sex.
- Using clean, sterile injecting equipment.
- Taking pre-exposure prophylaxis for people who are at risk of HIV transmission.
- achieving; and maintaining undetectable HIV viral loads if you are HIV-positive by taking HIV antiretroviral treatment as prescribed.
Depending on your risk factors and life circumstances, you may be more suited to other HIV prevention methods. It is important to find the right prevention method, or combination of methods, that works for you and your sexual partners.If you have used PEP more than once, you may wish to talk to your GP about starting pre-exposure prophylaxis or PrEP for HIV prevention. PrEP is a pill taken once a day and is 99% effective at preventing HIV transmission if taken consistently as prescribed.
Summary Of Current Controversies
1) The decision to initiate PEP is complicated and based on incomplete clinical and biological data. It represents a balance of risk and benefit for each individual patient. At a public health level, the costs of such treatment must be balanced against the risk of transmission associated with a given exposure. The interval after which PEP will have no benefit is not well defined and data are lacking to support a clear benefit when PEP is initiated >48 hours after exposure. Few studies and fewer still randomized trials comparing various regimens for PEP exist. The optimal number of antiretroviral agents to be used in a PEP regimen remains uncertain as the quantity and genetic diversity of infectious HIV typically delivered during all but the worst exposures is several orders of magnitude less that that seen when treating a patient with HIV. Thus, the treatment rules of 3+ drug therapy may not apply.
3) The role of mucosal drug concentration for prevention of mucosal /sexual transmission is not fully defined but may be important. Both tenofovir and emtricitabine have been shown to penetrate the genital tract well in animal models, reaching peak levels within 24 h of dosing, characteristics which may be advantageous for PEP in these settings. Both efavirenz and lopinavir had significantly lower concentrations in female genital secretions than tenofovir and lamivudine. Raltegravir and maraviroc have also been shown to achieve high levels in the genital tract.
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Have An Honest Conversation About Prep With Your Provider
Its important to have an open and honest conversation with your provider about your sexual activities and whether you use intravenous needles and might be at risk of contracting HIV.
Even if you are worried that you wont be able to afford PrEP without insurance, you should still talk to your healthcare provider, because there are now programs and options available to help individuals without insurance take PrEP for HIV prevention.
How Do You Take Pep
PEP consists of three drugs that you take onetwo times per day for 28 days. Ideally, the first dose of PEP should be administered immediately, within two hours but no later than 72 hours after an exposure, because the effectiveness of PEP decreases over time.
It is important to take all the dosesat the right time and in the right wayto give PEP the best chance of working.
Although PEP does not prevent 100% of HIV infections, it has been shown to decrease the transmission of HIV by more than 80%.
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Management Of The Exposed Site
Care of the exposure site should prioritize appropriate cleansing and infection preventive measures and minimize further trauma and irritation to the exposed wound site. The site of a wound or needlestick injury should be cleaned with soap and water only. It is best to avoid use of alcohol, hydrogen peroxide, povidone-iodine, or other chemical cleansers. Squeezing the wound may promote hyperemia and inflammation at the wound site, potentially increasing systemic exposure to HIV if present in the contaminating fluid. The use of surgical scrub brushes or other abrasive tools should be avoided, as they can cause further irritation and injury to the wound site. Eyes and other exposed mucous membranes should be flushed immediately with water or isotonic saline.
What Does It Involve
Before you’re given PEP, the clinician will ask you a few questions. For example, you may be asked about the person you had sex with, what sort of sex you had, and , what their viral load is.
After that, you’ll be asked to take an HIV test. This is to make sure you don’t already have HIV .
“If HIV is detected by a test, other forms of treatment will be recommended to you,” says Brady.
Once prescribed PEP, it’s important to be diligent. The medication used these days is a single tablet called Truvada, along with two tablets of raltegravir, which need to be taken each day for 28 days.
“If you skip a dose or fail to complete the full month, this makes it less likely to work,” says Brady. “If you do miss a dose and you remember in less than 24 hours, take the next one as soon as you remember.”
Although there are potential side-effects, these are likely to be minor – you may experience nausea, headaches or tiredness within the first few days, which should eventually settle down.
You’ll also need to take an HIV test 12 weeks after exposure, by which point the test will be conclusive. In the unlikely event you have contracted HIV, you can get started on treatment as soon as possible.
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How Many People Have Hiv In Canada
At the end of 2018, national HIV estimates suggested that there were approximately 62,050 Canadians living with HIV, of which, an estimated 8,300 were living undiagnosed. To put that in perspective, those 62,050 people represent a prevalence rate of 167/100,000 Canadians.
The number of new HIV infections has increased over the years in Canada, with an estimated 2,242 new infections recorded in 2018, reflecting an incidence rate of 6/100,000 people.
Unfortunately, of the above stated incidence rates, gay, bisexual, and other men who have sex with men represent just over 50% of all new HIV infections despite only representing 3-4% of the adult population in Canada, which is a depressing statistic.
These numbers can be scary on their own without an understanding of treatment and prevention methods and estimating the actual risk of contracting HIV is not a simple, generalizable task.
Pep Regimens For Patients Who Weigh <40 Kg
Pediatric PEP material lead author: Aracelis Fernandez, MD, with Lisa-Gaye Robinson, MD, and Ruby Fayorsey, MD
No clinical studies are available to determine the best regimens for HIV PEP in children. The recommendations for drug choices and dosages presented here follow current U.S. Department of Health and Human Services recommendations in Guidelines for the Use of Antiretroviral Agents in Pediatric HIV Infection, which are based on expert opinion. The recommended regimens reflect experience with ARV combinations that effectively suppress viral replication in children with HIV and with combinations that are well tolerated and increase adherence to PEP. The chosen preferred regimens have demonstrated good potency and tolerability.
The alternative PEP regimens for children are also based on expert opinion. They all have demonstrated potent antiviral activity. However, the PI-containing regimens are often more difficult to tolerate, secondary to gastrointestinal adverse effects. To improve adherence, clinicians can and should prescribe preemptive antiemetics for anticipated gastrointestinal side effects.
When choosing a PEP regimen, care providers should consider factors that may affect adherence, such as ARV drug intolerance, regimen complexity, expense, and drug availability.
|Table 4: Post-Exposure Prophylaxis Regimens for Patients 2 to 12 Years Old Who Weigh <40 kg|
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