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1st
appeared 1 December 1998
Researchers Make Recommendations for Treating
Nonoccupational Exposures to HIV
Immediate preventative treatment to ward off AIDS
following possible exposure to HIV through sex or injection drug use is warranted under
certain conditions, report UCSF and UC Berkeley researchers in the Nov. 25 Journal of the
American Medical Association.
Such "prophylactic" treatment is already available through the one-year-old
Post-Exposure Prevention (PEP) Project, which is operated jointly by the UCSF AIDS
Research Institute (ARI) and the City of San Francisco Department of Public Health (DPH).
However, most public health departments only offer HIV prevention treatment -- which
includes drugs and counseling -- for survivors of sexual assault or for medical workers
who experience accidental needlesticks.
"The ethical principle of fairness requires that clinically similar patients be
treated similarly, regardless of the route of HIV exposure," wrote the authors, who
include Peter Lurie, formerly on the UCSF faculty; Margaret Chesney, of the Center for
AIDS Prevention Studies; Frederick Hecht, Department of Medicine, AIDS Program; and
Bernard Lo, Program in Medical Ethics. "The issue of PEP after exposure through sex
or injection drug use is important because these modes of HIV transmission are far more
frequent than occupational transmission."
Probably the biggest objection that will be raised to the proposal -- which calls for
physicians to base treatment decisions on current Centers for Disease Control and
Prevention occupational PEP guidelines -- is the risk of developing resistance, both in
the patient, should HIV be contracted, and in the community, where resistant strains could
wreak havoc with present treatment strategies, said Suellen Miller, UC Berkeley Associate
Field Research Supervisor.
"These are potent drugs and they also require rigorous treatment regimens," she
said.
Although there is no data on the effectiveness of prophylactic treatment in
nonoccupational settings, the authors provide epidemiological guidelines and clinical
cases to assist clinicians in making the difficult decision of whether to treat. The
UCSF-affiliated PEP Project, in addition to offering free, comprehensive treatment to
people exposed to HIV, is organized as a research study to look at the effectiveness of
this type of early intervention in high-risk communities.
"Although providing prophylactics to patients with appropriate non-occupational
exposures to HIV is important, we need to monitor the impact on community levels of HIV
risk behavior," said Lurie. "Our analysis shows that, even under assumptions
favorable for treatment, a mere 10 percent increase in risk behaviors can obliterate any
benefit that might come from treatment."
The researchers point out in the JAMA article that not every exposure to HIV would call
for prophylactic treatment and recommend that physicians look at the prevalence of HIV in
their community and the method of exposure before making the decision on treatment.
The cost of prophylactic treatment could exceed $1,000 per exposure episode, with drug
costs ranging from $500 to $1,000 and requisite physician and office visits running
between $500 and $600. The researchers are optimistic that insurance plans will cover such
treatment in situations when the risk of infection is comparable to that experienced by
medical personnel following HIV occupational exposure.
Links:
JAMA
Post-Exposure Program Unveils
Innovative Ads
HIV Post-Exposure Prevention
Being Studied
SFGH Sets National Model for
HIV Prevention Intervention
Guidelines for Postexposure
Prophylaxis (PEP) After Sexual and Drug Exposures to HIV (PEPNet)
Source: Kathleen Scalise,
UC Berkeley and Paula Murphy, Daybreak editor |
