Canadians seeking help after being accidentally exposed to HIV through a sexual encounter can meet with a range of unhelpful responses and no clear policies.
Yet, if a month-long course of anti-HIV medication is initiated within 72 hours of exposure, evidence from a key study of occupational exposure among health workers indicates that infection can be prevented in most cases (MMWR 1995;44). It can also cost up to $1500.
But when used appropriately, the cost effectiveness of post-exposure prophylaxis (PEP) for HIV is “a no brainer,” says Toronto HIV physician Gordon Arbess. However, the lack of clear policy in this area is an “ongoing problem,” he said.
Although Canadian provinces and territories have guidelines for dealing with exposures during the course of work and at least 2 provinces (British Columbia and Ontario) have developed guidelines for dealing with sexual assault exposure, the delivery of PEP for accidental sexual exposure has received the least policy attention.
The whole area of PEP for HIV is “a relatively new field, just the last 10 years, and there has, as yet, been no real consensus in the area,” says Dr. Michelle Roland, the leading expert on non-occupational exposure to HIV and a physician with the Positive Health Program at the San Francisco General Hospital.
She is confident that recommendations from a forthcoming report from the WHO and the International Labour Organization will soon provide policy and service delivery guidance for both the developed and developing world in PEP for all types of HIV exposure.
While the US Centers for Disease Control and Prevention has issued guidelines in this area, the UK is arguably the leader in its guidelines for non-occupational exposure. As well, Britain's chief medical officer of health recently asked every primary care trust to ensure that PEP is one tool in their HIV prevention approaches.
“Previously PEP was available, but there was a prescribing lottery — you had to go to the right clinic and know the right things to say,” explained Will Nutland of the Terrence Higgins Trust, which offers an online risk self-assessment tool for those worried about accidental sexual exposure.
In Britain, if a physician concludes treatment is necessary, the cost of the 28-day course of 2 or 3 anti-HIV drugs is covered by the National Health Service. For Canadians whose drug costs are not covered by a public or private drug plan, the $1000 to $1500 price tag can be a major deterrent to treatment.
Dr. Matthew Schurter, a second-year family practice resident, says he recently saw 2 patients at an Ottawa emergency ward who inquired about PEP for HIV: a cleaner who had experienced a needle-stick injury while cleaning an outdoor area and a young gay man who was “extremely worried” because of a broken condom during sex with a man he said had HIV. “The [drug] cost would have been covered if I had a needle-stick [injury]... it didn't seem fair that they would have to pay. This seems to me to be an anomaly in the health care system.”
Roland agrees it is unfair that some have to pay, while others do not, but notes “you have to remember that this is not a unique equity issue within [Canadian] health care.”
It's easier for the system to respond to accidental HIV exposure among health care workers, for example, from accidental needle-stick injury, because the worker is usually available for HIV testing, Roland noted. Moreover, at sexual assault clinics, medical attention is accompanied by extensive counselling.
But the “real challenge” for other types of non-occupational exposures is service delivery and feasibility. Offering services to people who have been exposed to HIV through sex or some other non-occupational route “has a place, but it is very individual,” says Dr. Alastair McLeod, chair of the Committee on Accidental HIV Exposures at the BC Centre for Excellence in HIV/AIDS. “A doctor can provide this if he knows the person and the circumstances,” but emergency departments are not well suited to appropriate service delivery.
Like McLeod, Roland says the best setting to deal with these situations is at STD clinics, where there is the opportunity to provide risk reduction counselling at a time when patients, concerned about possible HIV exposure, are vulnerable and receptive. The Terrence Higgins Trust endorses this service delivery route and has written to every sexual health clinic in Britain seeking their policies and hours of operation.
Both Nutland and Roland say that primarily, HIV prevention remains essential and that demand for PEP for HIV is not very high. “This is not some big panacea, but we should make it available and link it to prevention,” says Roland.