HIV PEP Therapy: Is the United States Holding Back?

When I began volunteering at the Utah AIDS Foundation a year ago, I learned about HIV post-exposure prophylaxis (PEP) therapy as an option to prevent transmission after exposure.

During orientation, the foundation stressed how difficult it was for the general public to obtain a prescription for PEP therapy due to doctors’ reluctance to prescribe PEP therapy, the costs of the full regimen, and the lack of public education for this preventive option. With these issues in mind, I set out to see how countries like Australia and the United Kingdom are handling PEP therapy when it comes to accessibility, cost, and public education.

From my studies, I learned that other countries have been more proactive in the way they handle PEP therapy. Namely, patients who go on medical or volunteer missions are able to get prescriptions for PEP therapy when traveling to high-risk third-world countries, and they tend to be more educated on the effectiveness, side effects, and appropriateness of PEP therapy. Patients traveling to high-risk third-world countries are also able to visit travel clinics with educational resources for PEP therapy, which the United States does not provide.

Background

The Centers for Disease Control and Prevention estimates that more than 1.1 million people in the United States are living with HIV, and almost 1 out of 6 individuals is unaware of his or her infection. In addition, approximately 50,000 people each year will contract HIV in the United States.

The World Health Organization (WHO) recommends Truvada (emtricitabine/tenofovir disoproxil fumarate) as the drug of choice for HIV PEP therapy. PEP therapy is indicated for nonoccupational exposure (eg, patients who were sexually assaulted, injection drug users). It may also be used to treat occupational exposure (eg, patients who were exposed to blood through a needlestick injury or other accidents at work).

PEP must be prescribed within 72 hours of exposure, and the full regimen consists of 28 days. PEP is also available as a starter kit, which is a 3 to 5 day regimen to be used until the patient can return to the prescribing physician’s office for follow up and baseline HIV test. After the follow-up visit, the physician will prescribe the patient the remainder of the regimen.²

Currently, the United States follows the WHO guidelines and recommendations for HIV PEP therapy with initiation of PEP therapy within 72 hours of exposure and taken for 4 weeks, with the patient returning for additional HIV testing at 4 to 6 weeks, 3 months, and 6 months.¹

Before 2013, Truvada alone was recommended for PEP therapy, but since then, the US Public Health Service guidelines now recommend Truvada plus raltegravir for nonoccupational and occupational exposure.³

According to WHO guidelines, national governments are strongly urged to implement their own guidelines and policies on HIV PEP therapy.² When comparing the United States with the United Kingdom and Australia, all 3 countries’ guidelines are similar to the WHO recommendations (ie, a 28-day regimen with Truvada as the drug of choice).^1,4,5

Where these 3 countries differ is on who can obtain PEP therapy. The United Kingdom recommends PEP therapy to patients who are traveling to high-risk countries and Australia recommends PEP therapy to university students who are going on medical missions to high-risk countries.^1,4-7 The United States has no recommendations for patients in these specific situations.

In addition, the cost for PEP therapy in each country differs. In the United States, when there has been an occupational exposure, the patient’s employer will cover the costs for the patient. In nonoccupational situations, such as sexual assault, partial or total reimbursement comes from the US Department of Justice’s Office for Victims of Crime. Patients may also get assistance from the drug manufacturers.⁸

What I Learned

The large number of Americans living with HIV indicates that further education for the population about their options to prevent transmission is needed. There is a common belief that because there are treatment options for HIV and because patients who are currently on treatment are able to live longer lives than before, HIV is no longer a problem in the United States. I believe it is now more important than ever before to take action to educate yourself as a pharmacist, one of the most trusted health care professionals, so that you may further educate your patients and the general public on what options they have to prevent this disease.

Nadia Lin is a 2016 PharmD candidate and attends Roseman University of Health Sciences.

References

• PEP. Centers for Disease Control and Prevention website. www.cdc.gov/hiv/basics/pep.html. Updated August 12, 2014. Accessed November 6, 2014.
• World Health Organization Department of HIV/AIDS. Post-exposure prophylaxis to prevent HIV infection. . Geneva, Switerland: World Health Organization; 2007. http://whqlibdoc.who.int/publications/2007/9789241596374_eng.pdf?ua=1.Accessed November 6, 2014.
• Kuhar DT, Henderson DK, Struble KA, et al. Updated US Public Health Service Guidelines for the management of occupational exposures to human immunodeficiency virus and recommendations for postexposure prophylaxis. Infect Control Hosp Epidemiol. 2013;34(9): 875-892. doi: 10.1086/672271.
• Benn P, Fisher M, Kulasegaram R; BASHH; PEPSE Guidelines Writing Group Clinical Effectiveness Group.. UK guideline for the use of post-exposure prophylaxis for HIV following sexual exposure (2011). Int J STD AIDS. 2011;22(12):695-708. doi: 10.1258/ijsa.2011.171011.
• Australasian Society for HIV Medicine. National guidelines for post-exposure prophylaxis after non-occupational and occupational exposure to HIV. www.ashm.org.au/Documents/Guide%20for%20the%20Management%20of%20Occupational%20and%20Non-Occupational%20Post-Exposure%20Prophylaxis.pdf. Updated December 2013. Accessed May 30, 2015.
• Health Protection Scotland. HIV post-exposure prophylaxis (PEP) information for travelers. National Health Services Scotland website. www.fitfortravel.nhs.uk/advice/general-travel-health-advice/hiv-post-exposure-prophylaxis-(pep)-information-for-travellers.aspx. Published 1998. Updated 2015. Accessed May 30, 2015.
• University of Tasmania School of Medicine, Faculty of Health Science. HIV post exposure prophylaxis (PEP): guidelines for students on electives. www.utas.edu.au/__data/assets/pdf_file/0007/194137/smile_txt_HIV-PEP-guidelines_2.pdf. Updated January 2012. Accessed May 30, 2015.
• US Department of Health and Human Services. Post-exposure prophylaxis (PEP). https://aids.gov/hiv-aids-basics/prevention/reduce-your-risk/post-exposure-prophylaxis/ Published 2005. Updated March 30, 2015. Accessed May 30, 2015.