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Can HIV exposure regimen work for outpatients?

Postexposure prophylaxis has been a means of dealing with possible HIV exposures in the hospital for years. Now interest is building for widespread use.

By Victoria Stagg Elliott, amednews staff. May 12, 2003.

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Seven years after the establishment of guidelines for HIV postexposure prophylaxis in medical settings, physicians are starting to receive some guidance for use of the regimen in the broader community.

Rhode Island became the first state to release comprehensive guidelines last September. A bill is wending its way through the California State Legislature requiring the establishment of a task force to set up the state's own guidelines. And the American Academy of Pediatrics is expected to become the first major medical society to publish its own guidelines.

"We needed to say something about it because it's an issue that is faced often by pediatricians, internists and family practitioners, and there haven't been good guidelines," said Mark Kline, MD, professor of pediatrics at Baylor College of Medicine in Houston and chair of the AAP's committee on pediatric AIDS.

Each of these efforts is an attempt to harness a method for HIV prevention when primary prevention fails. What should a doctor do when presented with a patient stuck by a discarded needle, anxious after a sexual assault, or even feeling regret after unsafe sex?

"It's a very difficult topic," said Peter L. Havens, MD, lead author on the AAP guidelines and professor of pediatrics at the Medical College of Wisconsin in Milwaukee. "In the medical setting, if a patient is in the hospital, you know a lot about them or can find out very quickly if they have HIV if you get a needlestick. In the setting of real life, if you get raped, you don't know if the guy had HIV or not and you might not be able to find [out]."

The development of guidance, however, is hampered by a lack of evidence that prophylaxis in these situations can effectively reduce new HIV infections. The Centers for Disease Control and Prevention has a registry attempting to collect data that may answer this and other key questions. The drugs given are also expensive and have many unpleasant side effects, and it is unclear whether the risk outweighs the benefits.

There is also the uncomfortable question of whether patients would forgo primary prevention strategies such as safe sex if the availability of a "morning after" HIV drug regimen is widely known. So far, these possibilities have not been borne out in studies. "People are concerned that some people will be inclined to be less careful if they feel that there's something they can do after they take a risk," said Kenneth Mayer, MD, one of the authors of the Rhode Island guidelines and professor of medicine in community health at Brown University, Providence, R.I. "But in our experience, that's rare. People generally want to avoid putting themselves in that position."

There is, however, demand from both patients and physicians. A study in the March 2001 Journal of Acquired Immune Deficiency Syndromes. by researchers at John Snow Inc., the public health consulting firm that runs the CDC's registry, found that more than half of Massachusetts emergency departments received 30 requests per year from doctors and patients for the regimen, although only 15% actually had written guidelines for its use.

"Providers are becoming more aware and recognizing we shouldn't limit our thinking to just people who get exposures on the job," said Laurie Kunches, lead author and director of the registry. "If there are ways to interrupt other transmission episodes, we should at least offer the drugs."

The regimen is primarily the domain of the specialist clinic or the emergency department in a high-risk area. But, as awareness increases, it could move more into the scope of practice of the primary care physician. Postexposure prophylaxis should be initiated within 72 hours of a potential exposure, preferably within an hour. Access through a patient's own doctor may make it easier to get it within that window.

"Primary care [physicians] can play an important role," said Dr. Mayer. "But if the [physician] feels that he or she is not sufficiently knowledgeable about antiretrovirals and monitoring the side effects, they should at least know who the resources are."

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