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WHO IS: Dr. David Hoos, M.D., M.P.H., works in New York State health policy development

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by Dr. David Hoos

You never have sex with your HIV-positive partner without using a condom. Last night, though, either it broke, or you were both out of condoms and had partied harder than usual, so just this once you decided, hmmm, let's wing it!

Should you panic? Yes and no. It may now be possible to block HIV transmission after unprotected sex with medications called "antiretrovirals." But medical policy-makers are not sure they want this treatment to be standard emergency practice (comparable to shots for rabies).

Currently, the treatment, called Post-Exposure Prophylaxis (PEP), is routinely given to health-care workers who have been stuck by HIV-infected needles. The New York State Department of Health recommends PEP for women who have been raped.

But what about people who choose to have high-risk sex or to share needles when they shoot up? Some advocates want PEP administered routinely in these cases as well. Otherwise, they argue, it's a moral judgment instead of a medical one.

But there are good reasons to discourage widespread use of PEP. It means using three potent drugs, each of which can cause so many side effects that few health-care workers complete all four weeks of medication. Since most people exposed to HIV don't get infected, hundreds would undergo treatment needlessly. Lastly, some medical professionals worry that if people think there's a "morning after" pill for HIV, more will abandon safe sex (although so far there is no evidence for this).

As long as PEP after consensual sex has not been officially declared "standard treatment," if you've been exposed to HIV and want to take PEP, you may have trouble finding a doctor who even knows about it. And you won't have much time to find one: The window of opportunity for effective treatment closes after 24 hours. Also, because PEP is not an established standard of medical care, managed care programs may balk at paying the $1,000 that PEP costs.

The Upshot: It's best to negotiate emergency use of PEP with your doctor and HMO before you need it. When you have 24 hours in which to deal with a possible exposure to HIV, the riskiest thing you can do with them is wing it.

Related Links:
(1) HIV InSite — Post Exposure Prevention
Health Care Workers and Post-exposure Treatment

(2) HIV InSite
PEP after Sexual Exposure
Use of post exposure prevention for nonoccupational exposure raises certain ethical issues.

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