New HIV prophylaxis program not a solution for the ?morning after?

By Mel Waters
Monitor staff

A man suspects he?s been exposed to HIV. He remembers watching a news report about a 'morning-after' pill to fight HIV infection, available only in his hometown, San Francisco. Frantic, he rushes to the nearest public health center asking for a pill to stave off the virus.

Though eager to help, counselors inform him that the treatment involves more than taking a pill and is not guaranteed to work. It will require him, first of all, to discuss the 'hows' and 'whys' of his exposure. The counselors want more than basic details?they want to know what this man was thinking before he exposed himself to the virus.

And while treatment does include medication?a 28-day regimen of antiretroviral medication to prevent HIV infection?understanding the factors that led to this man?s risky behavior is the real focus of the HIV Post Exposure Prevention program.

A symposium on the innovative PEP approach was held during APA?s 1998 Annual Convention in San Francisco. Thomas Coates, PhD, of the University of California?San Francisco Center for AIDS Prevention Studies and four colleagues from the PEP study presented their most recent findings.

Critical of clinics that offered drug treatment without counseling, they decided to combine the two in their experimental PEP program. Unfortunately, they said, some people on the street see the program as a casual 'morning-after' solution. They emphasized it should not be viewed as a first-line defense, but as a behavior modification program.

Joshua Bamberger, MD, from San Francisco?s Department of Public Health, explained that PEP assigns a daily regimen of AZT or 3TC for 28 days within 72 hours of exposure. Bamberger admitted the PEP team members do not know if receiving antiretroviral medication so soon after exposure will prevent infection, nor do they know if PEP works.

'This treatment is unproven and untried, so [people should] remain responsible,' he said.

While medication plays a key role in PEP, researchers see counseling as the best way to prevent future high-risk exposure.

A first-time PEP applicant spends three hours undergoing health evaluations and counseling. Participants can expect to attend five counseling sessions in the first five weeks of treatment, and nine more sessions within a year.

These focus specifically on identifying and reducing risk behavior. Once the cause of the risk behavior has been identified, counselors work with participants to create a risk-reduction plan or contract which sets specific, concrete steps to addressing these problems.

Craig Waldo, PhD, from the University of California?San Francisco?s Center for AIDS Prevention Studies, said research has shown participants generally demonstrate a history of either low-risk behavior?placing themselves at risk episodically or periodically?or high-risk behavior, where individuals repeatedly expose themselves to the virus.

So far, the majority of individuals seeking PEP have engaged in low-risk behavior, he said. For example, the participant has taken normal precautions, but condom breakage occurs.

For high-risk behavior, researchers found a number of mental health issues affecting the participant:

? A feeling of loneliness and isolation that led individuals to make poor choices when searching for human contact; depression and low self-esteem also played a factor in the lack of regard for one?s well-being.

? Taking drugs that cause people to lose their inhibitions, such as LSD or ecstasy.

? Sexual compulsion or addiction.

? Immaturity regarding one?s own sexuality and the inability to set boundaries to what one will or will not do.

While research on PEP is still in its infancy, according to Bamberger, HIV prophylaxis has been available for years to health- care workers who prick themselves with contaminated needles. The Centers for Disease Control recommends such treatment for victims of sexual assault.

Though PEP researchers were optimistic, they recognized controversial elements of the program likely to be raised by their study:

? Will the availability of PEP lead to riskier sexual behavior?

? Will people view medication as their first line of prevention?

? What will be the recidivist sample of the project?

? How can the knowledge of PEP reach all socioeconomic communities?

To date, the PEP study has involved almost 200 participants, with funding for another 300 from the National Institutes of Health, the National Institute of Allergy and Infectious Disease, the San Francisco Department of Health, Glaxo-Wellcome, Chiron and the William McCarty Cooper Foundation.