SEPTEMBER 1998

NUMBER ONE

PEP Remains Sticky
"Morning after" pills worry critics.

About 5,000 people in the U.S. each year are accidentally exposed to needle sticks, while millions worldwide are exposed to HIV through contaminated needles and sexual contacts, including rape. In response, researchers have developed "morning after" treatments to prevent transmission immediately after exposure. Post-Exposure Prophylaxis, or PEP, is advocated on a case-by-case basis for pregnant women and health-care workers involved in high-risk occupational needle-stick accidents. It's increasingly available to rape victims as well.

At a San Francisco program, advocates recommend PEP to people who have had unprotected anal or vaginal sex with a person known to have or be at risk for HIV, as well as to people who have had receptive oral sex and swallowed their partner's semen. Others want PEP to be extended to sex workers, prison inmates, injection drug users, and people whose condoms have broke during sex.

Studies show PEP has reduced the risk of HIV infection by 81 percent in health-care workers involved in needle-stick accidents. Meanwhile, new research into acute HIV infection shows that early use of HAART can reduce disease progression by lowering viral load and may be critical to preserving a key element of the immune system and maintaining health. As a result, the Centers for Disease Control recently revised its guidelines for preventive treatment of health-care workers exposed to needle-stick accidents.

The CDC guidelines issued in May recommend that PEP be offered promptly to health-care workers after a high-risk occupational exposure, preferably within one to two hours after exposure. PEP will not be offered if 72 or more hours have passed since the time of contact. This is based on animal studies showing PEP is probably not effective when started later than 24 to 36 hours after exposure, although this issue remains unclear. PEP is also available to pregnant women in cases of acute infection, on a case-by-case basis. If a person's HIV status isn't known, use of PEP is decided on a case-by-case basis of the risk of exposure. A four-week course of antiviral treatment is recommended with either two drugs (AZT and 3TC) or, for people with higher-risk exposure, a three-drug regimen (AZT, 3TC, plus Crixivan or Viracept). Substitution of soft-gel Fortovase may be considered for an expanded PEP regimen if it's preferred by the prescribing doctor. Those taking PEP are asked to use condoms or abstain from sex to prevent secondary transmission during this period.

PEP programs are now available in five states, but the idea remains controversial. Critics worry that providing easy access to treatment will lead to increased risky behavior. To prevent this, a federally funded PEP program at the University of California Center for AIDS Prevention in San Francisco, for example, offers PEP participants HIV counseling, including risk-reduction and behavior-modification techniques.

Other critics worry about uncertain health consequences of early use of HIV meds, which some scientists feel can lead to earlier development of drug resistance if PEP regimens aren't strong enough. The standard of care for those with HIV infection is a three-drug regimen, not PEP's two-drug combo.

Since information is emerging daily about just how effective HIV drugs really are, consult the CDC or the HIV Post-Exposure Prophylaxis Registry at (888) 737-4448 for updates on PEP drugs. Health-care workers should call the 24-hour National Clinicians Post-Exposure Hotline at (888) 448-4911.

Clinton Flip-Flops on Needle Exchange
Prez's last-minute switch is widely criticized.

Shock and dismay greeted President Clinton's recent decision to retain a nine-year-old ban on federal funding for needle exchange. Just before gunning down the funding proposal, Health and Human Services Secretary Donna Shalala leaked the word in late April that the administration was preparing to lift the ban. Ironically, while doing the opposite, Clinton did publicly acknowledge numerous scientific studies that show needle-exchange programs are a safe, efficient way to reduce HIV transmission among injection drug users.

So what happened? It seems Clinton had a last minute change of heart after speaking to Barry McCaffrey, the retired general appointed by Clinton to run the Office of National Drug Policy. The drug czar somehow convinced Clinton that lifting the ban would legitimize drug abuse-and claimed he had hard evidence to back up his views. McCaffrey's dope? Two Canadian field studies which showed that addicts in Vancouver and Montreal who used needle-exchange programs had higher rates of HIV infection than those who didn't.

What McCaffrey left out was that the programs were set in the heroin capital of the world-the Eastside district of Vancouver-where 6,000 to 10,000 addicts live. Many studies show hardcore addicts are at the highest risk for HIV, which is exactly why prevention advocates target their outreach to this group. Thus, it makes sense that they would have higher rates of HIV infection. In fact, the authors of the Canadian field studies themselves publicly endorsed needle-exchange programs as effective. McCaffrey, they told reporters, misinterpreted their data.

What's the 411? Is it that the government knows needle exchange works but won't pay for it? So say HIV activists, who took their protest to the streets of New York this summer carrying 33 symbolic coffins-one for each infection they say will result each day from Clinton's turnabout.

But newer reports just may turn the tide. A collection of 17 studies presented at the recent World AIDS Conference in Geneva shows that needle-exchange programs have helped bring the epidemic among IV drug users in New York City under control-a remarkable finding. The studies were led by Dr. Don C. Des Jarlais, a top authority on drug addiction at Beth Israel's Medical Center in New York, in collaboration with the New York City Health Department. Des-Jarlais says, "The great news that it is possible to control this epidemic [among drug users] is one of the best things we've heard in more than 15 years."

Hey, Bill, didja catch that?