By Ben Wilcock, Senior Capacity Building and Projects Officer, Australian Federation of AIDS Organisations (AFAO).

Treatment as Prevention (TasP) and HIV Pre-Exposure Prophylaxis (PrEP) have dominated media on HIV in Australia in the last year. However, an overlooked biomedical prevention method, Post-Exposure Prophylaxis (PEP), deserves to stay firmly on the radar of the community-led HIV response.

PEP is a month-long course of medicine taken after possible exposure to HIV. The sooner someone starts the better. It is most effective within 24 hours of possible exposure and must be started within 72 hours. PEP is the same type of medicine some HIV-positive people use as treatment.

There is limited knowledge of what PEP is among gay men, and how to access the medication, particularly in non-urban areas. Seeking PEP through a hospital emergency department can be stressful due to the limited understanding of hospital staff of PEP.

The Seroconversion Study focused on the experiences of people recently diagnosed with HIV. It found a number of reasons people decided against seeking PEP after a high-risk event, including previous negative experiences. The study documented cases where people encountered negative attitudes of clinicians or hospital staff, and later seroconverted.

The following quotes are from survey participants:

“The last time I had asked about taking PEP at the local hospital I was met with attitude and condescension. This made me feel like asking for PEP was a crime and that I was taking up valuable resources by asking.” 

“Obtaining PEP was horrendous and one of the worst experiences of my life. [It’s] easier just to accept getting HIV, hence my decision not to go a third time” 

“On my previous two occasions I was grilled to a point I felt like I was begging; I would rather have just bought them over counter even if [for] $400”

Although these experiences were expressed by a minority of men in the study, these infections may have been prevented, had their experiences been different.[1]

This reflects other anecdotal reports of negative attitudes when seeking PEP, including among those re-presenting for PEP, as well as staff not knowing about PEP, or saying it is unavailable.

It is important clinicians respond to each presentation in a non-judgemental way, using non-stigmatising language, for all people presenting for PEP regardless of any population or the type of potential exposure. This will make people more comfortable re-presenting for PEP.

In August 2016, the Post-Exposure Prophylaxis after Non-Occupational and Occupational Exposure to HIV: Australian National Guidelines were updated (the guidelines can be found at https://www.ashm.org.au/HIV/PEP/). This update included the addition of information about the need for non-judgemental clinical responses for people seeking PEP.

The new guidelines highlight the opportunity to refer people for PrEP, as a practical and non-judgemental alternative response for repeat PEP presenters. The updated guidelines also provide information on the need to triage appropriately and for PEP eligibility to be based on the type of exposure determined during the clinical assessment. It also includes information on particular issues and populations. This is to help these populations receive appropriate care and minimise anxiety when accessing PEP. For example, this includes new information on gender identity and history, the importance of not making assumptions about gender identity, the type of sex people may have, or the level of risk associated with that sex.

To ensure the experience of accessing PEP is improved, there is a need for ongoing training of clinicians and hospital staff. This includes increasing awareness and knowledge of PEP and the new PEP guidelines, the importance of providing a non-judgemental service, and the implications of not doing so. There are tools available for clinicians to assist in the implementation of the new guidelines, which are available with the guidelines at https://www.ashm.org.au/HIV/PEP/.

With the increased uptake of TasP and PrEP as effective prevention strategies, there could arguably be less demand for PEP, at least among some populations or sub-populations. However, it is vital that people at risk of HIV – and not on PrEP – can access PEP to reduce the risk of HIV acquisition. This includes heightened awareness of PEP, where it can be accessed, and better availability outside major cities. The negative experiences of those seeking PEP must be minimised, while encouraging linkages to other prevention technologies such as PrEP, alongside education and care.

[1] Experiences of HIV: The Seroconversion Study Final Report 2007–2015. Monograph, The Kirby Institute, UNSW Australia, Sydney Australia, 2016;76.