AIDSbuzz

PEP is a treatment taken soon after a person has been exposed to an infective source in order to prevent an infection from occurring. For instance if someone is exposed to the HIV virus, either by having unprotected sex with someone who is HIV-positive or through certain types of contact with infected blood, then an immediate course of Antiretroviral (ARV) drugs can be taken to prevent HIV disease from developing. This treatment, which is called HIV PEP or PEP for short, must be taken for four weeks and will only be effective if it is started within 72 hours (three days) of the exposure. PEP, if taken correctly, appears to be at least 80% effective at preventing an infection from developing.

This section provides information on the following:

• Situations where PEP is administered (including exposure in the workplace and due to rape)
• What happens after exposure?
• What does PEP involve?
• Additional treatments given to rape survivors

Situations where PEP is administered

1) Exposure in the workplace

Healthcare workers can be exposed to the HIV virus when looking after HIV-positive people through the following situations:

• Needle stick injuries. These can accidentally occur when blood is being withdrawn or when injections are being given or drips set up. Infected blood can then pass directly from inside the needle (which is hollow) into the injured healthcare worker. The overall risk of contracting HIV through a needle stick injury is about 1 in 300. This means that for every 300 people who have needle-stick injuries only one will become HIV-positive. The risk is reduced if the injury occurs with a solid sharp object like a scalpel blade as the healthcare worker is usually exposed to smaller amounts of blood.
• Exposure to infected fluids such as blood. If infected blood is splashed into the eye or mouth, or comes into contact with skin that has cuts, abrasions or is damaged in any way, then the healthcare worker is at risk. This risk is less than with needle stick injuries. Contact with body fluids such as saliva and urine do not pose a risk, as they contain insignificant quantities of the HIV virus.

Non-medical people can also be put at similar risk through accidental injury or exposure to blood when assisting at an accident in the workplace or on the road, for example.

If any such exposure occurs and the HIV status of the person who is being treated or helped is positive or unknown, then medical advice must be sought immediately. PEP, if it is indicated, needs to be started as soon as possible, and definitely within 72 hours of the exposure, to be effective.

The Department of Health has undertaken to provide PEP to all healthcare workers who are accidentally put at risk. They will usually be able to obtain treatment at the place where they work or they will be referred to an appropriate facility.

A non-medical person who believes he or she may have been exposed to HIV through an accident or work-related injury should request treatment at the nearest government HIV Service Point. Phone the AIDS Helpline on 0800 012 322 to find out the nearest facility.

PEP can also be prescribed privately and will be covered by most medical aids.

2) Exposure due to rape

• The risk of contracting HIV disease through forced sexual acts, including both vaginal and anal sex, is not known. It is commonly assumed that the risk is much greater than during consensual sex as forced sex is associated with greater trauma to the vagina or anus. If there is any tearing or damage the virus can get into the bloodstream more easily.
• The risk of HIV infection through oral sex is extremely low. It is much lower than for other types of unprotected sexual activity.
• PEP treatment should be started as soon as possible after rape, especially for children, and definitely within 72 hours of the incident.

There are over 50 000 reported cases of rape a year in South Africa, with 40% involving children under 14 years (Government Statistics 2004). The AIDS Law Commission estimates that the true extent of rape is much greater and that well over a million rapes are happening each year in South Africa. Given the extent of the HIV epidemic this means that rape is a significant cause of HIV infection. Widespread availability of PEP is therefore an important way to help reduce the infection rate and save lives.

The government has passed a law that guarantees all rape survivors access to free PEP. However, this service is only available at the government health facilities where Antiretroviral Treatment (ART) is being provided (HIV Service Points), and some provinces are better served than others. This means that some rape survivors will not be able to access treatment within the necessary 72-hour period.

As the government’s capacity to provide ART increases for both adults and children, PEP access for rape survivors will also increase. This is especially important with regard to children. Nearly half of rape survivors are under the age of 12 years but many of the HIV Service Points do not yet provide ART for children.

A rape survivor does not need to lay a charge of rape in order to receive PEP.

Phone the AIDS Helpline on 0800 012 322 to find out the nearest government HIV Service Point. If the rape involves a child remember to check that the facility offers PEP for children.

The website www.speakout.org.za offers extensive advice for rape survivors, as well as a list of all PEP sites throughout the different provinces.

What Happens After Exposure?

• HIV tests will be performed on all people before commencing PEP, with their permission. They will also receive pre- and post-test counselling. If a person refuses an HIV test, PEP will not be provided. People who are either known to be HIV-positive or found to be HIV-positive will not be offered PEP. They will be counselled and referred to an appropriate health facility for long-term management. If the person is HIV-negative treatment will be started immediately.
• If a rapid HIV test is not available people will be started on PEP with a three-day starter pack. If the results come back positive the treatment will be discontinued and the person will be given appropriate advice. If the person is HIV-negative the full course of the treatment will then be provided.
• Children over 14 years do not need a parent’s or guardian’s permission to have an HIV test or to take PEP. Children under 14 years require consent from a parent or guardian. In emergency cases such as rape, treatment can be given to children under 14 years on the authority of the doctor or hospital superintendent.

The health professionals and counsellors who conduct and discuss the HIV test are bound, by law, to keep the results strictly confidential. Other people, such as families or friends, will only be told of the results with the person’s permission.

What does PEP involve?

• PEP is a four-week programme of antiretroviral medication that must be taken several times a day. The drugs can have unpleasant side effects such as nausea, headaches, fatigue, skin rashes, vomiting and diarrhoea. These side effects are not serious and usually do not last long. If they become difficult to cope with, a doctor should be consulted.
• PEP is not 100% effective but becomes even less effective if doses are missed or if the full four-week programme is not finished. It is important that a friend or family member support the rape survivor during treatment and make sure that the medication is taken properly for the full four weeks. Post-traumatic stress resulting from a rape can affect the person’s ability to take medication reliably.
• People receiving PEP should ideally be seen after one week and then again at six weeks, three months and six months after the exposure. HIV testing should be performed at the six-week, three-month and six-month visits. If the person is still negative after six months they can know for sure that they have not contracted HIV disease as a result of the exposure.

Additional treatments given to rape survivors

• Antibiotic treatments to prevent other sexually transmitted infections like venereal disease.
• The ‘morning after’ pill to prevent pregnancy.

Rape is very traumatic and rape survivors need both professional support and the support of families and friends. Rape survivors also have the right to be treated with respect and dignity at all times by the doctors, nurses, police officers, prosecutors and social workers who help them after the rape.