01 November 2009

Post Exposure Prophylaxis

While on the topic of HIV, I was reminded of a patient I saw a couple of years back, and an ethical dilemma.

A young man arrived in my casualty on a Sunday morning. He wouldn't tell anyone what was wrong, but wanted to speak to the doctor (me) privately. This sort of thing does happen, and usually relates to something urological.
When his turn to be seen arrived, I asked why he was there. He then proceeded to relate his situation, which was causing him much anxiety. He had the previous night engaged in extra-marital relations with a girl at a party. Only this morning had he heard from some friends that she quite a reputation for her less than ideal morals. He now wanted me to provide him with anti-retrovirals to prevent him from getting HIV.

I told him that that was not hospital policy, and therefore was not possible. I told him that if he still wanted to persue the subject, he should bring in the girl, and his wife, and I would test them all for HIV, and we could then take it from there. Thankfully, he declined, thereby saving me the difficult decision of whether to provide them to him or not. He didn't want to tell his wife what he'd been up to - pretty selfish I'd say, worried about getting HIV himself, but not about passing it on to his wife! (I have written about this attitude before)

He left me with some interesting questions though: (some of which really put pressure on my ethics training at medical school!)
  1. We provide the "morning after pill" to prevent pregnancy, which is a life altering complication of poorly planned sexual relations.
  2. We provide PEP (post-exposure-prophylaxis, ie. anti-retrovirals) for occupational exposure to blood or body fluids, and rape cases, and for mother to child transmission. In all these cases the recipient can be described as an "innocent" victim.
  3. The man in this case made a bad decision (as in the situation of (1) above), but is not an innocent victim - he had time to think about what he was doing and took a calculated risk, but could have made a better choice. Is he then also entitled to PEP as it is also a life altering complication of his mistake? Should we now condemn him to a life living with HIV?
  4. If we provide PEP to people in this situation, will we not reduce the spread of HIV? (admittedly, other sexually transmitted infections (STI) would still run rampant, but isn't this still a better alternative?)
  5. If we start providing PEP to people in this situation, will it lead to an alternative to, and therefore a reduction in condom usage? This would then cause an increase in the incidence of other STI's.
  6. The side effects of these drugs can be severe, and the compliance is poor (at least it is amongst my colleagues who have had to use it after needle-stick injuries). Would this lead to more resistant strains of the virus). I suppose you could argue that the side effects aren't worth providing the drugs everytime you have intercourse, but what if it's only "every now and then"? And you could argue that it's a small price to pay to avoid living a life with HIV?
  7. Also keep in mind that there aren't even enough of these medications available to treat everybody already infected with HIV.
What do you think? Would you have given them to him?

1 comment:

Bongi said...

i would have given him a private prescription for the meds.