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?

Stigma

(image source)

This week our president made some of the first positive statements I have heard from the government regarding the AIDS epidemic in our country. Hopefully this will mark the end of the denial phase in the process of grieving for our country's slow death from HIV. I pray that now, as our country must inevitably move through the rest of the stages, that we will come to accept that AIDS is here to stay, and then move forward in developing strategies to fight it's rampant spread. This has been a long time coming.

You may ask what is fuelling this rampage? I have some ideas, and although they are not by any means a comprehensive list of all the factors, I suspect them to be some of the major role players. The stigma surrounding HIV, and denial of it's existence (supported by the government up until now) and the belief that "it will never happen to me" lie at the heart of it.

Why is it that a patient will come to hospital (or even bring their infant or child), and then not want to find out what is wrong with them and refuse treatment? Why seek help in the first place?
The prevailing attitude is: "If I dont test myself for HIV, I dont have it, and I dont have to make any lifestyle adjustments."

I am of the opinion that HIV is no different from other chronic or terminal illnesses. It's survival rate is comparable with that of ischaemic heart disease and diabetes (untreated, you may have HIV for 5 to10 years before developing any symptoms), and is better than most forms of cancer! The difference is that it is infectious, and you have to make adjustments to your lifestyle to avoid giving it to others (ie. stop sleeping around). This is the hard part, giving up the risky behaviour, and the topic for another post.

I am also of the opinion that the stigma is no different from syphilis, or TB. Why is it then that these are notifiable diseases, and HIV is not? I think that this is the first step to de-stigmatising the disease - make it notifiable, and bring it out into the open. Let clinics, employers, insurance companies etc. test people routinely. Changing the existing HIV testing policy (VCT) from an "opt-in" to an "opt-out" type process (as suggested recently by some Western Cape Health Department MP's) would be the first step. With the prevalence then revealed, it would be very difficult to discriminate against those infected with HIV, as I suspect the incidence would be much higher than expected. (The antenatal prevalence is 29% in our country, and I believe this reflects the working population). This is the best way to increase awareness of the seriousness of the disease, and get people to start thinking about the risks they are taking. Infected individuals would, with the knowledge of their status, be able to access treatment earlier, and therefore most likely live longer and healthier. Their partners would be able to take proper precautions too, and reduce their risk of infection.

Everybody wins.