This is the third installment of a series looking at new and emerging HIV-prevention options and the barriers that are slowing down the beginning of what could be a sexual revolution for queer men. Previously: PrEP , U=U
Have you ever felt anxious, nervous, uncomfortable after a hookup? Have you ever regretted a choice you have made after the heat of the moment has passed? Have you ever felt, after the excitement has passed and you begin to entertain those sober, cold-shower-thoughts, that you may have put yourself at more risk than you are comfortable with?
Post Exposure Prophylaxis, or ‘PEP’ is a course of treatment that can be taken after an exposure to HIV and is a last line of defense against the virus taking hold in your body. Its like a morning-after pill (except one you have to take daily for three months). It is a very time-sensitive intervention (treatment must be started within 72 hours of exposure to HIV, and it most effective when started within 48 hours) so it is generally something you need to access through a hospital emergency room.
It is also unacceptably difficult to access this option, considering the difference it could make to HIV prevention efforts if it was simpler. PEP is also not widely advertised or talked about because it is expensive, often an emotionally taxing process to get ahold of, and is an emergency option, not advisable as a ‘strategy’. A lot of sexual health educators would rather talk about better on-going prevention options like PrEP.
PEP is admittedly not a great prevention strategy, especially when other great options like PrEP are available. But the unfortunate truth is, a lot of folks don’t want to think about HIV prevention until they are confronted with the reality of HIV risk, until they have had a ‘close call’. As we talked about in the piece on PrEP, so many of us are able to convince ourselves that we are not the ‘kind of people’ who are at risk. And then we do something that puts us at risk. Perhaps we might be willing to consider PrEP now, but it won’t do us any good if its too late. So guys need to know about PEP too.
Having said that, lets be clear about another thing – the three example scenarios at the beginning of this article are all definite grounds to consider yourself to be having a medical emergency. In each case, there is no certainty that the your partner is living with HIV. There is no certainty that if he is HIV-positive that he is not undetectable (and therefore not an infection risk). There is no certainty that even if he is HIV-positive AND has a detectable viral load that the virus found a point of entry into your bloodstream. There is also no certainty to the contrary. Any of these three examples, or any time you have a high-risk sexual encounter (penetrative sex with a partner of unknown HIV status and no prevention option like PrEP or condoms has been used) is absolutely reasonable grounds to get yourself to an emergency room.
Being honest with yourself and admitting that you might be at risk is, unfortunately, only half the battle. The first barrier to overcome is realistically assessing your risk – the second barrier often happens at that emergency room, because although I might convince you my readers that this situation is a medical emergency, convincing the hospital can be difficult.
For lots of reasons which can include homophobia, sex-negativity, poor harm-reduction practice, stigma and ignorance, it happens all too often that a person who is having this kind of emergency needs to convince a triage team that the situation is indeed that – an emergency they need to take seriously and addressed quickly. Hospital staff may advise you to go elsewhere – this is not acceptable as the clock is ticking and any hospital should be capable of addressing this situation whether the triage team thinks so or not. Hospital staff may not prioritize you appropriately because they do not realize how time-sensitive the situation is. hospitals generally have good PEP procedures for dealing with people who have been sexually assaulted, or people who have had a needle-stick incident on the job, but all to often these procedures do not extend to people who have self-identified the emergency due to consensual sex that they are now concerned about after the fact. Although this is not always the case, and you may have no trouble, its a good idea to hope for the best and prepare for the worst.
Much of the advice given on PEP is scripted talking points you should use if you are feeling resistance from emergency staff, in order to convince them that you are indeed having an emergency that needs to be addressed quickly. Being explicit and specific about why you consider this to be a high-risk scenario, being specific and explicit about what you want them to do about it, bringing a friend to support you if you do not trust yourself to stay calm, or asking them to contact an infectious diseases specialist to consult over the phone if you do not believe you are being taken seriously are all pieces of advice worth listening to. They are also completely unfair and quite frankly unacceptable responsibilities to put on a patient experiencing an emergency. Life is, unfortunately, sometimes unfair. So be prepared for an experience that may not be pleasant.
And then there is more difficult news. The third barrier is that PEP is rarely available for free, and can be expensive. It is a worthwhile expense if it is going to prevent you from contracting an incurable chronic condition, but is not always feasible for everyone. It is a good idea to ask (repeatedly and persistently, if necessary) for help if you cannot afford to pay for this treatment. Hospitals that house HIV-care practices are sometimes able to provide compassionate medications for people who can’t afford them, but this is not guaranteed. You might ask to speak to the social worker on staff – they may have resources the doctor you speak to does not know about.
At the very least, it is important to ask for a starting dose to take immediately before filling out your prescription, because as said, time is not on your side and the sooner treatment is started the better the chances are it will work and prevent you from becoming HIV-positive.
And if you have used PEP before, maybe consider a better long-term solution to your own HIV-prevention strategy. If the situation that lead to you being on PEP was a one-off, anomalous thing than keep-on-keeping-on with your condoms or monogamy or whatever it is you are doing. If not, maybe its time to get real with yourself and think about PrEP.
For more information about PEP, or if you have any questions about gay men’s sexual health in Hamilton, contact the Men4Men program of The AIDS Network at firstname.lastname@example.org or 905-528-0854 x 231