PEP – The After Pill

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Forgot the rubber? Worried about the last date‘s HIV status after having barebacked together? In doubt about the effectiveness of a steady HIV-positive sex partner‘s treatment and whether they really lie ‘below detection level’? Or just maybe (still) drunk or wasted and without a clue as to what precisely happened the other day?

– If you had unprotected sex, the best thing is to remain calm. A potential infection can be prevented, if you act quickly. With (access to) PEP you have this option.

What is PEP?

PEP is a short-term medical treatment: a 30-day long regimen, that can prevent the proliferation of the HIV virus in the body – an infection – following unprotected sex or other types of exposure to HIV.

PEP stands for:

  • Post (following)
  • Exposure (to the virus)
  • Prophylaxis (protection from infection)

PEP is an emergency treatment. It is neither meant as prevention nor is it a substitute for methods to prevent HIV transmission such as condom use, ‘ ‘treatment as prevention,’ (non-infective HIV-positive in effective therapy) or pre-exposure prophylaxis PrEP (preventive medication). A PEP treatment should begin as soon as possible after exposure to HIV – optimally after 2 hours or at least within the following 24 hours, the latest being 48 hours – and pills taken regularly over a period of 30 days. You must be vigilant in taking your PEP regimen every day.

How does it work?

The HIV-medication prevents the virus from multiplying in the cells of the immune system, once the virus has entered the body in large enough amounts. In this way the drugs boost the immune system to fight down the viruses.

For a PEP treatment to be effective it is therefore essential that you minimize delay. The later the treatment is initiated, the smaller the chance of successfully preventing infection. This means that even on the weekend or during holidays, you should seek treatment as soon as possible to maximize the effect of the drugs.

How effective is PEP?

According to studies, PEP works in around 80% of cases – depending on how early the treatment begins and adherence (to dosage). Using PEP therefore goes a long way and is undeniably worth it.

However even with timely administered treatment, successful prevention is not guaranteed. PEP can, for unknown reasons, fail in isolated cases. If PEP is started too late, it probably won’t work correctly and the virus will infect the body’s immune system.

Basic principle:

THE EARLIER – THE BETTER.

Another cause for the treatment to fail can be premature discontinuation of the medication. Once you’ve made the decision to start treatment, stick to the 30-day pill program – even if you start feeling ‘healthy enough’ along the way.

Who receives PEP?

If you go to an emergency room or any appropriate clinic (see below), the first matter in hand that’ll be decided is whether or not you need PEP.

For men who have sex with men, be they homosexual, bisexual, trans* or other type of men, a higher transmission risk is assumed. For this risk group, depending on the sexual practice, the following recommendations are given (according to the German-Austrian guidelines on PEP):

PEP is recommended for unsafe anal sex, when your sexual partner’s HIV status is known to be positive and his/its treatment status (viral load) is unknown. This goes for both the passive (receiving) as well as the active (penetrating) part; with or without ejaculation (coming) and without a condom or in case of a broken condom.

If the HIV status of your sexual partner is unknown, or cannot be ascertained, a PEP treatment can be offered after anal sex (active/passive; with/without coming; without a condom or a broken condom).

In the case of anal sex where the other sexual partner’s HIV-status is known to be positive, but their viral load lies below the detection limit (undetectable and noninfectious), no PEP treatment will be offered.

PEP is no longer recommended for oral sex, as the risk of infection is considered to be very low.

For the shared use of injection equipment as well as for puncture injuries with a recently used needle, PEP is recommended.

In the case of sex with persons who use intravenous drugs or who come from areas where HIV is widespread and whose HIV status is unknown, a high HIV transmission risk is assumed and PEP is more likely prescribed.

If your sexual partner is HIV-positive and their viral load exceeds 50 copies/ml, i.e. is no longer undetectable (below detection limit), then PEP will always be recommended regarding anal or vaginal intercourse.

On the other hand in the case of heterosexual “one night stands”, it is assumed that there is no high risk (if HIV status is unknown).

The doctor’s decision may result in PEP not being prescribed because the criteria for a risk exposure are not met. Borderline cases sometimes lead to a prescription after a clarifying conversation, when worries for an infection are high. Often the situation will be checked for a second time after a few days. If it turns out that PEP is not necessary, no further medication will be prescribed. However anyone who is beforehand well-informed and who can make realistic evaluations regarding transmission probabilities of HIV does not need to take drugs unnecessarily just to calm themselves down.

If your sex partner agrees, ask him or her to come with you to the emergency room. All questions can then in common be clarified.

How to do a PEP?

First you will have a blood sample taken from you in order to test you for HIV and to save blood for later laboratory tests. You will then receive your first dose of medication and a referral for a medical practice that specializes in the field.

You will then be given medical attention, your blood will be regularly (after two weeks) examined and you will finally be tested again for HIV.

At best, this result is negative. In a few cases, however, the test may also turn out positive if the PEP was not effective. This is why good medical supervision during PEP treatment is important.

In addition to the PEP treatment you may ask to be vaccinated against hepatitis A and B and to be tested for STDs (sexually transmitted diseases). This includes (depending on one’s sex practices) swab tests for chlamydia, gonorrhea and a test for hepatitis C – it’s best to ask afterwards!

How well is PEP tolerated?

The drugs used for PEP are usually tolerated well. The most common side effects include headaches, nausea and fatigue. The package slip can contain important information not mentioned by your doctor, so it’s a good idea to read it carefully.

Most side effects disappear after a few days, but occasionally they can persist. Severe side effects should not persist through the whole treatment. If this happens, the medication is usually changed.

Even light side effects could tempt you to discontinue the PEP. Try to think positive: It’s better to live with some annoying side effects for a few weeks than with HIV for the rest of your life! Some side effects can also be treated. Never stop PEP on your own, it’s extremely important to talk to your doctor first!

Where do I go for a PEP?

In the daytime and during the week the closest HIV practice is the best starting point (see link below). Outside of opening hours you are left with going to the emergency room of a clinic, which offers 24 hours a day PEP (aidshilfe.de/adressen).

The German AIDS-Hilfe telephone service provides information on where and how exactly PEP in the Federal Republic of Germany (FRG) is offered (for tlf. see below).

In Berlin you have access to PEP treatment around the clock: Immunological Day Clinic of the AVK (“Immunologische Tagesklinik”), Rubensstr. 125, 030 130202595 and emergency ambulance of the Charité, Hindenburgdamm 30, 030 8445-0 and Augustenburger Platz 1, 030 4505-0.

In Leipzig at the 2nd Clinic for Internal Medicine in the St. Georg Clinic (“2. Klinik für Inneres im Klinikum St. Georg”), Delitzscher Str. 141 (0341 9094005).

In Switzerland you’d be best off going to one of the checkpoints (link below). Apart from that all hospital emergency facilities offer PEP. In Zurich this is the emergency room of the University Hospital, Schmelzbergstr. 8, 8091 Zurich, Tel. 044 2551111.

Emergency rooms are open around the clock.

If you go to a clinic, you’ll have to expect that PEP might not be well known to all employees. It’s best to ask beforehand which facility of the hospital offers PEP and to call directly there. Often you have to ask for the internist on duty. Let them explain to you what the procedure is, whether you first have to be in the emergency room, etc. Generally you can count on more experience with PEP in metropolitan areas. A direct route can be of service here.

However, if you meet with inexperienced staff, insist on getting someone who knows about PEP. Take this info and just show it.

How expensive is PEP and who pays for it?

The four-week therapy alone costs around 1500EUR/1800CHF, plus medical consultations and laboratory tests.

Within the scope of emergency treatment the costs in Germany have to be paid by the health insurance companies (KV – Krankenversicherung) and in Switzerland by the basic insurance.

In the FRG, however, the KV sometimes refuses, and healthcare practices are accordingly cautious with making any prescription. In some cases PEP is (wrongly) judged to not be covered by statutory health insurance and the patients charged on the spot by the hospital. You can reject this and insist on your right. You can also first pay and later have your KV reimburse it.

After two treatments some health insurance funds will no longer be willing to pay for additional costs. However this should not hold you back from keeping on asking for PEP and a cost takeover. Often there are individual solutions available (e.g. donated drugs).

On the other hand there are no problems in the case of risk situations that are workplace related (for example in the case of needle-stick injuries among hospital personnel). Here the professional associations pay and the treatment is the same.

No health insurance?

There are no statutory provisions in Switzerland or the FRG.
Even without health insurance we recommend that you go directly and without delay to a relevant emergency room/clinic and to ask for a solution there.

In Berlin a network of AIDS practitioners deal specifically with people without health insurance (contact info: Migrant*inenberatung Berliner Aidshilfe, Mo + Th, 12-16h, in 5 languages). Here you can find out exactly where PEP is available for you.

In Switzerland PEP is free of charge for sex workers who are not insured in Switzerland (contact via Checkpoint).

Health services for refugees who have applied for asylum are taken over by the social welfare office in the FRG. The costs of PEP in this case must correspond to the benefits of the statutory health insurance.

PEP on the road

When abroad in the EU, PEP costs are only covered if they are part of the usual emergency measures in the respective country. Travel insurance (for 10EUR/year) usually covers these costs (ask in advance!).

If you are a foreigner or non-EU citizen working or temporarily studying in the FRG or Switzerland you need an international health insurance. Whether they cover PEP expenses has to be clarified from case to case. The same applies for tourist visits. International travel insurance is always recommended.

EU residents living in Germany (without German health insurance) and tourists from the EU are in emergency cases reimbursed by their health insurance of the country they live in. PEP is usually covered by it (ask before traveling!).

Sex accident – What to do right away?

Right after unsafe sex, the likelihood of an infection can be reduced according to the situation and the body region: You can wash your penis with water (roll back the foreskin carefully and without pressure) and pee. If somebody came in your mouth, the risk is so low according to today’s knowledge, that further measures (including PEP) are not necessary. If you want to further reduce this minimal risk, just rinse your mouth with water. If sperm gets into the eye: simply rinse with water or spit.

Apart from that: keep calm! Use of disinfectants, alcohol and colon cleaners are counterproductive: They irritate the skin and make it more vulnerable. If there was an exposure risk during anal sex: Start PEP immediately!

PEP – yes or no?

In a moment that requires quick decision-making, you’ll be wondering if you’re ready to take regular medications and to deal with the related restrictions for a month. If you can not answer this question clearly with yes, then you should probably forego this progress. From talking with a doctor you may learn about things which you yet didn’t know. Short-term use of PEP should not be expected to lead to any sustained damage to the body.

If you are unsure, take some time to weigh the pros and cons. For some people it helps to first discuss it with friends before making a final decision.

PEP and mixed-status partnerships

One of the two is HIV-positive and the other is not: PEP can still prevent HIV transmission after an unsafe situation. In the long term, the protective effects of an effective therapy (“under detection limit”), condom use and/or PrEP (Pre-Exposition Prophylaxe) are better options for effective protection. Only when the above are not given, should PEP be the choice for an emergency treatment.

Mixed-status partnerships have an inherent stress: The fear of the negative partner becoming infected as well as the fear that the positive partner will cause the infection. The stress is best dealt with by having considered the use of PEP beforehand together: Is it necessary at all? And if so, how and where?

And by the way: Do not just take the medication of your partner as as substitute for PEP!

After PEP, before the PEP?

PEP is not a type of safe(r) sex, but a good means to prevent an HIVinfection after having unsafe sex. See it as an opportunity to think about your needs and limits. If you exceed the latter time and again, you may need to change your behavior if you do not want to infect yourself with HIV. As mentioned at the beginning, there are nowadays many options for this. In countries where PrEP (Pre-Exposure Prophylaxis) is already available, persons who repeat a PEP treatment are advised to think about this new type of HIV prevention drug. PrEP can be taken on a daily basis or on an irregular, case-by-case basis, and hopefully soon it’ll start to being covered by health insurance companies in Germany.

For many, however, condoms will remain the prevention method of choice. Think about your use of condoms and find out in which situations they work and which they don’t.

You can ask HIV-positive sex partners whether their therapy works well, and if they are sure that they are not infectious (undetectable viral load). With them you can also have sex without condoms or PrEP, if you are regularly tested for STDs (sexually transmitted diseases) and if your current HIV status is known. HIV rapid tests can also provide clarity here and therefore more safety. Anyways: Sex should be horny! Safer sex is not magic! And talking about it blesses!

To do list

The public knowledge of PEP is not particularly widespread. Younger people often have no plans at all. That needs to change. To get PEP, however, is not as easy as it could be: gay health centers should offer their services without complications and accompany them with appropriate, scene-proximate and professional advice. Last but not least, unclear provisions for coverage of costs are responsible for inhibitions among doctors when they stand to prescribe them; often they are also just uninformed. Health insurance does not always pay, although the costs of lifetime HIV therapy would be much higher. And those who do not have health insurance also need easy access to PEP!

This can all be done better and is the task of a modern health policy: PEP is a far too good a method to prevent HIV infections to ignore!

Where can I find more information?

On the Website of Deutsche Aids-Hilfe you can find a list of clinics, providing PEP 24/7.
A list of specialized medical HIV practices (HIV-Schwerpunktpraxen) is on www.hivandmore.de/aerzteverzeichnis.

If you wanna talk with someone about PEP (in English, too):

Mancheck in Berlin
+49 30 44668870
www.mancheck-berlin.de

Checkpoint in Zürich
+41 44 455 59 10
www.checkpoint-zh.ch

or at the local Aids-Hilfe offices: The hotline 0180 33 19 411 (max. 9ct/min, German landline) is open Mo-Fr 9-21h and Sa-Su 12-14h. You may remain anonymous here.

Wanna be a Lovelazer?

We are an initiative independent of pharma and state institutions. At the moment we are writing flyers for “treatment as prevention” and “safer use with slamming,” because we do not consider the available information to be sufficient. Our first flyer regarding PrEP has already triggered many discussions. You can find it printed in German and English at Mancheck Berlin or here at www.lovelazers.org.

All kind of support of our work are always welcome! Contact us: info@lovelazers.org