Opinion: HIV 'morning after drug' can help end this pandemic

By now, we all know all too well there’s no one-size-fits-all solution to HIV/AIDS. If we are really committed to finishing off something so complex as a 40-plus-year-old pandemic, we should expand our well-intentioned push for PrEP, or preexposure prophylaxis, to also highlight PEP — post-exposure prophylaxis, an intervention that’s largely ignored to the detriment of many who need it and want it. Why is PEP glaringly nonexistent in HIV prevention programs — not only in Kenya, where we live and work, but also across the World Health Organization African region, with 25.6 million people living with HIV in 2022, and accounting for 50% of new HIV infections globally? One answer is that many people didn’t tolerate an earlier version of PEP. It was largely reserved for emergency use by health care workers who were accidentally exposed from a needle stick or rape survivors treated at health facilities. By the time PEP was improved to reduce side effects, new medicines taken before potential exposure to HIV, or PrEP, came on the market. Since it was approved in 2015 by the World Health Organization, PrEP offered the promise of almost total elimination of new infections — if available to all in need and used correctly. PrEP is all that anyone seems to talk about, but we’d like to turn some attention to the decades-old PEP that must be taken immediately, within 72 hours of a possible exposure, when a person still tests negative for HIV. One issue we’ve seen is that when a person needs PEP because they had risky sex without protection, they receive a dose of moralizing judgment from a tsk-tsking health care provider. The thinking there is: “If you’re going to be sexually active and potentially at risk for HIV, you should preemptively be taking the daily pill(s) known as PrEP, and protecting yourself before potential exposure to HIV, not after.” We know health care providers who, with all good intentions, have advised clients to gloss over the truth of their “oops” moment to avoid disrespectful lectures. But we don’t think that’s the solution. Making PEP freely available is. The push by clinicians and policymakers is for PrEP. And yet, preliminary analysis from an ongoing pilot study funded by the Gates Foundation reveals that for every person whose circumstances indicated initiation of PrEP through an online pharmacy, eight actually needed PEP, because of a recent possible exposure to HIV. For every person needing PrEP from a storefront pharmacy, two needed PEP. A surprising finding and a stark reminder that human behavior often runs counter to the best prevention science and public health guidance. In fact, the research initially had nothing to do with PEP. Its purpose was to test how feasible and effective it would be to expand access to PrEP. To circumvent known barriers and improve the standard of care, the study design made PrEP available through pharmacies, both online and in storefronts — neither of which are platforms through which PrEP is routinely offered. During the trial, people weren’t required to visit public health facilities/HIV-treatment clinics — places where PrEP users often feel stigmatized. When we started implementing the pilot study, we realized that quite a number of people visiting the online and storefront pharmacies had recent exposures to HIV, which made them candidates for PEP. That’s why we modified the research model to include PEP. The fact that many need PEP compels us to argue that it’s time to stop downplaying PEP as PrEP’s poor relation and reassign it a prominent place among a number of HIV prevention strategies that need to be readily accessible and affordable. The parallels with family planning are undeniable. The key to meeting national targets and global goals is to provide a big basket of various methods, with the aim that something in that basket will appeal to and work for someone with specific needs and preferences. As we reflect on why PrEP targets are not being met, we need to seriously consider those clients who came into our study needing PEP. After their 28-day course of medicine, we checked with them about ongoing risk: Would they benefit from PrEP? If the answer was yes, we counseled them and found out why many were still not willing to start PrEP, even if it was free and provided by pharmacies and in communities as opposed to only in facilities. PEP involves taking medicine for 28 days after exposure, while PrEP requires that a person take daily medicine throughout a so-called period of ongoing risk. Defining that can be tricky. It very well could mean for the rest of one’s life. As a result, some find it too daunting to commit to PrEP. The reality is that people often don’t perceive themselves to be at continued risk, even when they are. This makes PrEP a hard sell compared to PEP, because PEP addresses what’s already happened: a known risk of getting HIV, one that can’t be denied. While we are thrilled that longer-acting PrEP options are becoming more widely available in the form of injectables and vaginal rings, those options, like oral PrEP, need to be started before exposure, and may not appeal to those who are unwilling or unable to accept that they may be exposed to HIV. For these reasons, both new and tried-and-true options in terms of services must be offered to clients. Differentiated service delivery is especially important: making PrEP and PEP available in communities and from pharmacies — traditional stores and online — as well in health care facilities. As clinicians, we are excited about the freshest version of PEP delivery known as PEP-in-Pocket, or PIP, which involves prescribing PEP proactively to people, prior to any exposure, just in case. This method frees people from having to scramble to find a place where they can get PEP when the clock is ticking. Immediate use of PEP is best, so making immediate use possible is vital. We look forward to PIP someday becoming available in Kenya, progressive as it is. We know lots of people in our country and elsewhere depend on PEP. With HIV prevention, it’s not so much a question of either-or as a matter of both-and. That’s why it’s time to strongly advocate for PEP, recognize it as an important choice by many, and for policymakers and health care providers to make this HIV preventive medicine readily available and acceptable to all.