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The San Francisco Postexposure Prevention Program has demonstrated that it's feasible to provide postexposure prophylaxis in a city with a high incidence of HIV. The program enrolled over 400 persons with high risk exposures to HIV within a 72 hour window. With adherence counseling, 79% of participants completed 4 weeks of treatment, which is substantially higher than that seen among health care workers. One of the public health concerns expressed prior to the start of the study was that some persons might use PEP as a replacement for primary prevention. However, for the vast majority of participants, the exposure was relatively discrete and did not represent ongoing high risk behavior in the 3 month period prior to the exposure. On the other hand, 54 participants (13%) required more than one PEP treatment; however, none required continuous treatment. The median time from exposure to initial treatment was 33 hours. Although our program demonstrates that it is feasible to provide PEP, important questions remain unanswered. Is PEP efficacious and what study designs would demonstrate its efficacy? Since all but 5 participants in our program elected to take antiretroviral therapy (even though it was not required for our study) observational trials offering PEP are unlikely to establish efficacy. While there were no seroconversions within 6 months, there were 5 participants who seroconverted due to subsequent exposures. Improving our prevention counseling model to have more lasting prevention impact is important. The time from exposure to treatment was relatively long. Reducing this time interval would likely increase PEP efficacy. Perhaps, most importantly, it remains unclear how best to incorporate PEP into the ongoing prevention efforts of local health departments. |
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© 7th
Conference on Retroviruses and Opportunistic Infections, |