Post-Exposure Prophylaxis (PEP).

If you’ve recently been exposed to HIV, Post-Exposure Prophylaxis (PEP) can prevent transmission if started within 72-hours.

1) What is PEP?

HIV Post-Exposure Prophylaxis (PEP) is a four-week daily dose of HIV medications (in pill form) that can potentially stop HIV infection after exposure. PEP must be started within 72 hours of exposure. The sooner you start taking it the better.

Keep in mind that the term “PEP” is a general medical procedure to prevent many infections (e.g. Hep A and Hep B etc.) so it is important to say that you are talking about PEP for HIV when you are talking to medical professionals.

For more information about PEP use among gay, bi, and queer men visit: www.thesexyouwant.ca/PEP

For more information about PEP use among cis & trans women visit: www.whai.ca/resource/pep-women-2021

2) Why should I use it?

You should consider getting PEP to stop HIV as soon as possible if you have:

  • had a condom break during anal, vaginal, or front hole sex;
  • had anal, vaginal, or front hole sex with no condom, or;
  • shared syringes for injecting any substance.

Accessing PEP is especially important when you know your partner is living with HIV or AIDS and is inconsistent with taking their medications or taking no medications at all as their viral load may not be suppressed. It’s appropriate to consider PEP when you don’t know your partner’s HIV status as well.
 
You may also need PEP in a situation where there is a risk to you for HIV because of a sexual assault or because of an accident at work, usually in a medical or emergency services work setting such as a needle-prick injury.

3) Is PEP used after a sexual assault?

Yes, HIV PEP treatment is part of the standard of care at all 35 Sexual Assault / Domestic Violence Treatment Centres across Ontario. Work has been done by these centres to increase awareness among healthcare providers and emergency departments about how to administer PEP properly and how to ensure it will be free of cost to you in a sexual assault context.

Medical staff will need to discuss what happened to you in order to assess your risk for HIV and to determine if PEP should be started. This will likely be uncomfortable to talk about but is necessary.  Even if you don’t remember what happened, they will need to consider any evidence of risk and advise you to consider yourself at risk for HIV so you can consider protecting others from possible infection, such as your regular sex partners.

Be aware, administering PEP also involves getting a test for HIV so they can see that you are not already living with HIV as well as testing for other medical conditions.

4) Where can I get PEP?

Some emergency rooms can keep you waiting, but others will be more experienced in dealing with people asking for PEP; they will rate you as a higher priority and may have the ability to give you a starter kit of medication after your consultation. This will allow you to start PEP treatment right away until you can get to a pharmacy to fill your entire four weeks’ worth of medications.    

In Toronto, some hospital emergency rooms within the University Health Network (The Toronto General and The Toronto Western) as well as Mount Sinai Toronto have done some work with PEP and PrEP experts to be more familiar with PEP. St Michael’s Hospital has the oldest established practice of giving out PEP to the queer community in the city. 

Although any hospital should be able to handle this issue, keep in mind emergency rooms experience staff changes. As a result, attitudes towards queer people and people who inject drugs may be less than favorable, and their PEP expertise can be low. If a hospital turns you away or advises you to go elsewhere, consider requesting that they call an infectious diseases specialist for advice on how to handle the situation, since sending you to a different institution can result in delays in accessing PEP.

There are also select clinics (e.g. HQ, MedsExpert, Safer Six) who have experience with PEP and understand the urgency of getting it as soon as possible.

Sexual assault centers should be equipped to navigate how you can get PEP in sexual assault situations.

5) What do I need to get PEP?

You Need A Prescription: get one as soon as possible from someone who can write a prescription. As with other medications you can’t walk into a pharmacy or hospital and simply buy PEP. To get a prescription, the doctor who can give it to you has to be satisfied that you:

  • have had a likely exposure to HIV,
  • are not already living with HIV,
  • will be able to take the full four weeks of the medication (not start and stop it for whatever reason); and
  • have disclosed all other medical conditions, medications, or hormones you may be taking.

It is essential to get a prescription as soon as possible, so most people go to their local emergency room for this. It’s important to calmly and clearly explain to emergency staff that you believe PEP needs to be prescribed and started as soon as possible. 

  • Quick Access: For PEP to work properly you need to get it as soon as possible. After 72 hours from an exposure to HIV has passed, the effectiveness of PEP has declined so much that a medical professional would not prescribe it to you.viii xi
  • Money (or Insurance): A course of treatment of PEP can cost between $900 – $1300 depending on the medications prescribed.

In Ontario, if your private insurance cannot cover the cost, you should explore any public programs options for you to navigate, such as OHIP+ (for people aged 24 or younger), the Ontario Drug Benefit (for people aged 65 and older), as part of ODSP or Ontario Works benefits, or through enrollment in the Ontario Trillium Drug Benefit, for example. To learn more about your full range of options, a pharmacist or social service worker can help you figure it out.

If neither private nor public programs can’t cover the cost, you will have to pay for it out of your own pocket. That said, money should not be a barrier to accessing medication. If you are unable to afford the medications, you can ask if they can be provided to you at a lower cost or free of charge. There is no cost in a sexual assault situation and in many occupational exposure situations.

6) What else should I know about PEP and the medications involved?

  • Availability: Not all emergency rooms will automatically carry PEP or offer you PEP if you say that you were exposed to HIV through consensual sex or injection drug use. Emergency rooms vary in their procedures and experience with PEP.
  • Effectiveness: The treatment may not work. But, the sooner you begin PEP following a potential exposure, the more likely it is to be effective.
  • Interactions: your PEP medications could interact with other medications, recreational drugs, alcohol and/or possibly hormones. A medical professional will check for interactions, but if you are interested in specific drug interactions visit: https://www.hiv-druginteractions.org/checker
  • Side Effects: As with all medications, there can be side effects, but newer HIV medications are generally well tolerated by most people and last for a few days or possibly weeks. Side effects depend on the medications used, but the most common effects are feeling tired, diarrhea and nausea (feeling sick).

7) What if I’m a Woman and I am thinking about PEP?

Barriers to Accessing PEP for Women:

Emergency staff should know the protocol of giving HIV PEP to patients in a consensual sexual risk situation. Unfortunately, there is no guarantee that this will always be the case. If the staff are reluctant to prescrive PEP for you, consider requesting that they call an infectious diseases specialist for advice on how to handle the situation. Bringing a supportive friend that can advocate for you at the emergency room is a good tactic to consider.

Affordability of PEP may also be a barrier. In Ontario, if your private insurance cannot cover the cost, you should explore any public programs options for you to navigate such as OHIP+ (for people aged 24), the Ontario Drug Benefit  (for people aged 65 and older), as part of ODSP or Ontario Works benefits, or through enrollment in the Ontario Trillium Drug Benefit,  for example. To learn more about your full range of options, a pharmacist or social service worker can help you figure it out.

If neither private or public programs can’t cover the cost, you will have to pay for it out of your own pocket. That said, money should not be a barrier to accessing medication. If you are unable to afford the medications, you can ask if they can be provided to you at a lower cost or free of charge. There is no cost in a sexual assault situation and in many occupational exposure situations.

Pregnancy & PEP:

HIV can be passed from birth parent to baby during pregnancy, so it is crucial to begin taking PEP immediately after you have been potentially exposed to HIV. Please notify the emergency room staff that you’re pregnant when accessing PEP, this will help with your course of treatment.

Breast/Chest Feeding & PEP:

There haven’t been many studies on the effects on babies who are breast/chest-fed from their birthing parents taking PEP; therefore, the Canadian Guidelines on PrEP & nPEP don’t recommend breast/chest feeding while on PEP.

If the medical staff assess you to be at risk for HIV they will also likely recommend you not breast/chest feed since HIV can be passed on to the baby through breast/chest feeding.

8) What if I’m nonbinary or trans (masc or femme) and I’m thinking about PEP?

A common misconception about PEP (and PrEP) is that the medication can alter your weight and therefore your appearance; this is not true. PEP does not alter your appearance by redistributing fat.

Hormone Therapy & PEP:

If you are taking estrogen or testosterone mention this to emergency room staff as there may be a few test results that may confuse them and delay your access to PEP.

Pregnancy & PEP:

In a similar fashion to Hormone Replacement Therapy (HRT), PEP (or PrEP) is not a form of birth control. If you choose to have sex without a condom, you or your partner(s) may become pregnant if the anatomy involved is capable of pregnancy.

If you know you are already pregnant, inform emergency room staff. Disclosing your pregnancy to them allows them to consider potential HIV transmission risks not only for yourself, but also your future child and consider which PEP medications to involve. If you are breast/chest feeding a child, this should also be pointed out before administering PEP. They will likely recommend you not breast/chest feed during PEP as the Canadian Guidelines on PrEP & PEP don’t recommend this.

9) What if the emergency room keeps me waiting for a long time?

Emergency room staff may not be familiar with how to use PEP in a consensual sexual or injection drug use situation. Ask them to consult with an infectious disease physician to move forward with your request.

10) Would leaving an emergency room to find quicker service some where else help?

There is no clear answer to this since the emergency response system tries to distribute the work evenly among emergency rooms in each area of the city. Walk-in cases cannot be predicted.

11) Can I borrow my friend’s HIV medications if I don’t want to go to the emergency room or talk to a doctor?

No. PEP needs to be taken under medical supervision. Medical staff must check for:

  • any other conditions you might already have,
  • test if you already have HIV,
  • assess your reason for seeking PEP,
  • take into consideration what other sorts of medications, recreational drugs, alcohol and/or hormones you are taking, and
  • consider which medications are most appropriate for you. (Some medications commonly used for HIV treatment are not the best for PEP.)

Medical professionals are also useful in the follow-up while you are on medications to assist with any side effects and to make sure PEP has worked.

12) Can I be prescribed PEP more than once?

Yes. There are no indications that there are problems with using PEP more than once other than cost and potential short-term side effects while taking PEP. 

However:

  • If your medical condition has changed since the last time you took PEP your medical provider may point out new issues that need to be considered before taking PEP – for example, a concern regarding your liver. 
  • You always run the risk of being judged again due to the sex involved or because of drug use every time you ask for PEP with medical providers you don’t know. You can consider PIP (PEP in Pocket) which involves having PEP ahead of any potential exposure, but that again requires discussion with a medical practitioner, potentially a pharmacist as well and special arrangements made about follow-up and monitoring since this involves not knowing when you might use it.
  • Some medical providers may have concerns about providing PEP repeatedly if they see a person is consistently using PEP as their first means of protecting themselves instead of using PrEP or condoms. 

If you are consistently having sex with or sharing injection equipment with people living with HIV and their viral load is not suppressed, talk to a medical professional about getting PrEP or Pocket PEP if your potential exposures are less frequent over a year.

13) Can I get PEP in a non-emergency setting?

Pocket PEP or PEP In Your Pocket (PIP)

Being prepared with PEP already in your possession in case of an exposure is possible to arrange. Non-emergency PEP is helpful for those who find themselves in a situation where they might be exposed to HIV repeatedly, but not frequently enough that they need to be on PrEP. It’s also a great way to access PEP right after a potential exposure without waiting in line at an emergency room and repeatedly talking to staff about your experience.

Some doctors are less informed about HIV prevention options and may not be aware of PEP or PIP. These doctors may be hesitant to prescribe something before they fully understand how it works and how they can bill for it. A doctor may be particularly confused if you have already received prescriptions for PrEP and are using it episodically rather than consistently.

14) Now that I’m on PEP, what can I do to make it more effective?

  • Support your immune system: get plenty of sleep and nutritious food.
  • Be prepared to take extra time to rest if you experience side effects.
  • Follow your doctor’s instructions. PEP will work best when taken at the right dose, at the right time.
  • You may have to limit your use of drugs and alcohol if they interfere with your ability to rest, take your medications on time, or if they are incompatible with the medications you are taking for PEP.
  • Do not stop taking your prescribed doses without talking to your doctor.
  • Use your phone, watch or computer’s alarm to help you remember when to take your medications.
  • Know what to do if you miss a dose – ask your doctor ahead of time.
  • If you are travelling, keep your PEP drugs with you.
  • If you’re going out and aren’t sure if you’ll be back home in time for your next dose, take your pills with you (for example, if you’re sleeping over at someone’s place).
  • Follow-up with the contacts the emergency room gives you and after you have finished the therapy get tested for HIV to know if the PEP worked. It is important to make sure PEP worked after all the effort you made to access it and take it for the four weeks.

15) Can I cut the treatment short – not take it for the entire four weeks?

This is not recommended since the full treatment is necessary to ensure PEP will successfully prevent HIV. If the treatment does not work because you are not taking the PEP as recommended or stop taking it before the complete treatment you increase your chances of ending up with a drug-resistant form of HIV.

If you learn your sexual partner is HIV negative:  in consultation with your healthcare provider you could stop taking PEP.

If your sexual partner doesn’t know their HIV status: if it is safe for you to do so – encourage your partner to get tested and let you know.

If your sexual partner is HIV-positive: if it is safe for you to do so learn if they are on HIV medications and if they know if their viral load was suppressed at the time of sex. Someone with a suppressed viral load cannot pass on HIV to another person, and in consultation with your healthcare provider you could stop taking PEP.

16) Can I have sex while on PEP?

Yes.  

Keep in mind, having sex without a condom while you are taking PEP can potentially expose you to HIV again or your sex partner(s) to HIVor other sexually transmitted infections (STIs). It is important to take care of yourself and your immune system while your body is processing PEP and fighting HIV; getting an STI can be even more problematic.

If you are taking PEP and having sex with someone who is living with HIV, be aware that PEP can cause their virus to change and adapt to your meds if they are exposed. This can be problematic for your HIV positive partner because when their virus becomes drug resistant to your PEP HIV medication it can then limit their own treatment options. This exposure can happen through condomless sex and sharing needles. Exposure can also happen through internal piss play or theoretically through drinking breast/chest milk as well. (It is documented that medications are present in urine and breast/chest milk.)

Be aware PEP and PrEP are not birth control.

17) How do I reduce my risks so that I do not need PEP again in the future?

The most effective way to prevent HIV transmission is to supress the viral load of HIV in sexual partners living with HIV. HIV cannot be transmitted when someone has a low enough viral load. This is also called U=U (Undetectable=Untransmissible); however, the viral load someone carried in their blood does not have to be undetectable to be untransmissible; it simply needs to be low enough.

Other interventions that can prevent HIV transmission are:

  • PrEP (HIV Pre-Exposure Prophylaxis) and
  • the proper and consistent use of condoms and other barriers.

18) Why is medical care after taking PEP important?

It’s important to follow-up with your medical contacts to make sure PEP has worked. 

If the PEP did fail, having a form of HIV that is drug resistant would be an important issue to consider for future HIV treatment to begin. 

Other Resources

PEP and Other Issues Beyond Condoms: www.thesexyouwant.ca/PEP

PEP Fact Sheet from the CATIE: www.catie.ca/fact-sheets/prevention/post-exposure-prophylaxis-pep

Women and PEP: https://whai.ca/resource/pep-women-2021/

Safer Sex Information for Gay Men from ACT: www.actoronto.org/health-information/gay-men

HIV Clinic (Immunodeficiency Clinic) – University Health Network: HIV Clinic (Immunodeficiency Clinic) (uhn.ca)