PEP Questions and Answers

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

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

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 has HIV. It's often appropriate in cases when you don’t know their 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 EMS work setting.vii

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

• have had an 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 in order to make sure it works well. Some emergency rooms can keep you waiting, but others will be more experienced in dealing with people asking for PEP, rate you as a higher priority and may have the ability to give you a starter kit of medication after your consultation so you start right away until you can get to a pharmacy to fill your entire four weeks worth of medications. In Toronto, the hospital with the most experience with PEP is Women’s College Hospital, although any hospital should be able to handle this issue. If a hospital turns you away or advises you to go elsewhere, consider requesting that they call an infectious diseases specialist for telephone advice on how to handle this situation, since sending you to a different institution results in delays in accessing PEP.

2. Quick access: For PEP to work properly you need to get it as soon as possible. After 72 hours from your exposure to HIV has passed, the effectiveness of PEP is so little that the medical professional would hesitate prescribing it to you.^{viii xi}

3. Money: A month’s supply of PEP can cost between $900 - $1300 depending on the medications prescribed. Your private health insurance has to cover it, or you will have to pay for it out of your own pocket in Ontario.^x Money should not be a reason not to access medication. If you are unable to afford the medications, you can ask if they can be provided to you free of charge. There is no cost in a sexual assault situation and in many occupational exposure situations.^xi

• Side Effects: As with all medications, there can be side effects, but newer HIV medications are generally well tolerated by most people.
• Availability: Not all emergency rooms will automatically 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.

Be aware that having sex without a condom can leave you pregnant, even though you identify as a guy. A potential pregnancy should be one of the things the emergency room staff should consider, but may not be something they realize until you point this out to them.

If you think you have been exposed to HIV when you know you are already pregnant, be aware that the emergency room health care practitioners may not realize you are already pregnant. You should consider disclosing your pregnancy to them so that they can look at any protocol necessary to make the delivery safer. A form of PEP can be used to facilitate a safer delivery.

If you are taking hormones as either a trans male or a trans female, it would also be good to disclose this to the emergency room staff as some older forms HIV medications can suppress hormones (usually estrogen).

• You should say you believe you had an exposure to HIV and need access to PEP (Post-Exposure Prophylaxis) as quickly as possible.
• Be prepared to discuss the details of your exposure– this may need some honest, explicit and specific language on your part. It’s important the triage nurse understands the true level of risk you were exposed to. Emergency rooms may react better to you if they can’t smell alcohol on your breath or think you are high.
• If you think you need support from a friend or a trusted social service provider to help you say what you need, bring them with you.
• Emergency room staff will want to know exactly when you think you were exposed.
• You should ask about the HIV medications that will be prescribed, and ask if they are older HIV medications (such as Combivir) or newer ones. If they want to prescribe you older HIV medications, ask why the newer ones are not being prescribed as it has been shown that they have fewer side effects. There may be reasons that they can’t prescribe you newer medications (including availability of free medications, clinical considerations, etc.) Ask where you can get the medications immediately after leaving emergency – you need to start them as soon as possible. If there is no pharmacy open, ask if they provide a starter kit for taking the medications prior to you getting to pharmacy.
• Ask about how much it will cost. If you do not have the money to pay for the prescription, tell the emergency room and ask them if they can help you find treatment that is no cost. Tip: they should talk to their HIV treatment clinic if they have one in the hospital.

Emergency room staff may not be familiar with how to use PEP in a sexual or injection drug use situation. They may need to consult with an infectious disease physician in order to move forward with your request. You can ask for this.

There is no clear answer to this since the emergency response system tries to distribute the work evenly among emergency rooms in a given area of the city. Chances are if one department is busy with emergency cases being brought in by ambulance so will the others in the area. Walk-in cases cannot be predicted. In Toronto’s downtown, St Michael’s hospital will rate you highly in terms of urgency of care for PEP.

No. PEP needs to be taken under medical supervision. Medical staff have to 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 medications 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.

• Support your immune system: get plenty of sleep and nutritious food.
• Be prepared to take extra time off and 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 or take your medications on time.
• 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 do 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.
• Follow-up with the contacts the emergency room gives you and get tested for HIV to know if PEP worked, after you have finished the therapy. This follow-up can take up to six months to make sure everything is okay. It is important to make sure the PEP worked after all the effort you made to access it and take it for a month.

This is not recommended since the full treatment is necessary to ensure its effectiveness. If you learn your sex partner is HIV negative then, in consultation with your health care provider, you could stop taking PEP. If your partner doesn’t know their HIV status, encourage them to get tested anonymously and let you know. If they are HIV-positive, try and learn if they are on anti-HIV medications and if they knew their viral load at the time when you think you were exposed.

Yes. There are no indications that there are problems with using PEP more than once, other than the possible side effects from taking the medications, and the cost. 

However, you should be prepared that some medical providers may be concerned about your health if you have a medical issue that has changed since the last time you took PEP – for example, a concern regarding your liver. 

Some medical providers may judge you, perhaps due to the sex involved, or because the exposure involved drug use. 

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 and not using other means that are possible for them to access such as condoms. 

If you are in a situation where you may constantly be exposed to HIV, for example: you regularly have condomless sex with someone with HIV who has a detectable viral load, or you are having condomless sex with many people who you have reason to believe have HIV, you may want to talk to your doctor about this and how you can access PrEP (pre-exposure prophylaxis (medications you take ahead of time to prevent HIV).

Yes. However, many guys find that taking a break is a good idea. 

Having sex without a condom while you are taking PEP can potentially expose you or your sex partner(s) to HIV or other sexually transmitted infections (STIs). It is important to take care of yourself and your immune system; it’s not the time to get an STI. 

Using condoms and getting checked regularly for STIs is good practice.

PEP should not be confused with pre-exposure prophylaxis (PrEP) which involves other types of HIV medications to prevent HIV infection.

The best way to prevent HIV transmission is to use condoms during anal sex and get regularly tested and treated for sexually transmitted infections (STIs). 

If your partner has HIV, using a condom and getting your partners viral load down to undetectable levels is the most effective way of preventing HIV. 

For more information explore the following links!

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

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

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