PEP

PEP stands for post-exposure prophylaxis is used. PEP is an emergency measure used to prevent HIV infection in HIV-negative individuals following possible exposure to the virus. How does it work? By taking antiretroviral medications for 28 consecutive days within hours of unprotected sex (you must act as quickly as possible, ideally within 24 to 48 hours, up to a maximum of 72 hours). The sooner PEP is administered, the more effective it is; this prevents HIV from replicating in your body.

For HIV-negative individuals who may have been exposed to HIV during risky sexual activity. PEP may be prescribed when a condom breaks during anal or vaginal sex, or when a man has had anal or vaginal sex without a condom with a partner who is HIV-positive or whose HIV status is unknown.

Sexual intercourse involving penetration is considered high-risk if, for example, a condom was not used or did not remain in place for the entire duration of penetration, regardless of how long it lasted. It is also possible to prick oneself with a contaminated needle. This is why people who use injection equipment, as well as medical personnel, may also need to use PEP.

It is the medical staff’s responsibility to assess the potential risk of HIV infection and, therefore, whether PEP is appropriate. If you are unsure about your risk, please do not hesitate to consult a healthcare professional or contact us to discuss it.

With PEP, the sooner, the better. Studies clearly show that the sooner PEP is taken after a risky exposure, the higher the chances of preventing infection. Ideally, PEP should be started within two hours of exposure. After 72 hours, studies indicate that there is no longer any benefit to taking antiretrovirals to prevent infection. During the first three days (72 hours), the virus is present only in the bloodstream, where antiretrovirals can more easily combat it. After this time, the virus can reach and establish itself in various parts of the body, making it more difficult to combat with PEP.

During your first visit, the medical staff will work with you to assess whether you need to receive PPE. To do this, the nurse will need to determine:

• Your HIV status, determined through a rapid HIV test that will be offered to you. If the result is positive, PEP will not be prescribed.
• When possible, the HIV status of the person(s) with whom you had sexual contact (who must be HIV-positive or of unknown status).
• If the person is HIV-positive, their viral load, viral resistance status, and the antiretroviral medications they are taking will also be checked, if possible. PEP is not recommended when the person’s viral load is undetectable.
• The time elapsed since the risky exposure (Reminder: the evaluation must take place within 24–48 hours of exposure—ideally within two hours. Beyond this timeframe, PEP will not be prescribed.)
• The level of risk involved: situations involving high-risk exposure primarily involve unprotected anal or vaginal intercourse or the sharing of injection equipment.

To access PEP in Quebec, go to a hospital emergency room as soon as possible or visit a specialized clinic that offers PEP. Staff at the organization can also advise you and assist you if needed.

To be referred to an appropriate resource within the healthcare system, call the Info-Santé hotline at 811.

Here is a list of some specialized sexual health clinics that offer PPE in Montreal:

• SIDEP+ de la Visitation (The only clinic available that is not covered by RAMQ)
• Clinique l’Actuel
• Clinique Médicale Urbaine du Quartier Latin
• Prelib
• Clinique Quorum
• Clinique la Licorne

You can also get the first three days’ supply of PEP directly from a pharmacy. If you’ve been exposed to a risk, you can quickly go to a pharmacy to get this initial portion of the treatment without having to wait for a doctor’s appointment. This allows you to start taking antiretrovirals within the recommended timeframe, thereby maximizing your chances of preventing an infection.

Treatment for PPE consists of taking antiretroviral medications daily for 28 days (4 weeks) and receiving medical follow-up. The treatment is a triple therapy (two tablets, one of which is a combination of two medications, and the other contains a single medication). These include antiretrovirals designed to combat the replication of the virus in your blood at three different stages of the viral replication process, hence the name “triple therapy.” The antiretrovirals administered as part of PEP are generally the same as those used in treatment for HIV-positive individuals.

Starting treatment promptly and following it strictly every day, according to the schedule prescribed by the doctor, allows the medications to remain at high concentrations in the blood throughout the 28-day treatment period and thus fight the virus more effectively to prevent infection. It is important to note that PEP treatment offers a solution, but it is not without certain side effects that can be difficult to tolerate during the 28-day treatment period.

Medical staff may provide you with a starter pack. It contains three days’ worth of medication and a prescription for four days of treatment, which will then be extended following a second visit with the doctor. Not all facilities provide the starter pack; some may dispense the full 28-day supply directly. Take the first tablets (with or without food) as soon as possible.

Follow-up for PEP treatment generally involves six appointments. As mentioned above, the first appointment is to assess whether PEP is appropriate for you. You will then see the doctor for a second and third appointment, 2 and 4 weeks, respectively, after the first visit, to monitor for any side effects caused by the medication. At each visit, your medication may be adjusted, continued, or discontinued, depending on how your body reacts to it. The other appointments involve an HIV blood test 6 weeks, 3 months, and 6 months after potential exposure to HIV, and also provide an opportunity to be screened for other STIs.

Although PrEP reduces the risk of contracting HIV, this treatment is not foolproof. We know that the earlier treatment begins and the more consistently a person adheres to the regimen, the better our chances of success. Thus, if you follow the instructions for antiretroviral prophylaxis correctly during the 28-day treatment period, the concentration of the medications in your blood will remain high enough to fight the virus. It is therefore important to take the medications strictly every day to ensure the treatment’s effectiveness.

Since effectiveness is not 100% guaranteed, people taking PEP are advised to avoid sexual intercourse or to use a condom during any sexual activity for the three months following exposure to risk.

If you miss a dose or do not follow the dosage prescribed by your doctor, the concentration of antiretrovirals in your blood may be too low to stop HIV infection, allowing the virus to multiply and infect you. It is therefore essential not to miss any doses and to continue treatment for the entire prescribed duration.

When prescribing a PPE, the doctor explains the side effects that may occur. Most of these side effects are temporary and will go away on their own, but some need to be evaluated by the doctor. It is important to discuss side effects with a healthcare professional. Possible side effects include:

• Fatigue, vomiting, diarrhea, headaches, dizziness, loss of appetite.

These side effects go away once treatment is complete, but keep in mind that there are ways to relieve them. You can discuss this with the medical staff if needed.

The cost of PPE treatment without health insurance or RAMQ coverage is approximately $1,500.00 to $2,000.00. The amount varies depending on the type of treatment.

Coverage for this treatment is provided by Quebec’s drug insurance plan, which means that the maximum copayment for individuals covered by the public plan is $99.65 (2024—prices are subject to change without prior notice).

People covered by a private insurance plan should check with their insurance company to find out what coverage is available, as this can vary from one plan to another. Some may be required to pay the full amount and then be reimbursed later.

• CATIE – La PPE
• Guide pour la PPE après une exposition au VIH, VHB et au VHC (MSSS)
• Santé Montérégie – La PPE
• Santé Canada – La PPE