Taking care of an HIV patient can be one of the most challenging tasks but not for Suzan Mukandoli, who did not just sit back to watch her elder brother die in agony. Every morning she would make it a point to dress up his wound on the leg and thereafter administer medication. 

On one fateful morning, Mukandoli hurriedly picked her nursing kit from the side board and rushed to her brother’s bedroom. His frail look would suggest body pain and indeed his wound required minor surgery. 

Concerned as a sister, Mukandoli picked the surgical blade, pierced the bulge for the fluid to ooze out. Unfortunately, Mukandoli cut herself while fidgeting to fit the drainage gauze.

A seemingly minor cut instigating fear and only her slim medical exposure to lead her to the hospital where she picked Truvada, an antiretroviral drug (ARV). 

Whether her move was equitable medically, Post-Exposure Prophylaxis (Pep) as a mechanism to fight HIV is gaining momentum in individuals.

Indeed, it’s two years since the FDA approved the drug Truvada for reducing the risk of HIV infection, but the medical community is divided about the drug’s implications for individuals and for public health.

In giving the green light to Truvada on July 16, 2012, FDA Commissioner Dr Margaret A. Hamburg said, "Every year, about 50,000 US adults and adolescents are diagnosed with HIV infection, despite the availability of prevention methods and strategies to educate, test, and care for people living with the disease. 

"New treatments as well as prevention methods are needed to fight the HIV epidemic in this country.”

There is some agreement among the medical community that riskier sexual behavior is on the rise, and that more education about HIV/Aids prevention is crucial.

Many medical professionals agree that the current generation of sexually active young adults is more complacent about HIV/Aids than the generation before it.

For much of the 1980s and early 1990s, the lack of effective treatments for Aids made the disease more frightening. But current therapies are so effective that HIV/Aids is widely seen as a manageable health condition, not the death sentence it once was. And this may lead to young people being lax when it comes to safe sex practices.

What is Pep?

Pep is short-term antiretroviral treatment to reduce the likelihood of HIV infection after potential exposure, either occupationally or through sexual intercourse. 

The World Health Organisation recommends that within the health sector, Pep should be provided as part of a comprehensive universal precautions package that reduces staff exposure to infectious hazards at work. 

Pep involves taking anti-HIV medications as soon as possible after you may have been exposed to HIV as a way to reduce the chance of becoming HIV positive. 

These medications keep HIV from making copies of itself and spreading through your body. Pep can be occupational Pep, taken when someone working in a healthcare setting is potentially exposed to material infected with HIV, and non-occupational Pep, which is taken when someone is potentially exposed to HIV outside the workplace for example from sexual assault, or during episodes of unprotected sex or needle-sharing injection drug use.

What calls for Pep

Aisha, a commercial sex worker, says: "It is hard to access ARVs here since they are not available in the pharmacies. Only health centres approved by the government to carry out complete HIV treatment and rehabilitation have the capacity to provide the ARVs.”

"I understand it is illegal, but after having unprotected sex, I can create an imaginery rape story. The doctor will, of course, be concerned about providing first medication before dwelling into details of the rape case,” she adds.

Mukandoli uses her slim medical knowledge while Aisha tricks the health workers on several occassions. These two likely modes of infection are different but the preventative approach after exposure is the same.

Can Pep provide safety?

To ensure effectiveness of the drugs, Pep must begin within 72 hours of exposure because after HIV virus has entered your body, it makes copies of itself.

The earlier the emergency drug is started on, the better chances of efficacy.

The antiretroviral therapy consists of a combination of two to three antiretroviral medications and should be taken for 28 days. Medics usually determine the desirable drug combination for the treatment based on how one was exposed to HIV. 

Moris Ndekwe, a pharmacist at Vine Pharmacy in Remera, Kigali, warns that: "Anteretroviral drugs are not morning after pills. While girls would go and have sex, take a pill later,  people need to know that HIV is an infection and cannot be treated in a similar manner like fright for pregancy.”

Another pharmacist in Remera also states that: "People can find all ways of accessing drugs irrespective of the cost implications. For example, Morning-after pill goes for Rwf10,000 and the stock runs out very fast, that shows you how much people fear pregnancies.”

"Probably the same thing would happen with ARVs if government had authorised pharmacies to sell them,” he adds.

Dr Sabin Nsanzimana, head of HIV division at the Rwanda Biomedical Centre, says in order to bring treatment closer to home for a lot of people, advanced tests, including diagnosis and follow-ups, are done in the country and a number of health facilities in Rwanda provide testing and ARTs. These have increased in number since 2010.

"In 2010, there were 419 clinics that did testing and counselling, and 295 that provided antiretroviral therapy. By last year, the numbers had increased to 493 and 465, respectively,” Dr Nsanzimana says.

"Currently, 93 per cent of people who are eligible for ART in the country have access to treatment. However, this should be based on old eligibility criteria.”

Studies on the use of Pep

A study of healthcare workers published in the New England Journal of Medicine linked the rapid administration of the drug to an 81 per cent decrease in the risk of contracting the virus.

Although Ndekwe emphasises that, " ARVs have  a protocol and taking them after exposure does not guarantee 100 per cent safety, they may work or not. Besides, there is a risk, subsquent exposure to ARVs in non HIV individuals may result into the drug resistance.”

"Infact, in the ARV therapy, the lines are different, and they can be changed depending on the CD4 cell count. It is after diagnosis that the health worker may determine what is suitable for you inorder to provide the right medication.” Ndekwe adds.

Also, recent studies in June 2014, by the World Health Organisations on the use of Pep revealed that in 97 studies reporting outcomes on 21,462 individuals across 22 countries initiating Pep for a variety of reasons that also included follow up visit for HIV testing  for more than three months after Pep completion, 4 per cent of these people refused Pep.

All individuals initiating Pep and not subsequently found to be ineligible, 56.6 per cent completed the full standard 28 day course. Some 31.1 percent of those who completed Pep failed to attended a follow-up visit. 

Stick to safe sex 

WHO study indicated that losses are high at each step along the Pep tumble, with almost half of the people who need Pep failing to complete a full course of treatment.

Although Mukandoli and Aisha are still HIV negative, suggestions from health expert clearly indicate that Pep should be provided by trained personnel as recommended by government health ministry, and never mistaken for a morning afterpill and that’s why safety should come first before intercourse.