Intensive and targeted PEP counselling leads to less risky sex afterwards, fewer HIV infections

Via AIDSMap, by Roger Pebody.

Researchers in San Francisco wished to measure the impact of providing risk reduction counselling to people taking post-exposure prophylaxis (PEP) to prevent HIV infection. They measured changes in sexual behaviour one year later.

They randomised 457 people receiving PEP to either receive two sessions of standard counselling, or an enhanced programme of five counselling sessions.

The standard counselling intervention consisted of two sessions of 20 to 30 minutes each, individually tailored on the basis of social cognitive theory, motivational interviewing, and coping effectiveness training. In the first session, the counsellor and participant explored the details and context of the risk exposure and developed a written risk reduction plan. At the second session a week later, the baseline HIV test result was given. The participant was asked about risk behaviour in the past week and the effectiveness of the risk reduction plan, which was adjusted if necessary.

People receiving the enhanced intervention received the same two sessions, as well as three further sessions, during which difficulties in implementing the plan were explored, contextual factors (such as particular places or emotions) that led to high or low risk behaviour were identified and an increasingly personal risk reduction plan was developed. (A detailed protocol for the five sessions is freely available on the journal’s website).

Adherence counselling was also separately provided on three occasions.

Almost all participants were men, and PEP had commonly been prescribed after unprotected anal sex (80.1%), unprotected vaginal sex (7.5%) or oral sex to ejaculation (5.9%) in the previous 72 hours. Four out of ten people receiving PEP knew that their partner was HIV-positive.

To assess the impact of the two styles of counselling, the behaviour of participants was assessed at the time of taking PEP and one year later.

When the data for all participants were analysed together, the extra intervention appeared to provide a modest benefit, but perhaps one that could not justify the cost of its provision.

The study’s primary outcome was change in the number of unprotected anal or vaginal sex acts. In the six months before taking PEP, participants had had unprotected sex an average of 5.5 times. In people who received two counselling sessions, this dropped by a mean of 1.8, while those getting the extra sessions had 2.3 fewer unprotected sex acts.

The results are more interesting if we only look at those individuals who were taking more sexual risks to begin with. A fifth of the participants had had unprotected sex four or more times in the six months before taking PEP, and the extra counselling had much more impact in this group.

In terms of the primary outcome, those with higher risk receiving the standard two sessions had a reduction in 7.0 unprotected sexual acts, whereas in those getting the extra sessions the average reduction was 13.2 acts.

Whereas 31.5% of higher-risk individuals receiving the standard intervention felt the need to come back for a second course of PEP within a year, this was case in 17.1% of those receiving five sessions.

And most importantly, fewer people were HIV-positive one year later. Among those with higher risk who received two sessions, 12.3% seroconverted. In those who received five sessions, 2.4% did so. (These infections are likely to be due to risk behaviour in the months after taking PEP, not the failure of PEP to prevent infection).

Read the rest here.

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