I felt a lot of guilt and anxiety and within 16 hours, I started PEP with Isentress to be taken every 12 hours and Emtricitabine/Tenofovir every 24 hours. I am following the PEP medication at the exact prescribed time regularly so far. Questions

1. What is my risk of HIV with the above described encounter?

2. Today is the 9th day and I have no symptoms, was I correct in starting PEP. The guilt and fear of HIV is causing a lot of panic and anxiety so I started PEP.

1. This was a nearly zero risk exposure for HIV. Even without a condom, vaginal sex with an HIV infected woman has an average transmission risk for her male partner of one chance in 2,500. With a condom, that chance is 100 times lower, i.e. maybe around 1 in 250,000. And that's only if the woman is infected. If we assume a 10% chance the sex worker had HIV, the chance you were infected becomes 1 in 2.5 million. How your partner removed the condom makes no difference. Oral sex is even lower risk. There have never been any proved HIV transmissions oral to penis or by cunnilingus (oral-vaginal contact). The risk of other STDs is similarly very low for the exposure described, especially if you do not develop typical STD symptoms (penile discharge, painful urination, penile sores) within a couple of weeks.

2. As those comments suggest, in my view PEP was not necessary; had you been my patient, I would not have prescribed it. However, it is possible that the clinic or doctor who prescribed your PEP has more information than I do about risks. For example, if it is known that sex workers where you were exposed have are especially likely to have HIV, maybe it was the right choice. Therefore, I cannot advise you whether to continue or stop PEP, but you might discuss it with the doctor or clinic.

3. When you should test for HIV is directly related to PEP and how long you take it. Many people at risk, and even those who prescribe it, often do not consider that PEP greatly prolongs the time to conclusive testing and thus the duration of anxiety before knowing the answer. Without PEP, you could have conclusive results 6 weeks after exposure with an HIV antigen-antibody test (AgAb i.e. 4th generation); or nearly conclusive testing with an RNA ("viral load") test after 2 weeks. Following PEP, the window for testing begins after the last dose of drug, i.e. 4 weeks PEP plus 6 weeks means a conclusive AgAb test no sooner than 10 weeks after exposure; and some experts would advise 3 months, i.e. not until Christmas Day for your August 25 exposure.

As for other STDs, the risk is low enough that testing is optional. But if you would like the certainty of negative test results, you could have a urine gonorrhea/chlamydia test at any time, and a blood test for syphilis 6 weeks after exposure (around 6 October).

4. We are not relationship experts, so I can't give you clear guidance on discussion with your wife. In our experience, it's often very wise in situations like yours; a caring spouse can be extremely reassuring. But you know your wife and your relationship and I do not. As for sex, if you discuss it with your wife, her desires and comfort with unprotected sex is largely if not entirely her decision. However, your risk is so low from the events described that if I had somehow been in your situation I would not even be tested, would not have started PEP, and would continue unprotected sex with my wife without worry -- and would not necessarily have discussed the situation with her.

I hope these comments are helpful. Let me know if anything isn't clear or if I can provide further information.

HHH, MD

The clinic in Prague didn’t recommend PEP to me suggesting this was a low risk exposure. However, I insisted and so they prescribed with same wordings on the prescription that client insisted even with a recommendation to not start PEP.

It was my fear and anxiety and now ai understand the delay in test results. The course ends on 22 Sep considering I will follow the PEP course for 28 days. Also, I forgot to mention that the baseline test was negative for HIv but it did show antibodies for Hep B

I intend to follow the below test window.

1. Test immediately after the Pep course is complete for HIV using the 4th gen test.

2. Repeat the test at 4 weeks after PEP completion i.e on 22 OCT.

3. Repeat the same test at 8 weeks post PEP completion i.e 22 Nov and possibly one more on 22 DEC.

I understand its a long period given that I started PEP.

If all are negative, can I forget this episode and move ahead with my normal life?

Also, do you think, my risk is further reduced  with PEP that I could possibly not test at all unless I have any symptoms?

That said, I agree with the testing schedule. Should you not test at all? First, symptoms almost never are a useful guide; whether or not you have symptoms (even ones typical for ARS) should not make any difference. (Despite frequent online advice about ARS symptoms to watch for, in my 40 years in the HIV testing business I've never had a patient, or even heard of one, in which it was an important determinant of testing or not testing. The problem is that many or most new HIV infections cause no symptoms; and even the most typical symptoms usually have other causes.) Second, this is less a medical question than one related to anxiety, worry, etc. If you would be completely confident you weren't infected, it would be fine not to test, given the near zero risk of HIV anyway. But my guess is you would continue to worry about the possibility and would likely need the negative results to allow you to move on. It's up to you.