[Question #10747] Need for PEP?
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20 months ago
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Hello,
I had a lapse of judgement and had anal sex with a FSW from Europe. The sex was protected and from what I can tell the condom did not break. However, the FSW opened the condom with her teeth which has me slightly concerned that the condom could have been damaged, and I had trouble maintaining an erection which is making me concerned that the fit of the condom was not great, and some of her fluids may have come into contact with my penis.
She said that she gets regularly tested when I asked, but there is of course no way to know if she is telling the truth. I know that the statistics say that the risk for the insertive partner is not that high for a single exposure, BUT, the problem is that I am uncircumcised. Most of the statistics seem to be based on circumcised males, and the one I found regarding uncircumcised insertive anal sex, has a risk of 1 in 160, which seems awfully high... almost as high as for the receptive partner.
1) Based on the above, do you think there is a need for PEP? If you were my doctor and I asked for PEP, would you prescribe it to me for this situation?
2) If I do decide to take PEP, it will not be a simple or quick process to get the meds in my country. However, I do already have an unopened bottle of Truvada, and I see that some guidelines actually recommend a Truvada-only PEP regimen for my particular case. (See: https://pep.guidelines.org.au/guidelines/assessment-of-risk/what-is-the-hiv-status-of-the-source-individual/#table-2). The problem is that this Truvada expired in November 2019. Do you think it is still safe to take (as in no harmful health effects), and possibly even effective still? Or would I be doing more harm than good if I start taking this Truvada as PEP?
Thank you.
I had a lapse of judgement and had anal sex with a FSW from Europe. The sex was protected and from what I can tell the condom did not break. However, the FSW opened the condom with her teeth which has me slightly concerned that the condom could have been damaged, and I had trouble maintaining an erection which is making me concerned that the fit of the condom was not great, and some of her fluids may have come into contact with my penis.
She said that she gets regularly tested when I asked, but there is of course no way to know if she is telling the truth. I know that the statistics say that the risk for the insertive partner is not that high for a single exposure, BUT, the problem is that I am uncircumcised. Most of the statistics seem to be based on circumcised males, and the one I found regarding uncircumcised insertive anal sex, has a risk of 1 in 160, which seems awfully high... almost as high as for the receptive partner.
1) Based on the above, do you think there is a need for PEP? If you were my doctor and I asked for PEP, would you prescribe it to me for this situation?
2) If I do decide to take PEP, it will not be a simple or quick process to get the meds in my country. However, I do already have an unopened bottle of Truvada, and I see that some guidelines actually recommend a Truvada-only PEP regimen for my particular case. (See: https://pep.guidelines.org.au/guidelines/assessment-of-risk/what-is-the-hiv-status-of-the-source-individual/#table-2). The problem is that this Truvada expired in November 2019. Do you think it is still safe to take (as in no harmful health effects), and possibly even effective still? Or would I be doing more harm than good if I start taking this Truvada as PEP?
Thank you.
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H. Hunter Handsfield, MD
20 months ago
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Welcome to the forum. Thanks for your confidence in our services.
In general, we do not give specific advice for or against PEP. It comes too close to providing direct medical care; we ask forum participants to make treatment decisions with an in-person provider. Such persons also are more aware of local HIV epidemiology and risks -- for example, the likelihood a partner like yours might have HIV.
That said, this was a very low risk scenario for HIV. Being uncicrumcised really doesn't make much difference. At a population level, uncircumcised men have double the risk of HIV compared with circumcised men, all other things being equal. But on an individual level, double risk doesn't mean much. The average risk of catching HIV from a single episode of unprotected vaginal sex with an HIV infected female partner is one chance in 2,500. Double that risk means one chance in 1,250 -- still very low, right? (You are correct that anal sex is far higher risk than vaginal.)
In addition, it sounds unlikely your partner has HIV -- most people don't lie in that situation -- and condoms are highly effective. The details of how condoms are applied makes little or no difference in HIV/STI risk. All things considered, I would put the chance you were infected with HIV at well under one chance in a million.
1. If you were in my clinic in this situation, we would not prescribe PEP -- and probably would even refuse even if you asked for it. Still, some providers have a very low threshold and conceivably would recommend it.
2. Drug expiration dates don't mean much. It only means the drug has not been tested for potency and safety beyond a certain date, but in fact most drugs are entirely effective and safe many years later (assuming they weren't mishandled, like the proverbial hot glove compartment in a car in the summer).
Another aspect about PEP is often forgotten. If you don't take it, valid testing for HIV can be done in 4-6 weeks. Following PEP, that time is extended to at least 4-6 weeks after the last dose, and some experts advise three months. That means that the period of uncertainty and perhaps anxiety would go as long as 4 months from now, versus 4-6 weeks.
If somehow I were in your situation, I would not even be tested for HIV -- and I certainly would not take PEP.
I hope these comments are helpful. Let me know if anything isn't clear.
HHH, MD
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