[Question #11513] Risk Assessment - PEP

14 months ago

Hello Doctors and thank you for all of the work and effort you put into this forum.

I had intercourse with a new male partner (16/06/2024) for the very first time (insertive, safe) and, unfortunately, the condom I was wearing broke because my partner had either not put it on properly or was a bit too vigorous during sex. How and when it broke, I can’t exactly place; however, we were having sex from 11pm until around 12:00/12:20am. It was only after he had gotten off me to change positions that I noticed and paused. We finished off quickly after noticing without any additional penetration.

After we’d finished, I asked him about his status and all other relevant information I should know to plan, and he assured me that he’s on daily PrEP, exclusively plays safe (we both actually insisted on condoms) and had tested negative for HIV and other STIs one month ago. He’s visiting from California, if that bit of info helps.

Unfortunately, due to it being my first-time incident and him being new, paranoia got the better of me and I went and got PEP from the ER. I took my first dose at 3:00am and will continue to take the remaining course for the next 28 days.

(Posting my Questions in another box because I keep getting a technical error to trim my text)

14 months ago

1) Can you please kindly give me a risk evaluation on the incident? Before being given PEP, the GP seeing me ran a questionnaire-style form on her system and said that it did not recommend PEP, as it classed it as a ‘low risk’ incident, but I insisted, anyway. (She asked me all of the standard procedure questions)

2) I had a very slight feeling of pain around the tip/head of my penis yesterday, but this has since subsided as of today. No burning sensation/sensitivity/or swelling when peeing or anything – do you recommend I test for Gonorrhea and Chlamydia? I remember reading from other threads that in case 3-5 days go by and there’s no symptoms, there would be no need to test for either.

3) The GP who saw me also took a urine sample and analyzed it, not sure why. But she came back and said that there were “no microbes in it, but there was blood detected” which she said was most likely mine and caused by the intensity of the intercourse. This freaked me out a little bit and would appreciate some clarity from your end, if possible, and whether this affects the risk or heightens it.

14 months ago

4) I’m seeing conflicting information online of frequency and timing in taking of PEP. If I took my first dose at 3:00am, do I need to wait a full 24hrs until 3:00am today to take the second dose? Or can I take it earlier by an hour or two? I’m trying to understand and figure out whether the interval between doses affects the treatment and what the correct and best way (in terms of timing doses) to follow is. The GP told me I can take the next dose close to the time when I first took the initial one or at the exact time.

5) I feel completely fine after the initial dose, is it normal to not have any side effects at all? I am currently on 2x Raltegravir (Isentress) + 1x Disoproxil/Emtricitabine (Truvada) per day, taken together.

6) How effective (%) would PEP be in the case where I started 3hrs after a potential exposure? And would the nature of the risk (High vs. low) dictate a shorter window for testing post-PEP? Or does it remain the conservative 6-week window?

14 months ago

7) I masturbated today and noticed that my semen was a bit beige colored, does PEP affect semen color or is this something that I should be concerned about? I haven’t ejaculated since the 16^th, just to add.

8) I guess this isn’t a medical question, but I’m trying my best to remain calm and rational about this because all of the reading I’ve done on the forum so far tells me that it is indeed a low-risk event that probably didn’t even warrant PEP in the first place. Even the guy I was with last night answered me directly and didn’t seem dodgy or hesitant, but I just can’t shake the nagging paranoia that’s hanging over me. Is there any way to calculate the odds of being infected? Would greatly welcome any advice that would keep me grounded and level-headed about this.

As of today, I am one week on PEP taking it religiously on time for the entire 28 day period.

Thanks again for your help and efforts and apologies for the long thread and text boxes!

Edward W. Hook M.D.

14 months ago

Welcome back to the Forum. You have gone considerably over our word limit which is there for a reason. If there are follow-ups, please keep them brief. This all could have been said and asked far more succinctly. Straight to your questions:

1. This was a low risk encounter. The fact that your partner was taking PrEP and insisted on a condom all suggest that he, like most people, does not have HIV. Like the doctor who saw you, I would have not encouraged you to take PEP as it is almost certainly unnecessary. Taking PEP soon after the condom breakage reduces the risk even further.

2. Testing for gonorrhea and chlamydia is a personal choice. STIs are relatively common in persons who take PrEP. The symptoms you describe do not suggest gonorrhea or chlamydia. The absence of symptoms 5 days after the exposure also suggests that you were not infected.

3. It is not uncommon to have small amount of blood in a urine specimen. This is nothing to worry about and does not change your risk.

4. There is no reason to necessarily take your PEP at precisely the same time each day. If it is easier for you schedule-wise to take it a few hours earlier, that's fine, particularly now that you've been taking it for a week.

5. It's fine that you are not having side effects. The medications you are taking are well tolerated.

6. There is no hour-by-hour analysis of PEP effectiveness. Having started it so soon after the exposure certainly enhances its efficacy as opposed to waiting a day or two to start but how much is unknown. Starting soon does not change the recommendations for follow-up

7. This is not something to be concerned about

8. For someone as committed to safe sex as you are, a condom failure is anxiety producing. I understand it. As you note, this was a relatively low risk event. The only thing I might suggest to further address your anxiety is to see if your partner can be reached and is willing to test at this time. If he is tested at this time and is negative, he could not have infected you

I hope that this information is helpful. EWH

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13 months ago

Thank you, Dr. Hook for the answers and apologies again for the multi-posting.

1) The lab I routinely get tested at is using 5th gen HIV tests.
Do these tests allow me to get tested sooner or is the recommendation still to test 6 weeks post-PEP?

2) Is it safe to continue having safe sex even while on PEP or is the
recommendation to remain celibate until the full course has had its run?

3) In the unlikely event of another potential exposure or other incident
of condom breakage, would I still be protected while on PEP?

No further questions at this point, but if I can kindly request that you keep the thread open in case I forgot something or had a new question to ask, that would be much appreciated.

Edward W. Hook M.D.

13 months ago

Straight to your follow-ups

1. 4th generation test for HIV test simultaneously for both HIV antibodies and the HIV p24 antigen while the 5th generation tests test for them separately. While some 5th generation tests claim to provide results sooner than 4th generations tests, most experts still use the 6 week window period for conclusive results

2. Yes, as long as your tests are negative, it is safe to have sex while on PEP

3. An exposure while taking PEP is essentially the same as an exposure while taking PrEP and therefore would be close to no risk

EWH

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13 months ago

Hello Dr.Hook, hope you are doing well.
Today was my last day on PEP and I have been very religious in taking it for the entire 28 day period. Just a couple of follow-up questions, please:
1) What would the accuracy of a negative test (5th gen.) be respectively at 2, 3, 4 and 5 weeks?
2) I am considering on going on PREP but have yet to decide: Can I begin as soon as finishing PEP? Or should I wait for a confirmed negative result prior to going on it?

Many thanks.

Edward W. Hook M.D.

13 months ago

Thanks for your follow-ups. Let me address your specific questions First

1) What would the accuracy of a negative test (5th gen.) be respectively at 2, 3, 4 and 5 weeks?

AS I've already said, your risk for HIV was VERY low. PEP makes it even lower. I cannot provide specific numerical values for your risk at various periods after infection. That said, given your low risk for HIV to start with, if a test is negative at 5 weeks, I would put concerns aside and work to move forward.

2) I am considering on going on PREP but have yet to decide: Can I begin as soon as finishing PEP? Or should I wait for a confirmed negative result prior to going on it?

Yes, you can begin PrEP immediately as long as your tests are negative at this time

As you know, this completes this thread which will now be closed. Take care and PLEASE don't worry. EWH

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