[Question #11559] Possible HIV exposure MSM

13 months ago

I had sex with an anonymous male cross dresser on Grindr with a condom and unfortunately the condom broke completely as I finished, but who knows how long it was about 5 minytes session. He said before we met that he had taken a free 20 minute oral HIV test and was negative earlier that day and when I questioned them they swore by it.

With that, I already got prescribed PEP and I took doxy PreP 200mg that I had on hand already.

I am an idiot and have a partner, they will undoubtedly try to have sex with me so I am worried about that inevitable question.

My questions is what are the risks of HIV/STI exposure here, how reliable and safe am I taking PEP immediately (within hours of exposure) and what are the rules of sex on PEP so I can abide by them.

13 months ago

Just to follow up, we were both able to take the oraquick mouth tests and we were both negative at the time, but I am still going to take full course of PEP.

H. Hunter Handsfield, MD

13 months ago

Welcome back to the forum; thanks for your continued confidence in our services. FYI I reviewed your discussion with Dr. Hook a few months ago and agree with all he said.

Unprotected anal sex with an HIV infected bottom partner has an average risk for the top partner of about 1 in a thousand. Your risk might be lower, if the exposure after condom break was brief; and your partner's negative test further reduces your risk of HIV. While anti-HIV PEP in such situation is a persona choice, I would not have advised against it. There's a downside to to PEP you might not have considered (and many prescribing doctors also don't think of it): without PEP, you could have a reassuring negative HIV test of your own in 3 weeks (95% conclusive) with confirmation at 6 weeks (200%). If PEP fails to prevent HIV, a positive test might be delayed up to 6 weeks after the last dose of drug, i.e. 2.5 months from now. In other words, it prolongs the duration of uncertainty, and perhaps the timing of resumed sex with your regular partner. You might discuss this with the prescribing doc and decide together whether to continue PEP.

I certainly agree with doxy-PEP in this situation. (As it happens, the lead researcher in the US research studies of doxy-PEP is a close colleague and dear friend of mine; we recently finished a week in France together.) It has protected you with close to 100% certainty against chlamydia and syphilis, and it reduced the gonorrhea risk by about half. I would advise a urine or urethral swab test for gonorrhea 4-5 days or more after the event. (It will include an unnecessary chlamydia test, since gon/chl testing almost always are done together.) Because doxy-PEP may not be 100% effective against syphilis, a syphilis blood test would be wise in about 6 weeks.

Can you have sex with your partner while on HIV PEP? In this situation, almost certainly yes. Even if you were exposed and infected, it is very unlikely you could transmit HIV while taking anti-HIV drugs. OTOH, as implied above, nobody can guarantee it is 100% safe.

Finally, a word about your overall HIV/STI risks and prevention. It's triggered by the combination of the events described here and in your thread a few months ago. In the previous one you reveal that your regular partner has (at least had) other partners from time to time, and now you reveal the same about yourself. I would describe the two of you of participants in what prevention specialists call a sexual network. Most people with such lifestyles repeatedly find themselves in similar situations -- and even with safe sex intentions, condoms aren't perfect (as you have just been reminded). All this puts both you and your partner at pretty high risk. You might consider HIV pre-exposure prophylaxis (PrEP), rather than relying on PEP when events like this occur. And do continue the doxy-PEP in event of future events like this one.

I hope these comments are helpful. Let me know if anything isn't clear.

HHH, MD

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H. Hunter Handsfield, MD

13 months ago

You must have been writing your follow-up question while I was replying. It's up to you of course, but if you were my patient, my advice would be to not continue PEP. But definitely don't take my advice -- I'm not your doctor. But you might discuss it with the prescribing doctor or clinic.---

13 months ago

Thank you doctor, you are right, I didn’t learn from previous misconduct and I am planning to get some help to quell my sexual behaviors so I hopefully avoid these situations. I guess a couple of follow on questions.

1. If PEP is safe and then it’s not able to test for 6 weeks after the end of the course, in that time table is it safe the entire time or it’s unknown?

2. How much can I rely on the oraquick tests that we used? It seemed very straight forward but does say only detects 3 months after exposure?

3. Can an RNA test be done 10 days after today or when could I take that after PEP as I know this is able to be more conclusive quicker?

4. I was a bit confused, you said you wouldn’t have advised against PEP, are you saying the scenario with the oraquick makes sense to not actually take the PEP now? It got delayed from pharmacy until tomorrow morning now…

H. Hunter Handsfield, MD

13 months ago

1. There are no data on this. I've never heard of anyone transmitting HIV while taking anti-HIV drugs, but I cannot say it can't happen.

2. True about the oral fluids test lag time. Still, the negative result is very reliable.

3. A negative RNA test at 10 days would show you cannot transmit HIV, but since you're on HIV treatment, it doesn't necessarily prove you weren't infected.

4. Sorry, there's a typo above: I meant I WOULD advise AGAINST PEP. The overall odds you were exposed to HVI or caught it were too low to warrant PEP, in my judgment.

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13 months ago

Thank you for the clarification and I have one last follow up.

I have read and told by doctor that an RNA test is conclusive after 10 days from running the PEP, and recommended that, is that true and I can trust and use that? I will ofcourse follow on with final testing later.

My plan is to go ahead with the PEP because to be honest, I don’t trust the person I was with (they took poppers, etc) even though the oral test was negative and just made a bad decision to interact with that person. I will abstain from sex for 2 weeks to get my full panel test done, and then after if sex occurs during PEP I will use strict protection, then get the RNA test. Or do you feel better to just avoid (gonna be hard to do…).

Appreciate all that you do for people like me who have made bad decisions, have terrible health anxiety like me and hopefully learn from this and get myself the help I need to avoid risky situations and behaviors I have had the last 6 months or so…

H. Hunter Handsfield, MD

13 months ago

I know that many HIV specialists believe this, i.e. that RNA testing even on PEP is reliable evidence that infection didn't occur. However, to my knowledge there is no research and I tend to err on the side of caution. In any case, your provider probably knows as much or more about this as I do.

Your sexual plans seem fine to me.

Thanks for the thanks. I'm glad to have helped. That completes the two follow-up exchanges included with each question and so ends this thread. Best wishes and stay safe.

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13 months ago

Probably one other thing, for the doxy pep does it make sense to take it for a full week/2 weeks like I did prior?

H. Hunter Handsfield, MD

13 months ago

I forgot to close it -- this will be my last comment. The data on 200 mg single dose are strong and have supplanted the 7 day course previously advised for syphilis prevention. It wouldn't hurt to take 100 mg twice daily (or 200 mg once daily) for 7 days -- the former recommendation for syphilis prevention -- but really not necessary.

Best wishes and stay sfe.

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