Are there any PEP interactions with ketoconazole cream applied to penis roughly at the same time or fluconazole 150mg taken once a week 12 hours apart. Also vitamin D3 liquid taken 12 hours apart. I read online about 20% prevelance of hiv in Bali sex workers how does it affect my risk. If there was blood caused by my fingering would that increase risk. I am uncircumcised. I read online that PEP can cause a rash I have not experienced it yet can I still get it and if so what does it look/feel like. 

I am uncircumcised.

If I correctly understand, this was quite a low risk exposure, even if it's true that 20% of female sex workers in your area have HIV (which seems awfully high to me). It sounds like all vaginal penetration was condom protected, and oral sex is very safe without protection:  there has never been a proved HIV transmission mouth to penis. That doesn't mean it can't happen, but obviously the risk is miniscule. The fingering makes no difference, regardless of potential blood contact. Circumcision in theory doubles the chance of infection if sexually exposed to HIV, but this really isn't very significant. (For unprotected oral with an infected partner, maybe there's one chance in 10,000 you would be infected. Double risk make it 1 in 5,000 -- still very low.)

For those reasons, if you had you been in my clinic, we would not have advised PEP. However, we would have been willing to prescribe it if you requested it. 

There are no adverse intereactions of PEP drugs with either ketoconazole cream or fluconazole by mouth; and certainly no problem with D3 or any other vitamins. Indeed, I am unaware of any significant interactions with any drugs at all. Yes PEP drugs can cause allergic skin rash, but only rarely. Allergic rashes are highly variable, but usually they are body wide and itchy.

There is a downside to PEP that you might not have thought about, and many prescribing doctors don't consider it either. Without PEP, you could have a 99% conclusive PCR test in 10-12 days, and truly conclusive AgAb (4th generation) HIV blood test after 6 weeks. If PEP doesn't work, it can delay the time to reliable testing, so you won't know for sure that you were not infected for up to 3 months. Are you OK waiting that long? I'm not advising you stop PEP, but perhaps it's something to discuss with your doctor or clinic. Another option, if you are able to contact your partner, is for her to be tested. If she is HIV negative, of course you could safely stop PEP.

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

HHH, MD

I think I wasn’t able to properly explain. There was penetration without condom that lasted for about 5-10 seconds. With that in mind do you think PEP was warranted in this situation? If I was exposed to HIV how effective is the PEP I took (tenofovir , lamivudine and dolutegravir) at preventing infection when taken at 35 hours? 

Thank you 

Hour to hour data on PEP effectiveness do not exist, but the usual estimate is that protection is close to 100% effective in preventing HIV when started within 48 hours of exposure.

Yes, there was unprotected vaginal penetration that lasted around 5-10 seconds. My apologies for not being able to explain. Am I correct in assuming that my risk for this encounter was around 1 in 1000, going up to 1 in 500 if any STDs were present? Do you think the 20% prevalence is exaggerated, and if so, what would be a realistic figure? I wasn’t asking if I should continue PEP or not; I was trying to understand if you would have prescribed it in my situation. How long after finishing PEP is a PCR test conclusive? Thank you for being so helpful 

Whether or not to take PEP almost always should be the result of shared decision making -- i.e. an in-person discussion of the patient with a health care provider about the pros and cons. That's why knowledge of the local HIV situation, and a doctor in that location, is the only appropriate basis for the decision.

There are no conclusive data on the time to test after PEP, but most experts would consdier a PCR test nearly conclusive around 10-14 days after the last dose of drug; and an AgAb (4th generation) blood test at about 6 weeks.

That completes the two follow-up comments and replies included with each question and so ends this thread. I hope the discussion has been helpful. Best wishes.