[Question #11855] Unprotected Vaginal sex and PEP

11 months ago

Hi Doctor,

I'm seeking your advice regarding a recent situation. I met a 23-year-old woman in Dubai who is sexually active. We had sex twice, including oral sex both ways. During the first encounter, the sex was initially protected, but I made the mistake of removing the condom mid way as I couldnt ejaculate and then i finished outside. The second encounter, was fully unprotected insertive vaginal sex for about 40 minutes in different positions and strokes ( hard and soft sex). Unfortunately, I don't know her HIV status, and she has never been tested. While she appears healthy, I understand that this is not a reliable indicator.

Given the circumstances, should I start PEP? I have a bottle of Taffic (generic Biktarvy) on hand. This makes me super nervous as Dubai or the UAE has very strict rules when it comes to Hiv leading to deportation if positive.

Thank you for your guidance.

H. Hunter Handsfield, MD

11 months ago

Welcome back. But unfortunately, I don't think I can help very much. This is your fifth question in a year (and your second in a week), all about nearly identical exposures -- all of which have been low risk. The difference this time is that your vaginal exposure was unprotected part of the time. However, it was still low risk -- even with entirely unprotected vainal sex, the average risk of HIV from a single exposure is estimated at one chance in 2,500, and that's only if the female is infected. As for the oral sex component, in all four of your previous threads Dr. Hook has correctly advised you that oral sex is no risk for HIV. Further, it seems unlikely that your partner has HIV anyway. My understanding is that HIV is quite uncommon in female sex workers in Dubai -- or so I've been told by the director of an STD clinic there.

We never give specific advice for or against PEP; that comes too close to practicing medicine from a distance, which we cannot do. PEP decisions always must be made in consultation with a local provider who understands the risks in that area. For example, conceivably a Dubai physician or clinic has information different than mine about the chance a partner like yours has HIV.

The deportation if HIV positive business really is not an issue. Just being tested doesn't get anyone sent home; only positive results do that. And if an ex-pat IS infected, s/he has to return home anyway for life-extending treatment. This definitely is not a valid reason to avoid seeing a knowledgeable health professional.

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

HHH, MD

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11 months ago

Hi Doctor,

Following up on my previous message, I wanted to provide more details about my situation. The second exposure I mentioned was entirely unprotected, lasting nearly 40 minutes of intercourse. I'm concerned because HIV is relatively common in Dubai, and I've personally seen two people within my network who were infected and subsequently deported. I understand that the publicly available numbers may not fully reflect the situation on the ground, but in reality the figures are way higher.

Given these factors, I have two important questions:

1. Based on your experience and knowledge, if you were in my position, would you choose to take PEP after this exposure?

2. I currently have a bottle of Taffic (generic Biktarvy). Would this be as effective as the standard PEP regimen typically recommended?

Thank you for your continued support and advice.

H. Hunter Handsfield, MD

11 months ago

Thanks for clarifying the second exposure. But it still was low risk for HIV, for the reasons I gave above. I can't comment on your perception of reality versus official figures (https://www.unaids.org/en/regionscountries/countries/unitedarabemirates) but I gave other reasons your risk is very low anyway.

1. "...would you choose to take PEP after this exposure?" No I would not. I'm not even sure I would get tested for HIV.

2. All drug regimens effective in treating HIV probably are effective as PEP, whether or not they have been specifically studied or recommended for the purpose. (This does not mean I recommend PEP in your situation. I do not.)

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11 months ago

Hi Doctor,After considering your advice, I decided to forgo PEP. However, I'm still very anxious about the possibility of HIV, and the thought of waiting six weeks for a conclusive test result is overwhelming.I've been reading about the HIV RNA test and its effectiveness around 10 days post-exposure, but I’m finding conflicting information. Some infectious disease doctors in the region say that the RNA test is conclusive by day 9, while others suggest it's only about 90% accurate at that time.Based on your experience, what do you recommend? Would an HIV RNA test at around 10 days provide a near-conclusive result, or should I expect more uncertainty?Thank you again for your guidance.

H. Hunter Handsfield, MD

11 months ago

Hello again. I responded to this message a few hours ago, or intended to -- and closed the thread. But apparently my reply didn't get posted. Here it is again, and the thread is re-opened (but only briefly til I know you've been able to see it). My apology for any potential confusion or concern.

I did not advise you to forego PEP. I just stated the pros and cons and reasons I would not prescribe it -- but also said that PEP decisions must involve a local health care provider who understands the epidemiology of HIV in that area. The decision is strictly your responsibility. We never give specific treatment advice; it comes too close to practicing medicine from a distance.

Most experts state 11 or even 12 days as the time for conclusive HIV RNA/PCR results. Your estimate of 90% at 9 days probably is about right. But why would you test early when all you'd have to do is wait another day or two? Most experts also advise additional testing with an AgAb (4th generation) blood test at 4-6 weeks, but I would view that as optional given the near zero chance you acquired HIV.

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