[Question #1242] Recent Exposure - PEP?

48 months ago
Hello doctors,

Unfortunately I'm back on this forum and I wish I wasn't. The other night in NYC I got extremely drunk and I ended up going home with a young French woman. 

We engaged in the following:
Unprotected oral
Fingering, both vagina and anal
Genital to genital rubbing
Protected vaginal sex twice

I asked her numerous times (probably 10) if she was clean and had no stds. she assured me she was and she had a blood card(?) to prove it. Though I never actually saw the card.

So my questions are:
Should I go on pep based on this exposure? The incident happened on Saturday morning so I still have some time to get it.
What are my chances of catching an sti from my interactions?

I plan to get re-tested at the end of the week, then again a few weeks later.

Please advise, thanks
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
48 months ago
Welcome back to the forum. Congratulations for the wisdom to have only safe sex during this exposure, i.e. use of condoms for vaginal sex. Good move!

The risk of HIV from these events is extremely low.  First, it is statistically unlikely that a partner like yours has HIV, and people rarely lie about HIV or STD status when asked directly. Second, condoms work; they are nearly 100% protective against HIV if properly used (no penetration before placement or after removal of the condom) and do not break. Third, HIV is not transmitted by genital apposition or oral sex, or so rarley it can be ignored. There have never been any reported and scientifically proved cases of HIV transmission oral to penis by cunnilingus (oral-vaginal contact), genital apposition without penetration, fingering, or other hand-genital contact. 

Accordingly, I would not recommend PEP in this situation, especially since you used condoms for vaginal sex. However, this is a judgment call and others might disagree. Some physicians would prescribe PEP if you request it, especially if details about your partner are known to be associated with high risk of HIV in your particular area (where and how you met her, likelihood of drug use, and so on), PEP might be recommended if only for reassurance. If you want to pursue PEP, you should see a physician familiar with local HIV epidemiology, e.g. the NYC public health department or perhaps a local urgent care clinic. While technically true that you "still have time" before the recommended 72 hour limit, PEP is always best the earlier it is given. For sure don't wait any longer than 2 days, i.e. early Monday.

As for other STDs, those risks also are low, but not as low as for HIV. Oral sex risks gonorrhea, syphilis, and herpes due to HSV1, and maybe chlamydia, and even with condoms vaginal sex risks HSV2 and HPV. The usual approach in this situation would be to wait a few days and have urine test for gonorrhea and chlamydia, and have syphilis and HIV blood tests in a few weeks. However, some professionals would prescribe preventive treatment, e.g. ceftriaxone plus azithromycin to prevent gonorrhea, chlamydia, and syphilis.

In summary, I do not recommend PEP and would not do it myself if somehow I were in your situation. Instead I suggest visiting one of NYC health department's excellent STD clinics in 3-5 days for gonorrhea and chlamydia testing, and a syphilis blood test at 6 weeks. You might consider HIV testing as well (duo test at 4 weeks), but this is primarily for reassurance.

I hope this has been helpful. Let me know if anything isn't clear.

HHH, MD

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48 months ago
Thanks doc.

Couple of follow up questions:
Are the pep side effects severe? 
How many pills do I need to take a day and for how long?
Are these clinics open today in NYC? Or do I need to wait until tomorrow?
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
48 months ago
There are several PEP regimens. One of the most common is Truvada® (a 2 drug combination) once daily plus raltegravir twice daily, total 3 pills daily, for a month. They and other regimens can cause rare but potentially serious side effects, and proper care includes periodic follow-up blood tests to check for toxicity. Once started, it is recommended that PEP not be cut short; commit to the full month or don't startl. These are the reasons PEP decisions should not be taken lightly and are usually done only for HIV risks a lot higher than yours, and why it's always best to see an expert in judging risks and aiding in the decision. Lots of information is available online, e.g. via google.

I doubt any NYC health department clinics are open Sundays. That's why I mentioned urgent care clinics. You should be able to easily find health department clinic information online.

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H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
48 months ago
Another thing to consider before you seek or start PEP:  If PEP fails to prevent HIV, it might lengthen the time to reliable diagnostic testing, to as long as 3+ months after the exposure. So instead of a definitive test showing you weren't infected at 4 weeks, you can expect the anxiety of uncertainty going for 3, or even 6 months according to some experts' advice.

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48 months ago
Thanks, doc.

I went ahead and got pep yesterday from an emergency clinic. It was before I saw your response about it delaying the test results. Ive only taken one dose of the truvida and two doses of the the other medicine. My main logic for getting it was I don't know how safe I actually was during intercourse. I definitely used condoms but there was some very intense fingering (inclusive of anal) and genital to genital contact before sex. I also think the condom rolled up at one point during sex. It's very blurry and I don't know what I did vs didn't do. 

My questions are:
If I were to stop the pep today, would taking it for the day I have delay a test at 4 weeks?
What are the chances that this pep course will fail? I started it at around 37 hours post.

I have no way of contacting this woman, I am honestly not sure what to do. It's such a judgement call to either stay on this medicine or get off and I just need someone to advise me.

I'm happy to pay another 25 to continue the conversation but I really need some strict advice at this point.
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
48 months ago
One day of treatment won't have any effect on delayed diagnosis. There has been no rigorous research on the effectiveness of PEP and there are no scientific data on the chance of failure. But if we assume a one in a million chance you caught HIV based on this exposure, which I think is in the right ballpark, and 90% effectiveness of PEP, then at the end of treatment there would be a 1 in 10 million risk you were still infected. OTOH, even without PEP it's still only 1 in a million, which are good odds.

There is no way this forum can give you "strict advice". We are not your doctor and cannot practice medicine from a distance. If you're not confident in the expertise of the emergency clinic doctor, your best bet for "strict advice" (i.e. ongoing expert care) is to see a specialist in HIV treatment, such as an infectious diseases specialist. Such experts are readily available in NYC. Or perhaps follow-up in an NYC public health clinic.

That will end this thread. I would recommend you carefully re-read this entire discussion, concentrating on every word. You have had reasoned, science based, expert advice that should be highly reassuring. Please do not start a new thread; any additional advice here will be no different than you have had so far. 

Good luck.
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