[Question #12425] HIV and general STI risk
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7 months ago
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I recently had unprotected intercourse with a sex worker in the Philippines. It only lasted a few minutes, and I pulled out before I finished. The girl is training to be a nurse, and claims the first person she went with from the bar but you never know. Today she agreed to do a sexual health check with me and she was negative for HIV.
When I spoke to the nurse at the clinic, they said to me that even though she was negative, it was possible that she was in the incubation stage and therefore wasn't showing as positive on the test. Because it was a sex worker he suggested I take PEP for 28 days and I have the pills, but looking online it looks like PEP can be pretty severe on the body, and it seems like my risk should be very low based on her test being negative.
As this isn't an area I'm too familiar with, I guess my question is twofold: 1. Based on my exposure, what is the risk that I could develop HIV? 2. Would you recommend the PEP treatment?
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H. Hunter Handsfield, MD
7 months ago
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Welcome back to the forum. Thanks for your continued confidence in our services.
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I agree with your general sense that the risk of HIV was "very low based on her test being negative". The likelihood your partner was in the pre-test window seems very unlikely, from a statistical standpoint. That said, the clinic you saw may be quite experienced and have good reason to believe the risk is high. I do have to agree that her story that you were the first partner she went with from the bar seems pretty unlikely. But all things considered, I would expect the chance of HIV in this situation must be under one chance in a million or lower.
However, we do not make specific recommendations for or against PEP; we leave that to the exposed person in shared decision making with a health care provider who understands the epidemiology of HIV in that location. In considering your decision, also remember a factor that's often forgotten: Without PEP, you can have a conclusive HIV PCR/RNA test in 2 weeks and a confirmatory antigen-antibody (AgAb, 4th generation) blood test after 4-6 weeks. With PEP, the testing clock starts with the last dose of drug -- in other words, an additional 4 weeks of uncertainty before you know for sure you weren't infected. Would you be prepared for the delay in knowing the outcome?
It's probably more important, by the way, to be tested for other STDs, which are far more frequent than HIV: gonorrhea and chlamydia (valid urine testing 4-5 days after exposure) and a syphilis blood test at 6 weeks.
I hope these comments are helpful. Let me know if anything isn't clear.
HHH, MD
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7 months ago
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My main issue with the PEP is that I've already experienced low level headache/nausea, and yesterday back pain in the kidney area, which I'm hoping doesn't get worse. So when I sent the question yesterday, I was trying to balance the actual risk of catching HIV with the negative effect to the body of PEP. Do you know whether the symptoms are typically short term? Note, I've had kidney and liver checks and they are both healthy. The pills I'm taking are dolutegravir lamivudine and tenofovir disoproxil fumarate. The doctor I spoke to today said the side effects typically lessen after the first week.
My final question is in regards to the temperature the PEP pills should be kept at. After I went to the clinic today I stupidly went to the pool forgetting the pills were in the front pocket of my bag. After about 25 minutes I remembered, and noticed the plastic was very hot (it was 32 degrees celsius outside - about 90 degrees Fahrenheit). I quickly rushed up to the hotel room and within 5-10 minutes the plastic and pills had cooled. On the box it says. the pills shouldn't be stored above 30 degrees, so now I'm concerned I may have damaged the efficacy of the pills. Hopefully the short duration means these will be ok but I'd appreciate your professional opinion.
Thanks for your recommendation to test for both Gonorrhea and Chlamydia. I will complete this after 5 days. Syphilis is another one we were both tested for, and she was found to be negative.
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H. Hunter Handsfield, MD
7 months ago
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There usually isn't significant "effect on the body" of PEP, and your symptoms don't sound to me like PEP side effects, but your doctor may be more experienced in using PEP than I am.
Few if any drugs are likely to be adversely affected by only a few hours at higher than recommended temperatures. If it were such a serious issue, I would imagine almost all pharmacies in tropical climates would attach warnings to the prescription container. Beyond that, I have no idea. You could ask the pharmacy.
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7 months ago
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Thank you sir. On the point about side effects, last night I took my third dose of PEP and I was up almost all night throwing up. Do you happen to know which combinations are best to minimize side effects from PEP? The combination I’m taking is Dolutegravir, Lamivudine and Tenovir DF. The local clinic in Bangkok where I am at the moment mentioned Biktarvy (bictegravir, emtricibine, and tenovir alafeminide) is better on the kidneys but I don't know if that correlates with lower side effects or not. If I'm already very bad on day 3 I'm worried how this is going to go over the next month.