[Question #12491] HIV exposure & PEP assessment

7 months ago

On Jan 5th 2025 - I am a male that had sex with a black female sex worker in NYC and now I am concerned about contracting HIV. She inspected my genitals (feeling for bumps/sores) and questioned me about my STD status (all negative) She mentioned that she tests regularly and has no STD and uses truvada as Prep (i saw no proof of this and she is not willing to provide her testing results) I am worried she lied about her status

She gave me unprotected oral sex. then protected vagnial sex 15 mins, with condom on. I did not inspect to see if it broke but no slippage and it stayed on through vaginal sex. Afterward she removed condom and gave oral sex. I finished my self with a handjob. What is the probability of me contracting HIV and stds?

On Jan 6th - Got PEP (19 hrs after exposure) Doctor prescribed (for 3 days use only) Truvada 200mg - 300mg and isentress 400mg both oral and to take it for 3 days. Doctor said PEP is for emergency and and work place injuries and that 3 days is sufficient in my case. Then for me to test in 4-6 weeks

Is 3 days usage effective? Will my results be accurate in 4-6 weeks if I take his 3 day oral meds. Do I even need PEP? Should I get a different doctor to prescribe it for 28 days?

H. Hunter Handsfield, MD

7 months ago

Welcome to the forum. Thank you for your confidence in our services.

The only aspect of this exposure that could have resulted in HIV was the vaginal sex, if the condom failed (broke) and somehow you didn't notice. In the entire 40 year history of the worldwide HIV/AIDS epidemic, there have been few if any scientifically proved cases of HIV transmitted by oral sex mouth to penis. Also, condoms are virtually 100% protective when properly used and don't break. And even with no protection at all, the average chance of vaginal to penile transmission of the virus -- if the female partner has HIV -- has been calculated by CDC to be about one chance in 2,500. In addition to all that, you describe a partner who almost certainly does not have HIV. In fact, being on HIV PrEP would mean she could not transmit HIV to you even if she had been recently exposed herself.

For those reasons, I agree with your own inclinations as reflected in your closing three questions. Had you been in my clinic, we would not have recommended PEP; in fact, I wouldn't even advise HIV testing on account of risk, only for reassurance. If you had been at real risk, most experts would prescribe the standard PEP regimen, i.e. 4 weeks of Truvada or Descovy. I am not aware of any studies or data on the effectiveness of PEP using a PrEP regimen (2-3 day treatment). I'm inclined to agree with your doctor, that probably 3 days is sufficient -- but to my knowledge this just isn't known. In any case, I see no reason that negative HIV test results 4-6 weeks later would be conclusive regardless of this brief treatment.

These comments cover your three questions, but to be explicit: 1) Is 3 days effective? I would think so, but cannot guarantee it. 2) Will test results be accurate in 4-6 weeks? I'm sure they will. If you test at all, you can expect negative results. 3) PEP for 28 days? I definitely do not think this is necessary or wise. Don't forget an important downside of PEP: It means an extra 4 weeks until conclusive testing can be done. A lot of folks in your situation are not keen on the increased duration of uncertainty.

Another consideration is to contact your partner, if you are able, and ask her to be retested for HIV at this time. You might offer to pay for it. If negative, you'd know for sure you were not at risk.

Finally, you mention other STDs. I wouldn't worry at all. The condom protected vaginal exposure prevented any significant chance, and unprotected oral sex is very safe. If no symptoms of urethral discharge or genital sores within 2 weeks, that alone will be strong evidence you weren't infected. But if you'd like other reassurance, you could have a urine gonorrhea/chlamydia test 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

Thank you Dr Handsfield. If I understand correctly. The risk of me getting HIV from this event is extremely unlikely and other stds are also unlikely. The need for PEP is not necessary. The only thing that gave me concern is that I reached out to the sex worker and she is unwilling to do any testing and she said I should not contact her again. Her reasoning is that we did condom protected vag sex and that there was no raw penetration. I plan on doing a full STD screening in two weeks (just for peace of mind). I understand that the 4th gen hiv test would not be conclusive but if I did a HIV RNA test would that be conclusive? In your professional opinion should I abstain from sex with my partner or would protected sex be okay until I have definitive results? In your years of experience has a scenario like mine resulted in someone contracting HIV? Upon reflection I would like to think that I am not at risk and this is just guilt and anxiety where I am fixated on minuscule theoretical probability of infection but for real world/ practical purposes is close to a 0% chance of happening and that I am worried over nothing.

H. Hunter Handsfield, MD

7 months ago

I'm glad you understand and I agree exactly with your comments about anxietyn and "worrying over nothing".

Most labs' "comprehensive" (or "full") STD screening tests include several that really should not be done at all: bacteria that don't matter or don't need treatment in absence of symptoms, viruses for which there is little or no risk at all, or the results themselves are often unreliable. And two weeks is too soon for anything except a urine gonorrhea/chlamydia test (which can be done now, no need to wait 2 weeks). HIV RNA testing is overkill in this situation, but negative results are conclusive at 11 days and beyond.---

7 months ago

Hi Dr.Handsfield - today was my last day for the 3 day pep regiment my doctor gave (which i finished and agrees that I dont need more). I won't be requesting the additional amount to do a 28 day full treatment. I will be doing the HIV RNA test 14 days from today and I just wanted to make sure that my 3 day usage will not affect the results of the RNA test and it will still be conclusive so that i can test with confidence. Also as one form of reassurance, do you still believe that my exposure risk was next to nill? after the escort refused to provide her testing and assuming she has hiv?

H. Hunter Handsfield, MD

7 months ago

There are no data to conclusively answer your testing question, but I am confident the negative result in 2 weeks will be reliable. And I have not changed my mind about the virtually zero risk of HIV from the exposure you are concerned about. There is no reason for "assuming she has HIV"; almost certainly she does not.

That completes the two follow-up comments and replies included with each question and so ends this thread. A final comment that might further reassure you: In the 21 years of this and our previous forum, with thousands of questions from people worried about HIV, not one has ever reported they tested positive. You will not be the first. If and when it finally happens, surely it will be a genuinely high risk exposure (like unprotected anal sex between men) and not a near zero risk event like yours. Please stop worrying!

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