[Question #12631] HIV Risk Assessment

6 months ago

Hi Doctor, Im male and met up with another male. He said he was negative and on PrEP, and I ended up engaging with him in oral and unprotected Anal. I was the insertive partner, it lasted about 1-2 minutes and I ejaculated inside him. That is all that happened.

Afterwards, I was curious and asked him about what he is taking for PrEP, and he showed me him Biktarvy bottle. I had a feeling this was strictly an HIV drug, not for PrEP, so I asked him and he answered he was on some sort of trial for a Truvada alternative for HIV prevention. This seems like a lie to me, I now feel like he may be positive and taking Biktarvy. Which is great, but I do not know if he is undetectable, also, since he lied, I am not even sure if he takes his medication. I have read that people typically do not lie about their status, but it seems like this individual seems to be lying. I do not know what to think.

I am considering PEP, would you take this if it were you?

H. Hunter Handsfield, MD

6 months ago

Welcome back. While of course condoms are always advised for non-monogamos anal sex, you are at no risk of HIV. There is no chance he could have infected you, assuming he in fact is taking Biktarvy. All drugs effective and approved for HIV treatment also are generally believed to be 100% effective for PrEP. That Biktarvy hasn't been studied as PrEP and therefore not officially advised for that purpose, that doesn't mean it isn't effective. And it sounds like your partner probably is participating in a study with exactly this purpose. If he has HIV but, due to treatment has an undetectable viral load, nobody can be infected by him. From what you say, it seems unlikely he is lying -- but of course you have had the opportunity to judge him in this and I have not. Either way, it appears your risk for HIV is minimal despite an otherwise high risk exposure.

The bottom line is that I do not think PEP is warranted. However, opinions on this could vary between experts; and we take no responsibility for decisions either to take or not take PEP. That's always something to be determined through in-person care with a provider who understands local epidemiolgy of HIV. So it's up to you -- but if you wish to consider it, you'll need to see a local doctor or clinic. In the meantime, perhaps you could have another conversation with your partner about his HIV status; viral load if taking Biktarvy as treatment for known infection; and perhaps more detail about the Truvada/Biktarvy research study. (If indeed there such a trial underway in your community, the clinic where your partner is being treated would seem to be an excellent resource for you.)

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

HHH, MD

---

6 months ago

Hi Doctor thanks for answering!

I guess my main worry is that he’s not being truthful and is actually positive. I hope he is undetectable. I tried to ask him to clarify why he is taking Biktarvy if he claims to be negative and on PrEP, but he won’t respond which is more worrying. (My PEP prescriber said that’s not a PrEP medication).

Let’s just say worst case scenario, he is positive and detectable (maybe he doesn’t take his medication). This would be a high risk situation right? (me as the unprotected top/insertive partner - I am circumcised if that matters) I ended up getting PEP and started within a few hours of exposure.

Is PEP generally effective in this case? (My probably stupid worry is that he could be not only be detectable but also have a resistant strain if he’s not taking his medication since he won’t confirm his status and only says negative).

Side note - I have also read in the pamphlet that you should avoid calcium supplements with Tivicay for 6 hours before or 2 hours after. I had this large oat milk drink which had around 800-1000 mg of Calcium about 4 hours before my first dose which worries me. Any insight into that?

And finally, can you comment on testing post PEP? I have access to both PCR and 4th gen lab tests.

H. Hunter Handsfield, MD

6 months ago

I think your worst case scenario is very unlikely. If he is infected, it still would be very unlikely he would have a transmissible viral load from missing some Biktarvy doses, unless he skipped the drug entirely for a week or two. If he were infected and had a substantial viral load, PEP of course would be effective. It also is unlikely he has a resistant strain of HIV.

I have no insight into how much calcium would truly interfere with dolutegravir (Tivicay) absorption. Sorry. But here too I would not worry. For you to be at real risk here, several unlikely probabilities all would have to break in the wrong direction.

If you seek and obtain PEP, I would advise following that provider's advice about follow-up testing. There are no solid data, and opinions vary. For the most part, probably a negative RNA PCR test ~2 weeks after the last dose and a 4th generation test at 6 weeks. But I still think it would be dumb to seek or take PEP in this situation. (And any case, that you "have access" to testing, presumably on your own, I would still advise you not to follow our advice but to see a provider in person for proper personal care and advice.) I am not nearly as experienced in PEP as most community providers who commonly see infected or potentially infected patietns.

---

6 months ago

Thank you Dr. Handsfield. It is reassuring to hear that you think that PEP was probably not warranted. I think I am going to continue with my regimen now that I have it, just for peace of mind.

I had one final question (I know you said refer to my prescriber, but they are closed for the weekend). I took the first dosage at 4:30 pm, this is an inconvenient timing for me. (I read that moving it gradually is ok?) The next day I moved it earlier to 1:30 pm and then the next day 11:20 am where I will keep it for the reminder of the time. Is this ok? I guess this means that overall I’ll be short on PEP by about 6 hours. Is it true that such small variations don’t matter?

H. Hunter Handsfield, MD

6 months ago

Moving to a more convenient dosing schedule should be fine. I don't think you need do it gradually. It's OK to have a dose or two closer together (rather than spreading them apart) for a day or two.

That completes the two follow-up exchanges included with each question and so ends this thread. Best wishes and stay safe.

---