[Question #12850] PrEP on demand
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4 months ago
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Hi! I have a question regarding PrEP on demand / a possible STD exposure. This past Saturday (3/29) I took 2 doses of a generic brand of Truvada at 1:00pm. I did not end up having sex that night. The following day on Sunday (3/30) I took another 2 doses at 9:00am and ended up having insertive vaginal sex, insertive oral sex & I vaginally fingered a woman at 11:00am (exactly 2 hours after.) I then took a single dose the following two days (Monday & Tuesday) at 9:00am. My concern is that during insertive vaginal sex, the condom broke. Therefore, I would like to know if I took the PrEP on demand correctly and I was protected from HIV. Also, is there any chance I could have acquired HIV from receiving a blowjob and/or fingering the woman? Is there any medical reason for testing here? Thank you!
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H. Hunter Handsfield, MD
4 months ago
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Welcome. Thank you for your confidence in our services.
My first reaction is to congratulate you for having safe sex in this situation — by intent, anyway. Second, that nether PEP nor PrEP are advised in your situation. PEP is advised only for men having sex with men, and for heterosexual exposures more risky than yours — e.g. with partners known to be injection drug users or to have HIV and not on treatment. PrEP is advised only for MSM — and even there, only for anal sex. Even if you had not planned to use a condom, unprotected vaginal sex doesn’t warrant PrEP, either continuous or on demand.
That said, I see no reason for concern about the effectiveness of PrEP as you took it. The drugs are quite long acting and minor variations from the recommended doses or frequency probably make no difference. Because the research on PEP and PrEP was done with specific doses and timing, the same is advised for routine use. That doesn’t mean other doses and intervals don’t work, only that they haven’t been studied.
Generic anti-HIV drugs are equally effective as they brand name equivalents. Insertive oral sex is risk free for HIV (there has never been a proved case of HIV transmission oral to penis) and fingernail also is no risk.
“Is there any medical reason for testing here?” No, I would not advise testing for HIV in this situation, even had you not take PrEP. Of course you are free to be tested anyway; reassurance is a valid reason for testing for persons worried about an exposure, independent of actual risk.
The bottom lines are that you were at little or no risk of HIV; and that I hope you will hope these comments are helpful when it comes to future plans for sexual safety, PEP, and PrEP. Let me know if anything isn’t clear.
HHH, MD
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4 months ago
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Dr. Handsfield,
Thank you for the quick response! I'm glad to hear that HIV testing isn't necessary in this situation. I juts have a couple of quick follow up questions.
Even though PrEP on demand isn't typically recommended for insertive vaginal sex, oral sex, or fingering, does it still offer a high level of protection for those activities? I've had a bit of trouble finding a clear answer in the forum responses-apologies if I missed it.
I have a strong fear of HIV, so my PCP recommended PrEP on demand to help ease those worries. With that in mind, it would be reassuring to know that even though the condom breaking during vaginal sex was a low risk scenario, I still had an extra layer of protection thanks to PrEP on demand.
Lastly, I did some additional research, and it seems like I followed the PrEP on demand protocol correctly—taking a double dose 2 hours before the encounter (3/30), followed by single doses 24 (3/31) and 48 hours (4/1) later. I’m assuming the extra double dose I took on Saturday (3/29) was basically a waste but didn't interfere with the next double dose I took the following day—would that be correct?
Thanks again so much for your help!
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H. Hunter Handsfield, MD
4 months ago
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There has been no research on effectiveness of PrEP or PEP for nearly zero risk exposures. I imagine it would be effective, but when the risk is under one chance in millions (probably a good estimate for your exposures), what does it matter if PrEP reduces that risk? That said, I'm not criticizing your doctor for going along with on-demand PrEP; I agree that reassurance alone is a reasonable reason to use it. Just be clear that it really will make no important difference in the risk you will acquire HIV someday.
The details of the dosing scheduled don't matter very much. See my comments above in the paragraph starting "That said,...." Certainly taking an extra dose is not likely to be harmful or to further reduce the risk.
That concludes this thread. I hope the discussion has been helpful. Best wishes and stay safe.
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