[Question #13065] HIV PEP STIs

2 months ago

I had a possible exposure. I was extremely intoxicated, and unsure if I had unprotected vaginal intercourse with someone of unknown status. This would have been with someone other than my partner. (I am a heterosexual female). I do not remember engaging in the act of sex. The following morning I noticed my vaginal secretions were increased, smelled a bit off - chlorine like - and then later in the day a clump of stringy yellowish discharge came out while using the bathroom. After that, I began to spiral, was unsure if I had sex, no strong memory, only what family has suggested are fear-based images, and have since been filled with anxiety. I went to doc, given a full STD panel - all negative. I was started on Biktarvy, I am on day 18. I've had some headaches, diarrhea (today only) and my body/muscles are tired.

My questions are as follows:

How reliable will my test at 29 days post exposure be? Will my test at 6 weeks post exposure be reliable/conclusive? Have you seen anyone test positive when taking Biktarvy after testing negative at 29 days? When can I safely resume sex with my partner? Do my symptoms appear to be seroconversion? Lastly, when should I repeat a full panel for STDs, 6 weeks?

H. Hunter Handsfield, MD

2 months ago

Welcome back to the forum, five years after your handful of earlier questions. Thank you for your continued confidence in our services.

Intoxicated or not, you know more about this sexual exposure than I do: you were there and I wasn't. I'll say that no infection can cause a change in vaginal secretions (or any other symptoms) in less than 1-2 days; any change "the following morning" cannot be from an STI or other infection from the event. I'm surprised your doctor prescribed HIV post-exposure prophylaxis (PEP, i.e. treatment with Biktarvy): was there a reason to suspect your partner was high risk for HIV?

"How reliable will my test at 29 days post exposure be?" Zero. The clock for HIV testing starts with the last dose of PEP, not with time since exposure. A negative test at 6 weeks from exposure (2 weeks after completing Biktarvy) will be reassuring but not conclusive. Your symptoms do not suggest HIV or seroconversion -- but no symptoms while on PEP drugs are likely due to HIV. Just as with HIV testing, the clock for timing symptoms starts after the last dose of drug, not exposure.

Knowing nothing about your partner, I cannot judge the risk of other STDs. Have you been tested for gonorrhea, chlamydia and syphilis? If not, do it now. If those results are negative, you probably can safely resume sex with your partner. (The chance you have HIV is near zero.)

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

HHH, MD

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2 months ago

I have followed you and Dr. Hook for many years, and appreciate every bit of advice and solid knowledgeable answers.

The possible exposure was not with my long term partner. If it occurred, it would have been with someone I do not know, shamefully. I apologize, when I mentioned the vaginal secretions, I did not believe they were due to an infection so soon, but rather I was thinking it was possibly semen from the night before, which is what led to my downhill spiral. I too, could have been ovulating, as it does line up with the timing for that, but with memory gaps, I couldn't be sure, so I went straight to the doc, started Biktarvy approximately 40 hours after possible exposure. I was tested for and treated prophylactically for chlamydia and gonorhea (forgive the spelling).

Do you know why docs (this particular doc is working in an STD clinic, specializing in PEP and PrEP) recommend testing at 29 days or once PEP ends if it is virtually unreliable?

You mention the chance I have HIV is near zero. Can you give me an idea of what my real risk was if 1x vaginal intercourse did take place with ejaculation? I know there's a lot of information regarding this online, but would feel better hearing the data you go by.

Have you seen anyone test positive after taking Biktarvy as prescribed with NO NEW risk, NO continued risky behavior after testing negative at 29-30 days?

My anxiety and guilt are weighing on me terribly. And am just looking for a light at the end of the tunnel.

2 months ago

Sorry, meant to add this to my previous reply:

Will 6 weeks post last day of PEP be conclusive, or would I have to wait 12 weeks post last day of PEP?

And do you recommend the Oraquick HIV test at all?

H. Hunter Handsfield, MD

2 months ago

We generally use the results of a CDC analysis several years ago, which calculated one chance in a thousand of HIV transmission in a single episode of unprotected vaginal sex with an HIV infected male not on treatment. Assuming your partner is heterosexual and not an injection drug user, the chance he had HIV probably was in the ballpark of one in a thousand. If so, your risk of HIV would calculate at one in a million, in my view too low for PEP. CDC's PEP recommendations are for its use only in known HIV exposures, i.e. if your partner were known to have it. At a minimum, I would have discussed the pros and cons with you before prescribing it.

It is entirely normal to test for HIV at the end of PEP. If it fails, testing may be positive at that time. As you apparently know, however, additional testing is advised over the next few weeks.

Your question about timing of a final test is timely. It's 6 or 8 weeks after the last dose, i.e. 10 or 12 weeks after exposure. There is some uncertainty: CDC's latest revision of PEP guidelines (released just 3 weeks ago) now calls for final testing 12 weeks after exposure, i.e. 8 weeks after the last dose of PEP. Our advice has been that 6 weeks after the last dose is conclusive, and some experts believe the latest CDC recommendations overly conservative, hence the uncertainty. My personal experience is that I've never had a patient, nor known of a colleague's patient, who tested positive following PEP -- undoubtedly because PEP is so highly effective.

The oral fluids test (Oraquick) has its place for those not at very high risk and want periodic reassurance. However, the up to 5% of infected persons never develop enough antibody in oral fluids to test positive. For true high risk or for anxious persons who desire an absolutely conclusive test result, a lab based test is necessary.

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2 months ago

I've read your posts for years; even when you were on Medhelp. I know this is my last question, but I have to ask.

With all of the information I've shared with you, my 1x possible exposure, starting PEP (Biktarvy) at 40 hours post possible exposure, do you think I will be the first to test positive after taking this as prescribed?

I do apologize for the question, and I understand you cannot tell the future, I just mean in terms of your experience and available data.

Thank you in advance for everything you do for all of us worrying on the other end of the screen and those you see in person. Thank you.

2 months ago

Hello. Since my question from a few days ago is still open, I figured I'd add something else I thought of, and if you could answer it, along with the other open question

(My likelihood of being the first person for Biktarvy to fail?)

And...

I plan to repeat an STD panel. When can I test (post exposure) and expect conclusive results in regard to Hep B & C, syphilis and trich. I do plan on repeating my Trich test bc the one I tested negative for was only 36-40 hours post possible exposure. I was given antibiotics prophylaxis for chlamydia and gonorhea - would you say I would need a repeat test for those two?

That is all. Thank you so much.

H. Hunter Handsfield, MD

2 months ago

Sorry for the delayed reply. And thanks for your long time loyalty and support.

I see no reason to suspect your PEP to fail. As discussed, in my view it doesn't matter anyway, because the chance you were exposed to HIV is nil for all practical purposes.

I am unaware of data on time to conclusive urine or vaginal swab testing for trichomonas. Forty hours undoubtedly is too soon, but I would expect reliable results after 4-5 days, as for gonorrhea and chlamydia. Hepatitis C was zero risk -- not transmitted by vaginal sex or so rarely to be ignored. Hep B nearly zero because of its rarity in heterosexual males, but testing is conclusive 6 weeks after exposure. There is no point in another gon/chl test.

That concludes this thread. Do your best to relax and stop worrying. I am confident any and all tests of any kind at any time in the future will remain negative. Best wishes and stay safe.

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