Hello doctor, I would like to ask your opinion about my situation. During oral sex, my throat and pharynx were significantly irritated and there was active bleeding in both areas — at some moments quite a noticeable amount of blood. The bleeding has now stopped, but I am concerned about the risk of HIV transmission in this case.

My partner had an HIV test 40 days ago which was negative, but it is possible that they may have had risky contacts since then. I am a passive gay man, which already places me in a higher risk group for HIV. I live in Turkey, where PEP is not always free of charge and it is very expensive for me.

Do you think in this scenario I really need to start PEP, or would careful HIV testing follow-up be sufficient? Thank you very much.

The encounter you describe was low risk.  You do not know that your partner has HIV and given the fact that until 40 days ago he has remained HIV negative makes it likely that he still is negative.  Further the estimated risk for acquiring HIV from an infected partner due to performing oral sex is low, about 1 infection in 10,000 acts of oral sex on an infected partner (in other words even if your partner had HIV there is a more than 99.99% change that you would NOT become infected.  That your throat was irritated does not change this estimate.

PEP is always a personal choice for all of the reason we have discussed in the past.  Personally, I would not pursue PEP for the encounter you describe. 

Finally, given th problems that you have had in th past as well as the concerns you express now, I wonder if you have concerned starting PrEP.  It is widely available and highly effective.   EWH

Dear Doctor,

About 2–3 weeks after the exposure, I developed a high fever up to 39.5°C and had a severe sore throat. My CRP level was 130 (normally it should be between 0–5). I recovered within a week after taking antibiotics.

I’m planning to take a 4th-generation HIV test on day 28. If it comes back negative, would you recommend repeating it again on day 42 for confirmation?

Also, I haven’t received the HPV vaccine yet. If a high-risk (cancer-related) HPV infection has already occurred, would the vaccine still be effective afterwards? In other words, can the vaccine help the body clear existing HPV, or would it stay permanently?

In addition, I’m seriously considering starting PrEP. However, it’s quite expensive in Turkey. How many days before a potential exposure should I start taking it, and how exactly should it be used? If my HIV test comes back negative, I plan to use PrEP before future contacts. Does it have to be taken daily, and are there any blood tests required before starting? I’ve heard Truvada is recommended — is that correct and sufficient?

Thank you very much for your help and guidance. I truly appreciate your time.

If your 28 day test is negative that will prove that your fever and sore throat were due to something other than HIV.  At 28 days, 4th generation HIV tests are more than 98% conclusive although there are rare occasions when tests become positive between 28 and 42-45 days.  Neither of us on the Forum has ever seen or heard of such a case however.  Personally, if I were in your situation and had a negative test at 28 days I would not test further but that is, of course, a personal decision.  

The HPV vaccine has been suggested to accelerate clearance of infections existing before vaccination but there are no studies which conclusively show that this is the case.  In addition, it would virtually eliminate your risk for acquiring any of the vaccine-covered HPV types that you have not been infected with.

Starting PrEP is a personal decision and is best considered following a discussion with the provider who will be prescribing and following you.  Before starting PrEP you should have at the very least, a negative 4th generation test for HIV and should be periodically tested for other STIs after starting the medication.  Many providers who check your general health status before prescribing PrEP.  Truvada  is widely used for PrEP.

Again, my apologies for the delay in responding to your follow-ups.  You have on follow-up remaining.  EWH