[Question #1877] Risk and PEP?

80 months ago

Hi,Made a big error in judgement in the red light area in Mumbai where HIV is highly prevalent.  I was with 2 different female csw's on separate occasions over a period of several hours and had protected anal and vaginal sex with them as well as unprotected oral.  


The problem is that in both cases, during vaginal, the condom slipped off as I was quite inebriated and was flaccid.  The first csw mentioned that the condom became lodged in her vagina and my penis was not inside (but I am not sure about this, so the risk would be unprotected vaginal for about a minute).  Same thing in the second case, but she also said the same thing (again I am not sure about this, but have a higher certainty than the first one).  


During anal for both of them, no lube was used, and I was not able to penetrate fully but did penetrate a little bit from time to time.  I am fairly certain the condom did not come off, but as I was not fully erect, there was a lot of "loose" condom space.  I am not sure of the quality of condoms as they were provided and the second one even told me to use 2 condoms (which I did for anal, but makes me more worried that she was infected) and with the amount of pressure exerted trying to penetrate anally, I am worried if the condoms stayed intact.I started Truvada within 24 hours and added Isentress around 36 hours as PEP.  I dont have a doctor here.  


My questions are:

1.  What is the risk in your opinion?

2.  Would you have prescribed PEP in this situation?

3.  Would you have taken PEP if you were me?

4.  Do you think I should continue PEP?

5.  If I continue PEP, will it affect my liver (I have fatty liver) and also take crestor and baby aspirin will there be an adverse reaction with these medicines?

6.  How long after PEP can I reliably be tested and what test (i.e. duo or antibody)?

7.  Is PEP really effective or is it just a guess that it would work?

H. Hunter Handsfield, MD
80 months ago
Welcome to the forum. I logged in shortly after your message arrived, and am traveling in a time zone not far from Mumbai's. Most users, especially those outside North America, should not expect nearly real-time replies!

My first reaction is to congratulate you on your wise decision to use condoms for these exposures. It didn't work out perfectly, but your intentions were good and protection against HIV probably was also pretty good. To your questions:

1) Although HIV is more common in CSWs in India than many other places, still the large majority are not infected. I would estimate less than a 5% chance either of your partners had HIV. Second, the average transmission risk for a single episode of vaginal sex is 1 in 2,000; for anal sex it's somewhere around 1in in 500. So even if you had had entirely unprotected sex, the odds you would have caught HIV would be under 1 in 10,000. Finally, it usually counts as protected sex when the penis slides out, leaving the condom behind. So all things considered, your risk of having acquired HIV probably is 1 in 100,000 or lower, perhaps under 1 in a million.

2,3) With such low odds, I would not normally prescribe PEP and would not have taken in myself if somehow I were in your situation. However, PEP decisions always must be local, with better knowlege than I have about transmission experiences, prevalence of HIV in partners, etc.

4) I cannot and will not advise you on treatment, continuing PEP, etc. This forum does not provide direct medical care or advice; we only assess things generally, advise on risk, etc. Since you apparently are already on PEP, you should contact the doctor or clinic where it was prescribed and discuss whether or not to continue.

5) The risk of liver or other side effects is very low with PEP, but it also depends on the specific drugs. Again, this is for discussion with the prescribing doctor or clinic.

6) There is no good research on how long positive blood tests may be delayed if PEP doesn't work. Probably testing remains reliable a month or so after exposure, but to be safe, most experts recommend delaying testing to 3 or even 6 months. This is one of the important problems with PEP, i.e. prolonging the period of anxiety until conclusive testing can be done. Also something to discuss with your doctor.

7) Again, there is no good research. But most experts believe that PEP is nearly 100% effective if started within 24 hours of exposure, probably progressively less so after 48 and up to 72 hr, and likely ineffective after that.

The bottom lines:  Your risk of HIV seems to have been low, and PEP may not be necessary. But you'll need to discuss it all with the prescribing doctor or clinic. You could consider printing out this thread as a framework for discussion.

Best wishes and stay safe--  HHH, MD
80 months ago
Dear Dr. Handsfield,

Thank you for your reply.  

I do have some follow up questions I would appreciate your advice on:

1.  I am not circumcised - would this change the odds in any way, and if so, how?
2.  Are there any specific STI's I should also check for - I did take 2g zithro a week ago for unrelated issue so would there be enough in my system to act as a prophylaxis against any STI or would it more likely cause resistance if I was infected with an STI?
3.  Why does PEP delay seroconversion?  If PEP doesnt work, wouldn't seroconversion happen in the same time frame as everybody else not taking PEP and a 4 week Duo be sufficient to detect the same?  Would ARS also be delayed or happen in the same time frame - i.e. 2-4 weeks from exposure?
4.  If I stopped PEP today (i.e. few days after starting), would I still be able to take the duo test at 4 weeks from exposure for a definitive result?
5.  Given that you would not have taken PEP if you were somehow in my situation, would you have tested yourself at 4 weeks with duo from this exposure?

Again, thanks for your help.  I really did try to be safe, but there were hiccups due to my not being sober - this is something I will correct for sure going forward.  I just hope I have another chance and its not too late.

H. Hunter Handsfield, MD
80 months ago
1) Like HSV2, being uncircumcised roughy doubles the risk if sexually exposed to HIV. So if your risk with circumcision would have been one in a million, being uncirumcised would raise it to 1 in 500,000. Still extremely low.
2) You might have considered testing for gonorrhea and chlamydia, but it's pointless now. 2 g azithromycin would have cured either one, so a negative test now would be meaningless. And a positive very unlikely. One dose of antibiotic almost never causes significant anbibiotic resistance.
3) This is a theoretical issue. It isn't known whether PEP delays development of positive blood tests, but some scientists who study HIV biology and treatment think it might be possible. I'm not one of those scientists and cannot say why or why not it might happen.
4) This also is unknown.
5) After PEP, all experts would recommend 4th generation (duo) testing at 4 weeks. But they would also recommend later testing, e.g. at 2 and 3 months.

Thanks for the thanks. I'm glad to have helped.

80 months ago

Dear Dr. Handsfield,


Thank you for your reply.  A few final clarifications:


I meant that I had taken 2g Zithro one week prior to this event, so would the medicine still be in the system such that it would void any bacterial std from even presenting or would it present in a diminished form?  The reason I ask is that the second day post exposure I noticed a dried yellowish substance when I rubbed the foreskin underneath the urethral opening and the odor was bad.  This was accompanied by discomfort at urethral opening intermittently throughout the day, but I did not notice any wet discharge (even though at times it felt like there was discharge coming out).  The following day, I noticed the exact same symptoms (except no odor).  Finally, today I have noticed a very slight clear sticky substance at urethral opening.  At no time have I had pain/discomfort urinating.  I am concerned that it may be an std, which makes me believe that the condom did not slide off leaving the condom behind, but rather, the condom slipped off and sex continued for a few minutes (which makes me even more nervous about this entire episode).  Do you feel this could be an std and is it accurate to test now for gono/chlam (i.e. 4 days post)?


Just want your comments to see if my logic is right – if one takes PEP and it fails to stop infection, a PCR test during PEP will be of no value because the virus would be undetectable.  However, once PEP was stopped, the PCR would become positive within 2 weeks as the virus would return to the bloodstream.  Therefore, PCR would theoretically detect HIV faster than Duo because there may be delay in antigen/antibody formation due to the PEP.  Alternately, the PCR could also be positive during PEP if the PEP worked in aborting the infection and the PCR was detecting the “dead” HIV RNA fragments.


Finally, if odds are so low for contracting HIV sexually, why are there so many cases every day, especially in the developing world where heterosexual transmission is the highest mode?  And for insertive anal sex, is the HIV risk due to exposure to blood (from tearing of skin) or from some other fluid?


Thanks again!

80 months ago
Oh, sorry, forgot to add this to the final question.  I took truvada as PEP within 24 hours but was not able to take isentress until 36 hours.  Also, since I took Isentress at 3 pm, I did not take it again until 9 am the next morning (gap of 18 hours) when the gap should only be 12 hours.  Would this lag in dosage and medication lower the effectiveness of PEP in your opinion?  
H. Hunter Handsfield, MD
80 months ago
Sorry I misunderstood the timing. Azithromycin persists in blood and tissues for 10-14 days after a single dose. Exposure a week after taking it would prevent gonorrhea, chlamydia, and most syphilis. It would not increase the chance of antibiotic resistance.

It sounds like you accumulated normal smegma (the white, pasty material that normally collects under the foreskin). But if you think you might have a urethral discharge, see a doctor for exmaination and STD testing.

Your analysis about PEP and testing is faulty. PCR for HIV DNA probably does not detect infection any sooner than testing for p24 antigen, which is part of the duo test. Or only slightly earlier (a day or two). More important, PCR testing will never detect HIV if PEP worked in aborting infection. If PEP is effective, HIV would never escape the initially exposed site, i.e. could not appear in the blood. If someone has a true positive p24 or DNA test, they are infected with HIV. There are no exceptions.

The number of HIV cases actually is quite low in comparison to the number of people exposed to it. Blood probably accounts for many cases of sexual transmission, but most cases are from exposure to genital fluids like semen, cervical mucus, etc.

The timing of your early PEP drug doses are not likely to make any difference in their effectiveness.

That completes the two follow-up comments and questions included with each question, and so concludes this thread. As discussed above, my main advice remains to re-visit the doctor or clinic that prexcribed PEP and discuss these issues with them. In the meantime, also note my other main advice:  that this exposure carried almost no risk of HIV. You are way more worried than warranted by the exposure described.

Best wishes and stay safe.