[Question #3174] time sensitive question regarding pep

38 months ago
hi,

i was csw and the condom slipped off.   i think it slipped off  on withdrawal.  when i looked down, however,I could not see it, but it didnt feel like the tip was exposed.  i think it was on.   i removed immediately and went to wash and urinate.  if it did slip it couldn't have been more than 2 minutes. i was keeping  steadying eye on it.  she told me that she was tested a few weeks ago.  i've read though other post and know that chances are small...if money is not a cost, shouldnt i take pep just to be on the safe side.  what is downside.   how small do you think my risk is.  this is definitely last time.
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
38 months ago
Welcome and thanks for your question. However, we do not provide direct care or urgent medical advice; there is no such thing as a "time sensitive" question on this forum, or at least no question we will treat as such. And because we don't provide direct care or advice, we will not advise for or against PEP in this situation. For that, you'll have to see a provider in person. Among other things, a local provider will be more knowledgeable than I am about the epidemiology of HIV in your area, i.e. the chance your CSW partner might have HIV. So you're on your own for that answer.  Sorry, but I'm sure you understand.

OK, that's the official word. If I were in your situation, I would not seek PEP, unless maybe I knew for sure the woman had untreated HIV. First, it is unlikely a partner like yours has HIV, probably under 1 chance in a thousand -- and in this case even less likely since she was tested recently with negative results. (People rarely lie about this when asked directly.) Even if had untreated HIV, the average risk for a single episode of unprotected vaginal sex is 1 in 2,500. Third, it sounds like your exposure was mostly if not entirely protected. Protection is considered complete if the penis withdraws from the condom which remains in the vagina. Even if that doesn't apply, you are correct that 2 minutes is is a brief exposure with probable low risk.

What are the downsides of PEP? Cost, as you mention (depending on insurance coverage). The inconvenience of remembering to take a drug daily for a month. Side effects -- not very common, but sometimes severe. Finally, a factor many people forget about:  if PEP doesn't work, it may delay the time until a blood test for HIV becomes positive. After PEP, testing must be continued for at least 3 months and some experts advise 6 months. Without PEP, you can have a conclusive test in 6 weeks. So it's the difference between knowing for sure you weren't infected either in mid February or not until April or maybe July.

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

HHH, MD

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38 months ago
Hi.  Thank you. I am in Phoenix so I would imagine not higher than anywhere else.  She was higher end escort and fairy new.  I think I would be able to tell if it was totally off even if it did it could have been more than minute or 2 since I was watching it.  Leaning toward no pep.  How often do you run across infections when repoted few minutes of exposure?
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
38 months ago
In general, escorts ("higher end" female sex workers, usually working by appointment) are believed to be especially low risk for HIV and other STDs. They usually use condoms consistently, are tested regularly, and their clients typically are low risk -- men like you! I can't say whether I've ever cared for a patient who was infected after an exposure like yours. The vast majority my personal patients over the years had multiple unprotected exposures, not only a single exposure that was the only possible source of infection. So I don't recall that it ever came up as an issue.

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37 months ago
Hi. One last follow up.  I went and got tested abd it was negative.  Its 17 days since possible exposure and a 4th generation test.  Do you think i am good since risk was low.
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
37 months ago
At 17 days, the Ag/Ab (4th generation) HIV tests will detect around 80% of new infections at 17 days. So if your original risk of having HIV was, say, 1 chance in a million (probably a pretty good ball park figure), the chance you caught HIV has now declined to 1 chance in 5 million. Only you can decide whether you're comfortable with these odds, or whether you might continue to worry unless and until you have had a test that is 100% conclusive, i.e. to repeat the Ag/Ab test 6 weeks or more after the exposure.

That concludes the two follow-up comments and replies included with each question and so concludes this thread. I hope the discussion has been helfpul. Best wishes and stay safe!

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