[Question #3652] How Risky? Very Worried!

87 months ago

Doctors,

Yesterday morning after a night of heavy drinking I solicited a MTF escort from the internet. Before we had sex she told me she was HIV negative. We engaged in anal intercourse with me being the insertive partner. I applied a condom but it was tight fitting and after inserting my penis briefly I pulled out to find that it had broken. I was not inside of her very long and did not ejaculate. When I saw this I panicked (even though she said she was negative) and asked her to come with me to get a rapid HIV test, to which she agreed.

We went to a public clinic and both had finger prick antibody blood tests done. My results came back negative and she told me hers did as well, although I never saw any documentation that showed her results. I left before her because I only wanted the screen done, whereas she opted to see a doctor.

While I didn’t see anything that showed her results I am inclined to believe her. She also texted me today letting me know the doctor prescribed her Tivicay and Truvada. When I looked this up it appears to be used for PEP, so I am a bit concerned that maybe she had another risky exposure aside from ours. This got me to thinking that perhaps she has a fairly new infection and is in the acute phase. I know that’s the riskiest time to be exposed to the virus.

So, given that - even though she tested negative yesterday morning should I seek PEP? I am now 30 hours post exposure. Also, I have read that a single insertive act carries a risk of 1 in 909 exposures or .11% for circumsized men, which I am. If she does have a new infection how much would it affect those numbers? How concerned should I be after this exposure or can I feel a bit more at ease given the negative results just a day ago? Also, can the drug combo she has been prescribed be used as PrEP as well? That is what she told me she was given as PrEP - since she has decided to take it now. But what I read online it seems to be used at PEP, so just a bit confused about that.

I appreciate your help and advice here!

H. Hunter Handsfield, MD

87 months ago

Welcome back to the forum.

In the circumstances you describe, I would not recommend PEP and don't fully understand why your partner was prescribed it. However, we don't know exactly what she told her doctor about the exposure and her trust in your sexual history, test results, etc; maybe she exaggerated your risk or wasn't entirely candid about your test result. Or, as you suggest, she had another recent exposure. Or her doctor is just being conservative. In any case, for a final decision about whether you should be on PEP for this event, we don't make conclusive recommendations on this forum. All PEP decisions should be made by the potentially exposed person after a personal visit with a doctor or clinic experienced in PEP and knowledgeable about local HIV epidemiology and risks. So the best thing is to see your own doctor about that decision, or return to the public health clinic for their advice.

In any case, based on the exposures described in this and your previous three threads, you're not all that safe yourself. It seems you intend safe sex, but you described at least one unprotected anal sex exposure, plus this one, with a broken condom. Anybody who has fairly frequent sexual contact, including anal sex (with or without condoms) with MTF transsexuals is, statistically, at high risk for HIV. As long as this sexual lifestyle continues, you can pretty much expect to have HIV someday unless something changes. It seems to me you should consider getting on PrEP yourself. I hope you're also being tested regularly at all potentially exposed sites (urine or urethral swab, rectum, throat) for gonorrhea; urine/urethra and rectum for chlamydia; and periodic blood tests for syphilis, in addition to HIV.

As for specific drugs, the same ones often are used for (and believed to equally effective as) PEP and PrEP.

I hope this information is helpful. However, you really should not be getting into a pattern of relying on this forum for this sort of advice. Among other things, you can't always expect such prompt replies. We usually are able to reply within a few hours, but it often take 24 hours or even more -- and PEP decisions should never be delayed even a few hours more than necessary. (72 hr is the normal cut-off, but the earlier the better: 12 hr is better than 24, and that's certainly better than say 30-72 hours.)

Let me know if anything isn't clear.

HHH, MD

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87 months ago

Dr. Handsfield,

I appreciate the quick reply and candid feedback. Your points are all well taken, especially about the change in lifestyle. While I do always intend on practicing safe sex, clearly I have missed the mark on that a few times. I also practice regular testing for all STD's and was last tested in mid-January where I tested negative for all STD's, not just HIV. As I am sure you can imagine, it is a bit unsettling to hear that if I don't make drastic changes that I am most likely bound to end up with HIV. It makes me wonder if I have pushed the envelope one too many times with this one.

Given these circumstances, how concerned should I be about this particular exposure? I am very shaken up and just trying to put things into perspective. I know that symptoms are never a way of diagnosing, but I will certainly be paying attention to my body and any potential issues that arise between the next 2-4 weeks. When would you recommend I go for follow-up testing: 4 or 6 weeks? Finally, you state the same drugs are used for PEP and PrEP - could she have been prescribed those drugs as a form of PrEP and not PEP, as she indicated to me this morning?

Trust me - your point about my potential fate has truly resonated and something I will be taking to heart. If it is alright, I'd like for you to keep this thread open so that I can report back on my follow-up testing at the appropriate time.

Again, thank you for the candid feedback and insight - I am truly very grateful and will also take your advice about not being reliant on this forum for critical advice in the future.

H. Hunter Handsfield, MD

87 months ago

Thanks for the feedback. I'm happy my comments are having their intended impact.

My two messages -- that you are not at significant risk of HIV from the most recent event and that in the long run your risk is high -- are not in conflict. Do your best to consider them separately. Risk rises with the number of exposures. Playing Russian roulette with a mythical pistol with 1,000 chambers can be considered low risk done once but extremely high risk if done 500 times. Same sort of deal with sexual risks for HIV.

I've given you my reasoning about PEP in this situation and this doesn't change it. Probably not needed, but that's a decision best made with a personal health care provider who understands HIV, its prevention, and local HIV/AIDS epidemiology.

And yes, I see no reason why your partner couldn't have been prescribed treatment as PrEP, not PEP. That would be most consistent with what most doctors familiar with HIV prevention (as her doctor may be) might recommend.

Your anxieties and fears seem to be leading you to over-examine every detail that comes to mind. Try to avoid that tendency and focus on the big picture. If the result is an altered sexual lifestyle, all the better. Of course this is the norm for many sexually active singles, especially MSM: a number of years with multiple partners and lots of sexual experimentation, later becoming more conservative and often leading to mutually committed monogamy. (And yes, I consider you a man having sex with men, assuming your TG partners have mostly not yet had sexual reassignment surgery. Anatomically that's the case, whether or not you view the attraction as heterosexual.)

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