[Question #3763] HIV risk factors and PEP

35 months ago
Hi Doctors

Follow-up questions to my last post.  I've become a little addicted to this forum, and I'm *hoping* some  more answers will help me not look at it for a while.  (I know this is like saying "one last cigarette", but still.) 

1. In my first post I said I had had unprotected insertive vaginal sex with a sex worker in NYC and then when on PEP. Dr. Handsfield said that "at least some sex workers there have a very high risk for HIV".  This woman was white, 600/hr. and from a website where that price was probably on the low end of average.  She said she doesn't do condom-less with everyone but what do I know?At least she had a condom on her and when I pulled out after a few min because I was worried, she said we should use it. Does her price etc. change your feeling on the risk at all?  I gather socioeconomic factors correlate with risk factors in this arena.

2. All the stats say my risk if she *was* HIV-positive is about 1 in 1,000 (since I'm HSV-2 positive). Which sounds reassuring. But I actually did get HSV-2 from just one encounter 8 years ago (the woman I got it from had literally just gotten it herself but was pre-symptomatic so I think she was highly contagious, but still. we were friends, so that's how i know all that). I've seen similarly reassuring stats on HSV-2 "odds" (1 in 1,000 or 500 or whatever), so I'm just trying to square it all. I got very unlucky once and it makes me scared it could happen again.

3. I mentioned in my first thread that I had fingered the woman in my recent encounter and there was blood. I know fingering is virtually no risk, but what if the sex was after, and blood was still present when my penis was inside her? Does that add to the risk?

Now on to PEP. Which I started about 12-14 hours after the encounter. 

4. For the first 3 doses, it was Travuda and Tivicay (that was during  the weekend, when the script was filled before a consult). Then I was switched to Stribild.  Is this a good regimen in your opinion?

5. I totally understand why "hard" numbers aren't available on the effectiveness of non-occupational-exposure PEP, but I was hoping you had thoughts on how effective PEP is. As in, a ballpark number. I've been taking the doses *religiously*.

6. I am supposed to have a rapid test after I finish PEP (4 weeks post-encounter) and then again in 2 months. How accurate would the first test be? I've read that a negative result won't mean much because of the PEP so am I basically testing just in case it's positive? Can I feel any relief (knock on wood) if it's negative?

7. This is not a gotcha question, but in my first thread, Doctor Handsfield said that the clinic probably gave me a blood test before PEP to make sure I didn't have any condition that would affect PEP. But later, when I asked if HSV-2 could affect PEP, he said there are no conditions known to affect the effectiveness of PEP. Can you help me square that? (I didn't notice the contradiction at first.)

That's all I can think of right now. 

Again thanks for being there. I think I'd be even more scared without this forum because I'd feel so in the dark. Just writing this all down feels therapeutic. 

-DB
35 months ago
slight typo in my post.  "Then when on PEP" should be "then *went* on PEP."  I did not repeat the act on PEP. PEP is no aphrodisiac. 
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
35 months ago
Welcome back, but sorry you found it necessary. We strong discourage repeat questions. My replies will be brief, and this will have to be your last question concerning this exposure, testing, PEP, etc.

1) Escorts (expensive female sex workers by appointment) are generally believed to have low rates of HIV and other STDs. PEP may not have been necessary in this situation.

2) I don't understand what you don't understand the in the data you quote. All such numerical estimates are very wide. But no matter how you slice it, with or without your HSV2 infection, the odds are exceedingly high that you did not catch HIV; and in the very small chance you did, the PEP will eradicate it.

3) If her blood were in the vagina, maybe a slightly higher HIV risk. Certainly your blood being there couldn't make any difference.

4,5) Both these PEP regimens are equally effective. Best estimate is >95% effective when started within 24 hr of exposure, maybe close to 100%.

6) There are no published data on how quickly antigen, antibody, or RNA develop after PEP, if PEP fails, but i some cases (e.g. if a drug resistant HIV strain) infection could progress while on PEP. I agree your doctor probably recommends that test as a negative baseline going forward, but  negative result should be at least a little reassuring. 

7) I said no such thing, no mention of detecting any condition that would raise your risk of HIV. Re-read that comment. Although I didn't think to say it last time, I imagine your doc did general testing (CBC, blood chemistries) as a check against health conditions that might increase risk of adverse effects from the PEP drugs. But even that is just a guess.

Do your best to stop all this overthinking. In the 14 years I have been doing this and my prior forum, with thousands of questions on HIV exposure, risks, testing, etc, not a single person turned out to have acqually acquired HIV. You won't be the first. If an when that happens, it will be someone with genuine high risk, not a trivial risk like yours, with PEP also in the picture. You really are overreacting:  when all is said and done, this should all be a non-event in your life. Try to start now to view it that way.

HHH, MD
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35 months ago
got it. thank you!