[Question #4049] PEP or not

33 months ago

I had risky behavior about 8 weeks ago, the condom fell off while I had insertive anal intercourse. I tested hiv negative 2 days after, 5 weeks after and 8 weeks after with Ag/Ab rapid test; but chalymedia positive 5 weeks after.  Symptoms include yeast infection in my genitals about 2 days after the encounter, sore throat and white coating on my tongue 5 days after. The white coating is very obvious in the morning, with white strip linings around my tongue and thick coatings on top. I got treated for oral thrush but it did not help.

While I am waiting for my three month check, things became more complicated when I had another insertive anal intercourse with a stranger (8 weeks after the first). Even though I had condom on this time, but I fingered him and maybe touched my genitals/eyes after. So I went to test again, and the nurse recommended PEP for me, she said better safe than sorry. So here I am, taken first dose of PEP (truvada and raltegravir) 60 hrs after that encounter.

I know you would argue that my benefit of taking PEP is very low but I only took it because that nurse said it will be no harm to take it (other than side effects). Do you think her statement is true? In my case, could it actually be harmful? Does taking PEP interfere with finding out if I am infected 8 weeks ago? If so, would stopping PEP after 30days put me at risk by allowing time for the virus to grow resistance, because consistency is super important for ARV? What should I do? ?

H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
33 months ago
Welcome to the forum. Thanks for your question.

In general, I would recommend against PEP after a condom protected exposure. Indeed, side effects are the main downside -- and although they usually are minor, serious and even fatal consequences, although very rare, are possible. In any case,PEP decisions in general are best left to exposed persons and their health care providers, especially if the provider is knowledgeable about local HIV epidemiology and risks. In many areas, where HIV transmission among men is uncommon, it would generally not be recommended after an exposure like your recent one, which apparently was condom protected. OTOH, if the event were in a geographic area or neighborhood with particularly high risk or known high rates of HIV in men like your partner -- which knowledge might be best known by your nurse -- it might make sense.

You raise an important and often neglected aspect of PEP. If PEP doesn't work, i.e. if HIV infection takes hold despite the drugs, it may take up to 3 or even 6 months for blood tests to show it. So instead of conclusive testing 4-6 weeks after exposure, if you continue PEP for the month prescribed, you'll be looking at final testing at least 3 and perhaps for 6 months after exposure to know conclusively you were not infected.

Without PEP, there is no need for testing at 3 months. That's outmoded advice, especially with the AgAb tests you had at 5 and 8 weeks. Those results prove you did not catch HIV during the earlier exposure (regardless of apparently acquiring chlamydia). They also prove your various symptoms had nothing to do with HIV. For the same reasons, your current PEP is irrelevant to that event.

What should you do? I will not advise you on continuing or stopping PEP now that you have started it. That's strictly between you and the nurse or clinic where it was prescribed. Contact them. Feel free to show them my advice -- some users have found it useful to print out their threads as a framework of discussion with their providers.

Finally, a bit of general HIV prevention advice. You obviously are dedicated to safe sex in using condoms consistently for anal sex with other men. However, you don't mention your partners' HIV status. There really is no excuse for not knowing that information. In the modern era, the watchword is "do ask, do tell". Ask all potential partners about their HIV status and share your own; and avoid sex (or have only the safest practices) with those who are positive and not on effective treatment, don't know, or seem evasive about it. But most men at risk these days know their status and are happy to share it honestly. It's not a perfect system, but it markedly reduces HIV transmission risk. When combined with consistent condom use, it essentially eliminates HIV risk among men having sex with men.

I hope this information is helpful. Let me know if anything isn't clear.

HHH, MD
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33 months ago
Hi Dr Huntsman,

Thanks for the reply. 
I have been on PEP for 12 days now; I noticed my white tongue has gotten better in the morning, which troubles me. My white tongue developed after my first unprotected sex. Does this hint it have something to do with hiv? should i be alerted? 
Also, I read from web Truvada (PrEP) is not recommended for people infected because it might increase virus mutation rates; but there is no such statement for PEP. I wonder why? has the effect of PEP usage on acute hiv infection been studied before?
To your last point, I do not mention their status is because most people who are most infectious are actually in their window period; so this information is much less useful. 
As to this date, can I say in terms of hiv protection, PrEP is the most effective way? is there any vaccines being developed other than drugs? 

H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
33 months ago
Questions about your current treatment and potential side effects should be discussed with the doctor managing your PEP treatment. I'll just say that white coated tongue is extremely common and has multiple causes (nutritional, drug, infectious, hygiene, and others). It's not possibly due to HIV while you're taking PEP, and might be related to the drug itself.

All HIV drugs have the potential to induce resistance in HIV. It's a rare problem in the PEP context. I see no cause for worry, but you could ask the prescribing doctor. I'm not sure what research has been done on "the effect of PEP usage on acute HIV infection", but probably not much; developing acute HIV while taking PEP is very rare, so difficult to study.

You're wrong about HIV risks and discussing HIV status with partners. The data are clear. Although true that this strategy cannot protect against all exposures, including partners in the window period, that's rare. That's when infectiousness often is highest, but the large majority of transmissions occur from people with more prolonged infection, especially those who have not been tested or don't know their HIV status. Avoiding sex with those who say they are positive but untreated, who haven't been tested recently, or who seem evasive about it is an effective HIV prevention strategy in populations with high rates of infection, especially men who have sex with men.
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