[Question #4715] Incorrect PreP use & STD

27 months ago
I used "On-demand" PREP. I took 2 tablets before sex with a TS. It is advised Prep is taken 2-24 hours before sex. Receptive sex occurred sooner than recommended (1 hour) so condoms were used. Post sex I have continued with PreP as per the daily guidelines. She performed unprotected oral on me. 3 days after the session I developed a white discharge from my penis. A doctor prescribed treatment for both Gonorrhea & Chlamydia (1 x 1g Azithromycin, 7 days Doxycycline & 7 days Norflaxin).

My questions are:

1. Hypothetically, had condoms failed (i'm unsure), in the article linked below it says Emriticibine reaches protective rectal tissue levels in about 30 minutes (despite the 2-hour recommendation). So should I have at least some protection? http://www.aidsmap.com/Intermittent-PrEP-may-be-a-robust-strategy-for-anal-sex-vaginal-much-less-certain/page/2986809/?fbclid=IwAR26g0E0ZpOSB7WG5DfjQe4EJ7TxA6vyLget6ZUqSGreuPnc9PxazbTdTl0

2.  Truvada was previously prescribed as PEP alone. So if I continue with PREP for the next 28 days & beyond am I giving myself PEP protection too?

3.  Is the bacterial STD likely a result of the oral element of the sex?  

4. I have a female partner with no symptoms who began the same antibiotic treatment I did. What are the chances I passed my infection to her before we started the treatment?

5. The discharge has lessened but not gone after 3 days treatment. When will it likely resolve?

TIA for evaluating my question

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

1,2. You've delved deeply into PEP, PREP, and the details of their use.  I'm pretty sure that the general advice for PREP to be taken at least 2 hours before sex is an artifact of the design of studies of its use. If that's how study subjects were instructed, it cannot be guaranteed that earlier treatment would be effective. But that doesn't mean it's not effective, and from a biologic standpoint, I cannot imagine there is significantly reduced effeicacy if take only an hour before exposure. This conclusion also follows from the fact that PEP is effective when taken as long as 24 hours and perhaps 72 hours after exposure -- so having drug on board at the actual time of exposure may not be important. As these words imply, this conclusion is based on the known biology of the drugs and HIV infection, moret han actual research -- which probably hasn't been done. And yes, lolgically if you continue treatment, you are on PEP as well as PrEP.

3. Oral sex is low risk for all STDs and virtually zero risk for some. However, I agree it is likely you acquried gonorrhea from the oral sex exposure. Chlamydia is rarely transmitted by oral sex (because oral infections are uncommon, unlike gonorrhea); and both chlamydia and nongonococcal urethritis (NGU) generally don't cause symptoms sooner than 7-10 days. Ideal care would have included diagnostic testing for at least for gonorrhea and preferably chlamydia as well, but apparently not done or you would have said somethbing about it.
4. If you had sex with your GF after the TS exposure, it is likely she was infected, especially if you have gonorrhea. However, it sounds like she was treated promptly and likely the infection would have been aborted before it took hold. However....

5. ...your treatment was not ideal for gonorrhea. Where are you? In most geographic locations world wide, the standard recommendation is an initial dose of ceftriaxone (by injection) followed by either azithromyvcin or docycycline.  Norfloxacin (Noroxin) is not recommended anywhere, for any of the three main causes of urethritis (gonorrhea, chlamydia, NGU). With persistent symptoms, there is at least a fair possibility your infection has been inadequately treated -- you need to return to the doctor or clinic, or perhaps try to find someone with apparently greater STD expertise. Or perhaps its NGU after all, for which symptoms tend to resolve more gradually than with gonorrhea. (If so, perhaps it was brewing from some prior sexual exposure, not acquired during the more recent event. Or you acquired it from your regular partner, depending on her own sexual lifestyle and potential for other partnerships.) Eiither way, you should be reevaluated -- either right away, or for sure if any symptoms are persisting after 5-7 days treatment. In the meantime, please no sex with your girlfriend.

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


27 months ago
Thank you, Doctor, for the response, much appreciated. I'm glad I found this resource.

Interesting about the Norfloxacin. I forgot to mention, I was also in fact also prescribed an IM shot of Ceftrixone alongside a single 1g dose of Azithromycin with Doxycycline for a further 7 days (overkill perhaps even). 

This is a relatively new relationship with my girlfriend so it is very possible it came from her. I don't believe she has tested for a long time. I had a full STI panel prior to unprotected sex with her. Furthermore, the TS is the only isolated incident to occur beyond our relationship. 

However, no pointing fingers I just want it sorted and to move on. I'm not without guilt over this whole incident.

My final questions are:

1. Can you evaluate my HIV risk from what I have outlined in my original post (based on being receptive, condoms & my truvada usuage)?

2. You say no sex with my partner. The doctor also suggested this for 7-10 days. Once symptoms do resolve, & we both finish our antibiotics, do you believe we can resume sex without reinfecting each other?

3. My symptoms have certainly improved over the last 48hours. But I had heard of people experiencing faster relief. If in fact, it was NGU as you indicate a possibility. Would the antibiotics I have been prescribed for gonorrhoea also be adequate & what would the timeframe for that be to resolve?

Thank you and Merry Christmas

H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
27 months ago
OK, you're good to go regarding gonorrhea. I suggest you hold off a few more days before being reexamined.

Also good to hear you have an open mind and understanding about your new partner and the possibility she is the source of your infection -- which would make it more likely to be NGU or chlamydia. Too bad she has already been treated, but if it's still within a few days of her treatment, testing for chlamydia might still be useful.

1. Given your PeEP/PEP, plus only a single exposure, the chance you have HIV is near zero. I really wouldn't worry about it. But to be maximally safe, you should have an AgAb (duo) HIV blood tests 6-8 weeks after completing the anti-HIV treatment.

2. The advice about no sex was based on the concern that you might have inadequately treated gonorrhea. That's no longer likely. There shouldn't be any harm in continued sex with each other.

3. It sounds like your improvement is on track. From the original description, it wasn't clear there has been this much improvement. As implied above -- i.e. the time frame to get reevaluated -- it can take a week for symptoms to resolve completely, for either gonorrhea or NGU, maybe even a bit more.