[Question #4841] HIV Exposure and PEP

26 months ago
36 hours ago I had sex with a trans escort, higher end.  I received receptive anal protected.  I also gave her protected oral.  Here is my issue.  I asked ahead of time and she said she was negative.  Technically I said I had been tested and was negative she responded she is tested regularly.  This was in Colorado. 

So I have read your site and have a decent understanding of the risks.  Issue is I noticed some discharge from my anus after that looked a little like ejaculate, though it could have been lube.  Also, the condom she used didn’t have much in it but she said she ejaculated. I know she had a condom on when we started but didn’t confirm when we stopped.  She did put one on when I gave her oral.  Could just be fear but nagging feeling she may have taken the condom off to finish.  36 hours since exposure just got me thinking about PEP.  I’m in a long term relationship, with kids, so all the ensuing stress is going on here.  I sent an email asking about if she finished with a condom but from our interactions after not sure I trust the response. 

1). Thoughts on PEP?  
2). I know that the PCR test at 8 days isn’t conclusive but as you have seen many times my stress is sky high.  I’d rather overtest early, not concerned about cost on this.  I was thinking of testing at 8 days (PCR) and then 2 weeks for DUO and confirm at 4 weeks. 
26 months ago
I did hear back from her, friendly exchange.  Said she did not finish, just said that.  Thought it was the silicone lube.  Still going to be paranoid until I confirm.  My brain isn’t built for this stuff.  Hopefully I’ll remember next time.  I assume you would not recommend PEP in this scenario?  Window closing fast and I don’t have a time machine. 
Edward W. Hook M.D.
Edward W. Hook M.D.
26 months ago
Welcome to our Forum.  I'll be glad to comment.  Since we know quite well who benefits from PEP, the decision in the situation you describe comes down to trust.  I'll provide some information which I hope will be helpful.
1.  In the Denver area (population, >2.5 million) there are about 10,000 people living with HIV.  About 90% of those are men who have sex with other men (the data for trans persons is harder to get and less reliable).  Thus most people, even most men with male sex partners do not have HIV.  Your partner said she tested and we negative and that condoms were used (don't know who suggested) is a good sign that is associated with lower risk on her part.
2.  I'm likewise impressed that even oral sex was condom-protected. This too suggests lower risk.
3.  There are logical alternative answers for the anal discharge and the smallish condom volume you noted.
4. She replied and was not dismissive of your f/u questions- another good sign.

Thus, all things considered, there is a lot to suggest that this was not an exposure where PEP is needed, as long as you trust her and her responses.

Thus, in answer to your questions:
1). Thoughts on PEP?  
Based on the things I mentioned above and as long as you trust her, I don't feel strongly that PEP is needed.  OTOH, PEP is also pretty well tolerated and effective, particularly if started within 24-48 hours of exposure (there seems to be little efficacy of PEP after 72 hours, the 48-72 hour efficacy is unclear) 
2). I know that the PCR test at 8 days isn’t conclusive but as you have seen many times my stress is sky high.  I’d rather overtest early, not concerned about cost on this.  I was thinking of testing at 8 days (PCR) and then 2 weeks for DUO and confirm at 4 weeks.
Testing-wise, and 8 day PCR would be evidence that you were not infected but I would not have absolute confidence until about day 14.

I hope these replies help you with your decision. EWH

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26 months ago
Thanks for the response.  Trust is funny with people you don’t know.  I find her answer believable.  While I prefer it too, she wanted the condom for oral and anal.   Started from the get go that way.  Nice to see people taking the subject seriously!  I’d say I 85% believe her.  The remaining 15 is reasonable doubt and anxiety I’d guess. 

So if I test at 8 days with PCR, for some peace of mind,  you are saying at 14 days if I were to repeat the PCR it would be an answered question?
26 months ago
And of course I’m feeling like I’m getting a cold.  Aches, tired etc.  Guessing from my adrenaline gland working overtime.  If it is of value and you leave this thread open to me I will post my results when available.  
Edward W. Hook M.D.
Edward W. Hook M.D.
26 months ago
Thanks for the additional information.  I couldn't agree with you more about trust. My sense from what you've said is I'd probably pass on PEP but of course, this is entirely your decision and I really do not think there is a wrong decision.

Regarding the PCR, you're right on target.  If your 14 day PCR is negative, I would not worry further.  EWH


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Edward W. Hook M.D.
Edward W. Hook M.D.
26 months ago
Thanks.  I think our replies crossed.  I will leave the thread open until we hear your results or several additional weeks have passed, whichever comes first. EWH---
26 months ago
I had a sample taken for HIV RNA last Wednesday.  Still waiting on results, somewhat stressful.  Was having symptoms that I’m sure erroneously made me think I had ARS.  I have read on the site symptoms aren’t a good (or even useful indicator) but I had read elashwere that is you actually are having ARS the duo test will be positive. So I got it at 11 days, 2 days after my symptoms started (sore throat, malaise, aches, no fever or rash).  It was negative.   I know it was probably just a waste of time and money but it made me feel better to see the negative.  Psychology is goofy.   I had the second HIV RNA test taken yesterday.  So exposure was on a Tuesday night and almost 2 weeks later on a Monday afternoon I had the second sample drawn.  I’ll post results when I get them. 
Edward W. Hook M.D.
Edward W. Hook M.D.
26 months ago
Thanks for the follow-up.  When persons are experiencing ARS symptoms, they typically have very, very high levels of circulating HIV.   Thus, the fact that your test was negative two days after symptoms onset is strong evidence that you did not acquired HIV.  I look forward to hearing about your further test results which I am confident will be negative.  EWH---
26 months ago
Just received the results from the RNA test on Monday.  So effectively day 13 as exposure was 2 weeks previous Tuesday night.  Non detected was the result.  From what we have discussed there is no need to confirm at 4 weeks with DUO?  I want to close this chapter.
Edward W. Hook M.D.
Edward W. Hook M.D.
26 months ago
Thanks for the follow-up.  I must say, all things considered, I'm not surprised at the outcome but I do understand your motivation for testing.  At this time, while our "party line" is that to be entirely confident that you are not infected, you should follow with a combination HIV antigen/antibody test at 4-6 weeks, I also must say, I have never heard of someone in your circumstance (protected exposures,  partner who states she was tested, negative RNA PCR on day 13, etc.) turn positive.  I certainly would not worry if I were you and personally, probably would not feel the need for further testing. 

I hope these responses have been helpful.  This thread will be closed later today as per Forum guidelines.  Take care.  Please don't worry.  EWH
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26 months ago
Thank you Dr. Hook.  Valuable social service here!  I want to make sure I’m ok to resume unprotected sex with my partner.  What I risk with my body is one thing something entirely different to risk with someone else’s.  
26 months ago
And the results from day 8 just came in for RNA.  Negative as well.  Which they of course should be. 
Edward W. Hook M.D.
Edward W. Hook M.D.
26 months ago
I would have no concerns regarding resuming unprotected intercourse with your regular partner.

Closing thread now. EWH
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