[Question #5098] HIV possible high risk incident, PEP please help.

23 months ago
Hello doctors. I had sex with a transsexual sex worker in Bangkok. We used a condom but while I was the receiving partner of anal sex the condom split. My trans partner realised it had happened and stopped (we had sex only for about 2 minutes). She took off the condom and there was a hole about 1.5cm just below where the tip of the penis would normally be. She did not cum in me and all other sexual activities were performed with different condoms which remained intact.  She told me she is tested regularly for HIV and showed me a test result from Jan. She was worried about my status. She said she always used condoms for anal sex but not for oral (although it's something I insisted on). 

We both went to a clinic in Bangkok the next day to be tested, both were negative with a rapid HIV antibody test and rapid syphilis test. The clinic suggested I use PEP, so I have started on a months course, first tablets taken 14 hours after the incident.  

I am married, I feel terrible with extreme guilt. My wife and I always use condoms and have never had one split.

My questions: My private doctor back home in the UK can do a duo P24/antibody test he recommends this after 28 days. Will PEP effect this test? 

I have seen experts online say it can delay the production of antibody's but that it will detect the P24 antigen?

He can also offer: Qual HIV-1:CEPHEID test (after 10 days) or NAT PCR rapid test (after 10 days) would either of these be beneficial? 

I want to get some sort of testing done asap for piece of mind as mentally I am suffering at the moment. 

I will of course re-test at 90 days for absolute reassurance. 

I assume I should also get an anal swab for Chlamydia, Gonorrhea and Syphilis. 

We also french kissed apart from the obvious HSV1 is there anything about this contact that should worry me? 

I hope you can offer me some reassurance, I am extremely worried but trying to put my mind at rest because of the test results and the fact PEP is quite effective.

Many Thanks
Edward W. Hook M.D.
Edward W. Hook M.D.
23 months ago
Welcome to our Forum and sorry to hear of your condom mishap.  From the sounds of things however, you have done everything right.  Both your partner's statements and still more importantly, the negative tests you had after the break make it very, very unlikely that you were exposed to HIV but given the nature of your partner and her likely multiple other recent exposures, started PEP was a prudent thing to do as well.  That you started it less than 24 hours after exposure is likewise a good thing.  All of this makes it very unlikely that you are infected but it is absolutely appropriate for you to want to be tested sooner than later. The PEP would potentially delay development of positive HIV tests of any sort and so repeat testing after completion of PEP is quite important.  Before then nucleic acid amplification tests such as the Cepheid assay  or the HIV PCR test are the most sensitive tests and typically would be positive before the combination HIV antigen/antibody tests and are preferable.

Yes, you should certainly also have rectal testing for gonorrhea and chlamydia as well as a syphilis blood test. Since your partner performed oral sex on you, I would also have a urine test for gonorrhea and chlamydia. The gonorrhea and chlamydial tests will be accurate at this time. The syphilis blood test will not be conclusive until at least 30 days after exposure.  Having said that, your risk for syphilis is substantially lower than your risk for gonorrhea or chlamydia.

I hope this information is helpful.  Overall I would place your risk for HIV as being very low but I do endorse the steps you are taking to make sure.  EWH
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23 months ago
Thank you for your response. It really helps my mental state that you think its very very unlikely I was exposed. 

On the testing: when is the earliest baring in mind my taking PEP that a Cepheid assay would give some meaningful result? would 14 days be long enough?
I assume I would then do a duo test at 28 day and then 8 weeks? 

Although we had oral sex it was with a condom which remained intact, would you still recommend a urine test for Chlamydia, Gonorrhea?

I will get the anal swab and the blood test for Syphilis. I have been taking Doxycycline for a sinus infection, I have heard this also kills syphilis, is that true?
Edward W. Hook M.D.
Edward W. Hook M.D.
23 months ago
PEP is anti-HIV therapy. It is logical that this could slow or delay detectable viral growth or the host antibody response to it.  There is not precise quantification of how much of this occurs.  The only completely reliable testing will be that that occurs 4-5 weeks AFTER you complete PEP, not while you are taking it.  Thus while tests before that time will be suggestive, they should not be considered definitive.  For all testing, as I said above, the tests for the virus itself, i.e. the Cepheid or PCR tests will be positive before the combination test.  SO, again, ANY tests taken before the completion of PEP should not be considered definitive.  A 14 day PCR or Cepheid test after completion of PEP will provide strong evidence you were not infected, as would a duo test at 28 days.  A negative duo at 6 weeks after completion of PEP can be considered conclusive.  

Thanks for pointing out that a condom was used for receipt of oral sex- I missed that.  This makes the urine testing net necessary for this exposure.  

The doxycycline you were taking at the time of exposure would be expected to effectively prevent acquisition of syphilis and chlamydia but not necessarily gonorrhea.  EWH
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23 months ago
Thank you for your responses doctor. I will see my doctor and get a Cepheid assay test at 14 days post exposure to try and put my mind at rest a bit, then do a Cepheid assay at 14 days after PEP has finished to get "strong evidence" I am not infected, and finally a duo at 6 weeks post PEP to be sure.  My mental state is extremely fragile at the moment and I am going to get some counselling to try and cope with all of this. 

Last question, you did not mention the kissing? I assume apart form HSV1 I am at no risk of anything else from this. 

Once again thank you for this wonderful resource.


Edward W. Hook M.D.
Edward W. Hook M.D.
23 months ago
Good plan

Kissing is not a risk fact of HIV or any other STIs.  The are some investigators who worry that gonorrhea may be spread by exchange of saliva in the course of open mouth, "French" kissing but this hypothesis is not proven and hotly debated.  I would not worry about kissing,

Our Forum provides up to three responses to each person's question over a period of up to 30 days.  This is my 3rd response, therefore this thread will be closed in a few hours.  I hope my responses have been helpful.  Please don't worry, you have done everything right.  EWH
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