[Question #5593] Prep on demand and assessment

74 months ago

Drs, since my last visit I used what I learned from you and completed the HPV vaccine since the FDA raised the age limit. Your advice helps! These days my STI acquisition risk tolerance is non-existent. However, based on your assessment of gay outercourse being no risk (mutual JO, frottage, massage) I limit myself to that and I never let genital regions touch together. My full STD panel 2 months ago was negative.

I have a general question and specific scenario question.

I can’t find anything in the forums about Prep on demand (aka Prep 211). I know Australia and SF AIDS Foundation support it but the US govt does not. What is your take? Is it effective? I think about taking it but want to limit the side effects and cost given my low risk. Do you think CDC will eventually adopt this?

Onto my case, 10 days ago I did frottage with a Latin male mid-20s claimed to be on prep and tested negative for STDs a month prior. He was naked but I kept my underware and shorts on. My bare stomach and chest rubbed against his back/chest but all above the waistline. I did not see any lesions on his torso. No skin touched his genital regions nor did any part of him touch mine. In examining myself for lesions post frottage, I’ve found some where the top of my abs are. Some look like ingrown hairs but about 4 look like they may have fluid. They are small. Three are within 1” of each other. They don’t look clustered and the entire area is not red. They are not growing nor painful and I have no general body symptoms like fever or swollen glands. Is there anyway his back could have transferred HSV2 to my stomach? Or is HSV2 only transmitted from genitals to genitals? Given my body hair these bumps and redness could have been there prior and I am only now noticing but they make me nervous given the timing. I know you say HSV acquisition is theoretical only but are these lesions concerning? Or given no genital contact is this impossible to be HSV?

Edward W. Hook M.D.

74 months ago

Welcome back to the Forum. I'm pleased that our prior interactions have proven helpful to you and endorse your continuing practice of safe sex. As you no doubt know, the concept of PrEP on demand is somewhat controversial. While there is no doubt that PrEP on demand reduced HIV risk for men in several studies, there are concerns that it may be somewhat less effective than daily PrEP for men (there is no doubt that the pharmacology of the PrEP medications mean that PrEP on demand would be less effective in women because of failure to reach adequate tissue levels after a single dose of medication. In a perfect world in which cost was not a factor and acknowledging that sex is sometimes not planned, daily PrEP is preferred but I totally understand the desire for simplification. My guess is that official agencies such a CDC will gradually acknowledge that PrEP on demand reduces risk for HIV. I also suspect that they'll somehow qualify their endorsement as is typical for them.

Regarding HSV. HSV can occur on almost any body site and theoretically could also be transmitted through contact with such infected sites. OTOH, the likelihood of this occurring is exceedingly low and the lesions you describe really do not sound at al like HSV Like you I would bet on folliculitis. I suspect the timing is coincidental and perhaps influenced by heightened awareness on your part.

I hope this information is helpful. Again, congratulations on your commitment to safe sex. EWH

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74 months ago

Thanks Dr. H. In summary it sounds like for men, Prep on Demand provides more protection than no Prep (which is what i assumed) but not enough protection for it to be widely recommended and the daily pill should be taken if Prep is wanted/needed. Is the efficacy rate of Prep on Demand known yet?

If HSV2 can be transmitted from any body part, why is it classified as an STI? (I already have HSV1 though never any outbreaks). Is transmission this way theoretical or actual? Your answer there surprises me as I've not read similar things before but have read many times that the risk of herpes from frottage is theoretical and you’re not aware of any cases. Dr. Handsfield said “Although some STDs can be transmitted by skin-to-skin contact, even this is no risk when there is no direct genital-genital, anal-genital, oral-genital contact.“ So I thought I was 100% safe? I’ve read repeatedly that lesion diseases need to be thoroughly massaged into skin to take hold. How much friction are we talking about? I did not see any lesions and the body to body rubbing was not as friction filled as intercourse. It’s been over 2 weeks since I first noticed the fluid filled lesions and there’s been no change (no ulceration or scabs). Would they have changed by now if they were herpes?

I always want to keep myself safe so fully understanding risks helps to make appropriate choices. If mutual masturbation is not a risk for any STI but any direct touching of skin to skin, even in non genital areas, is a risk (theoretical?) of lesion diseases then that's good to know.

Edward W. Hook M.D.

74 months ago

PrEP on demand looks hopeful and promising for HIV prevention in men (but not women) however there is far less research on it than there is on daily PrEP. Most experts would like to see more research

Most HSV-2 occurs in the ano-genital area and most transmission of this virus occurs during sexual activity in the broad sense. OTOH, other parts of the body can be inoculated during sexual activity other than genital or ano-genital penetrations and lesions in that area can transmit infection to others. The risk of transmission in frottage or other non-penetrative sexual activities is miniscule and not something to spend a lot of time worrying about. I urge you not to do so. EWH

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73 months ago

For my last response, those bumps on my upper stomach eventually sprouted hairs! I took a HSV2 IGG test at 4 weeks 3 days post potential exposure (again my genital area was fully covered by shorts and his genitals did not touch me, we only had upper body rubbing). The result was negative. According to STDCheck.com this FDA cleared test is 97% accurate at 4 weeks after potential exposure. They said those stats come from the test manufacturer. My online research seems to say 97% at 4 weeks is a bit high. What say you? If you think accuracy is lower, how can the manufacturer claim a higher amount?

I was fine with test results and had moved on but then two days ago (5 weeks 2 days post potential exposure) I developed a 1.5” horizontal line of red bumps on the inner portion of my lower thigh about 1-2” above the knee. This is well below the boxer shorts region. The whole line is red and itches. It was swollen the first day but that has since gone down. I can identify numerous lesions in this red line. I also have one red itchy lesion on the outer thigh (i.e. other side of my leg) at about the same height above the knee. All are around the bottom line of the shorts I was wearing three days ago when I remember feeling like a bug was biting me around that same area and after awhile I checked but didn’t see any bug. These could be bites but certainly look herpes-esq given the redness of the area and multiple itchy lesions in a row. Do Herpes typically show up in a line like this? Still no other genital or body-wide symptoms.

Given this scenario of no genital touching but torso rubbing and a negative HSV2 at 4 weeks 3 days post potential exposure, do I need to worry about this as a potential outbreak at 5 weeks 2 days post potential exposure? Do I need to test again? Thanks Dr. Hook. Take care.

Edward W. Hook M.D.

73 months ago

As you note and as per Forum guidelines, this will be my final reply. I'm sorry you chose to have a HSV blood test and am please that you were fortunate to not have a falsely positive test which is something we see commonly. As I suspect you know,, we recommend against testing for HSV using currently available blood tests. That said, with your negative test, this is further evidence that you did not acquire HSV and at this time I would urge you to stop worrying and move forward.

We agree that the manufacturer's estimates of HSV test performance are a bit optimistic. Their package insert estimates reflect the design of the studies they used to get approval for their test and not use of the test in the way you or most people use the test.

The hairs you noted make it all the more likely that the lesions you noted were folliculitis. There is nothing about the location or your description of your new skin lesions to suggest they are HSV. I really think you are all too worried about HSV. I hope my comments will help you to put your unwarranted fears aside. EWH

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