[Question #6953] Prep, abrasion, HIV risk

10 months ago
Dear Drs,

I am a heterosexual circumcised male obsessed specifically with HIV and to a much lesser extent to other STIs.  Over the last year and so, I am on a "daily" Prep (Truvada) and never missed a single dose.  I have regular unprotected oral sex but almost always wear condom for vaginal sex and never go for anal sex.  During this time I have been monitored every 3 months for HIV and other STIs and was always clean.  However, during my last exposure with a white college student stripper, in the middle of protected vaginal sex, I got emotional and took off my condom and continued unprotected vaginal sex for a few minutes.  Then without cleaning my penis I wore another condom and continued protected sex.  After the sex I realized a bit abrasion on my penis (no bleeding at all) which made me worried.  I went to internet to do some research on HIV spread in my state.  Fortunately, according to data in my state only about 10,000 people are recorded HIV positive (and less than 1000 women are recorded HIV positive among them).  However, this experience with presence of the abrasion on my penis which I mentioned earlier worries me.   About HIV, to have a full peace of mind I can do an expensive HIV RNA test in 9 days (with 95% accuracy according to the center) but not covered by my insurance.  Do you think to achieve this peace of mind, does this test help or totally useless and waste of money?  Again what worries me is the abrasion I talked about.  Regarding other STIs when can I do all of them together at the latest (my insurance covers this part)?  I appreciate your professional opinion.  
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
10 months ago
Welcome back to the forum. Thanks for your continued confidence in our services.

Stopping for a preliminary reply before I read beyond the second sentence:  Taking PrEP and never missing a dose is, all by itself, virtually 100% assurance you do not have HIV. Failures of PrEP in this circumstance do not occur, or so rarely that they can be ignored. So unless there is a serious surprise in the rest of your message, I'm pretty sure you needn't be at all worried about HIV. It could be a different story for other STIs, however.

Now I have read the rest. I remain 100% confident you could not have caught HIV. You have already done the research to document the low chance your partner had HIV. Even with entirely unprotected sex and no PrEP, the average transmission risk for vaginal sex, if the female partner is infectged, is 1 in 2,500. Having an abrasion may raise the risk, but not by much. So even without PrEP, you were at little or no risk. With PrEP, there is simply no chance you were infeced and I see no need for your to have RNA testing or any other testing for HIV on account of this event.

As implied above, the risk of other STIs was higher, although still not vety likely after any single exposure, especially since you're apparently not having any symptoms to suggest infection. But assuming you would like the reassurance of negative test results, you can have a urine gonorrhea/chlamydia test at any time (valid any time more than 4-5 days after exposure). A conclusive syphilis blood test can be done 6 weeks after the event. In the absence of symptoms, I do not recommend any other STD tests.

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

HHH, MD
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10 months ago
Dear Dr. Handsfield,

Thanks for your prompt and clear response.  Let me ask you a hypothetical question and hear your professional opinion on this.  Between consistent and correct use of condom or daily take of Truvada for just HIV prevention (not other STIs), which method do you think is more effective?  I understand both methods are effective.  But which one is a bit more effective?
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
10 months ago
I've seen no data on this, but would judge PrEP to be more reliable -- assuming compulsive compliance -- because even careful condom use has risk of breakage.---
10 months ago
And my last question is about Prep-Truvada dosage.  I see in several articles, it is said that any number beyond 4 pills (but up to 7 pills) per week is sufficiently enough to protect the person from HIV. Do you agree with this? If yes, why it is recommended to have one pill per day? 
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
10 months ago
I'm not sure, but probably the manufacturer understood that taking any drug every other day (or any less frequently than once daily) is strongly associated with failure to take it on schedule. The studies may have been designed to take into account the effectiveness in people who miss occasional doses. That they studied a 4x weekly regimen doesn't necessarily imply it was ever intended to be recommnded to patients.

Further to my previous comment, of course condoms also work for STD prevention other than HIV. Your current use of both is the right way to go.

That completes the two follow-up exchanges included with each question and so ends this thread. I hope the discussion has been helpful. Best wishes and stay safe (meaning both sexually and for coronavirus).
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H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
10 months ago
Even though closed, I thought of one last comment I didn't remember above, potentially making this thread more helpful for others as well (and one I might refer to in reply to future questions like yours). PrEP really isn't designed or in general recommended for people at such low risk of HIV as you are. The main target population in industrialzied countries in men having sex with men, in particular those with multiple partners. While it's a good idea for heterosexually active persons in some parts of the world, such as sub-Saharan Africa, most experts in the US and western Europe would not recommed it for all but the most sexually active straight men. If you were having 3x weekly unprotected sex with high risk sex workers, sure.

That said, the good news is that PrEP is very safe. Even so, it wouldn't surprise me if the low risk of serious side effects still might be higher than the chance you would catch HIV without it. Finally, another factor is simple reassurance:  if taking the drug gives someone confidence and contributes to less frequent black thoughts in the middle of the night, that in itself is a reasonable consideration. Perhaps all food for thought in discussing with your doctor someday.
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