[Question #7179] High Risk HIV + PEP

60 months ago

Hello Doctor Handsfield,

I’ve made mistakes. I am 39 years, uncircumcised. In July I had protected anal (insertive) sex with a cross dresser in China a few times and licked her anus. On 25^th July, my penis touched and may have slightly penetrated her anus only for a few seconds. I asked about her HIV status; she refused to tell and added that we used condoms so ‘no worries’. I panicked. On 26^th July (36 hours later) started PEP (the hospital also did RNA HIV test- Negative). However, stupidly, while drunk on August 2^nd (7/8 days into PEP) I had two more risks. With a transgender escort, I mistakenly put my penis into her anus for about one second, then had protected insertive anal sex with her. Then, later that evening, I had unprotected vaginal sex with a Vietnamese prostitute for around 1-2 minutes (noticed menstrual blood on my penis after this). To what extent would the PEP protect me for the latter exposures? The PEP was expensive- over 800 dollars; it was Truvada and Tivicay Dolutegravir. Now- I actually have some old PEP medicines that expired some months ago, but the combination of the old PEP is Truvada (expired 04/2020) and Raltegravir (expired 10/2019)-both prescribed in the UK a couple of years ago. They have been kept dry, but probably not in cool conditions. Should I take 7 more days of the old, expired, PEP (even though the mix of the PEP ingredients is different), or go back to the doctor for 28 days more PEP? What do you think of my risks? Thank you so much.

H. Hunter Handsfield, MD

60 months ago

Welcome to the forum. Thanks for your confidence in our services. FYI, it's only by chance I'm answering. Dr. Hook and I answer all non-herpes questions on the forum, regardless of requests for either of us. It happened to be my turn for your question.

Pre-exposure prophylaxis, or PrEP -- taking anti-HIV drugs before exposure -- is 100% effective in preventing HIV. PEP with the drugs you have been taing is identifcial to PrEP. In other words, PEP for a particular exposure is PrEP for any expousre that occur later while taking the drugs. So there was no risk for HIV from the exposures while taking the drugs.

Properly stored drugs typically remain effective and nontoxic long after their official expiration dates. (A drug expiration date of, say, 3 years in the future, means the manufacterer determines it will still be effective at that time. It doesn't mean it won't last longer. Just like most foods are entirely nutritious and safe long after the "best by" date stamped on the container.) I can't directly advise you to use outdated drugs for PEP/PrEP. However, if I were in your situation I would not hesitate to use the outdated ones. On the other hand, you should discuss this with the clinica or doctor or who prescribed PEP -- not so much because of the drug beyond it's date, but because of the difference in drugs. Probably no harm in changing, but we don't provide direct treatment advice on this forum.

I suggest you look into PrEP on demand. With traditional PrEP, anti-HIV drugs are taken continually. With on demand PrEP, a single dose of anti-HIV drugs are taken 2-24 hours before an anticipated exposure, then 2 more doses in the next 1-2 days afterward, then stop. It's equally effective in preventing HIV as standard PrEP or PEP and most people find it much more convenient.

In response to "What do you think of my risks?" On one hand, the particular expousre for which you were given PEP seems pretty low risk. With such brief anal contact +/- penetration, the chance of HIV was very low, even if your partner was infected. That said, I can't say that risk was zero. A lot would depend on what is known about persons similar to your partner in that particula rlocation. If such persons are known to have high rates of HIV, PEP probably was a good idea. Or on-demand PrEP going forward.

Finally, it seems you're missing an important element of safe sex to prevent HIV. Discuss HIV status and recent testing with any and alal partners before haviing any contact. For any partner who is positive (and not on treatment), doesn't know, or -- like your partner, evasive -- it's "Sayonara, Baby -- I'm out of here." Please don't ever have sex again without such a conversation, at least with other men, trans women, etc.

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

HHH, MD

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60 months ago

Dear Doctor Handsfield,

Thank you so much for your kind and detailed reply- it was so helpful. To confirm, I am now on day 24 of PEP-Truvada and Tivicay Dolutegravir- and because the two risky exposures occurred on day 7 of my PEP, you mean that I was thus protected and can stop this course of PEP on day 28? (I wasn’t sure because you mentioned asking my Doctor about the possibility of using the different PEP drugs prescribed in the UK). When you said you wouldn’t hesitate to use the outdated PEP- did you mean as a potential form of ‘PrEp on Demand’ in the future? Thank you. (I seem to remember in the past you mentioning that PEP often fails because some individuals may continue to have risky exposures whilst on PEP; is this still the case?)

I’ll look into ‘PrEp on demand’- thank you. By the way, I have since met another trans-lady (on hormones), who seems to be a little more honest about her HIV status. She says she was tested 4 months ago (though I didn’t ask for proof). Do you think it would be wise to ask her to do a rapid saliva or blood prick test with me, so I can see her results in person and immediately? Would this be meaningful as reassurance? I guess for the next 4 days I’ll be on PEP, so I’m safe to have protected anal intercourse with her until then. I will be much more vigilant with condoms in future. Thank you again so much Doctor.

H. Hunter Handsfield, MD

60 months ago

Yes, you can stop PEP after 28 days; there was no chance of being infected in your later exposures, while on PEP.

I do not recommend you start PrEP (on demand or standard) on your own. Get professional advice about it in person, then follow that provider's advice, including whatever s/he recommends abou the drugs you have on hand.

in general, people do not lie about HIV status when asked directly. I don't recommend spot tesiing potential partners who say they have been tested recently with negative results.

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