[Question #7921] PEP and PrEP question

50 months ago

Dr.HHH,

I have a couple of questions about PEP and PrEP. I recently had protected vaginal sex. I rarely engage in it (about twice a year) as I am terrified of HIV. However, when I was taking out the condom after sex, it got easily torn apart. Basically, the part of condom towards the base of my penis broke wide open. The head of penis was still covered though. I didn’t properly check if the part of condom covering my head had any tear or hole. There wasn’t any obvious breakage though. Also, 14 hours before sex, I had taken one pill of Truvada(about 10 months old pill but made my Gilead). Then again 2 hours before sex, I took a generic version of Truvada. After sex I continued taking the generic Truvada for a week, once a day.

My questions are following:

(1) On demand PrEP(the 2-1-1) schedule has been recommended for men who engage in anal sex with other men. However, it’s not recommended for vaginal sex. But if it’s protective for insertive anal sex, should it also not be protective for insertive vaginal sex?

(2) Is ten months old Truvada still affective? I kept it in a bottle but can’t guarantee that the room I kept it in was always in the recommended temperature range. I also took generic version of Truvada. Can I expect it’s effectiveness to be similar to the original version?

(3) I know that for PEP, Truvada is often recommended in addition to other meds like Tivicay. Is Truvada alone useless though? Is it better to not take Truvada at all if other meds are beyond access for reasons such as cost? Tivicay costs $2000 for four weeks supply. Generic Truvada costs around $600. Buying both runs around $2600. So if one can’t afford both, they shouldn’t do any PEP at all? Or taking generic Truvada for PEP may still be better?

Edward W. Hook M.D.

50 months ago

Welcome to our forum and thanks for your question. FYI, Dr. Handsfield and I have worked together for nearly 40 years and have chosen to share the forum in order to provide more timely responses. We never differ in the facts of our responses although our verbal styles vary. Today I happen to pick up your question and will be answering.

I’m sorry to hear about your condom mishap. In general however as long as condoms cover the head of the penis they are effective and when they tear near the base of the penis as yours did, they most probably still work.

You have taken a version of what is often referred to as “PrEP on demand” in which persons are expected or recommended to take two Truvada pills up to 24 hours before having sex and then to follow that with two single doses of Truvada at 24 hour intervals for two doses after the first dose. Most typically persons take their two before sex pills at the same time to make sure that blood levels of the drugs are well into the effective range. I anticipate that the way you took your two pre-encounter doses will be effective. PeEP on demand is highly effective for HIV prevention. While best studied among persons engaging in rectal intercourse, there is no reason to think it would not be equally effective for vaginal sex. In answer to your specific questions:

1. See my comments above. PrEP on demand should be equally effective for prevention of HIV acquisition due to vaginal exposures.

2. I presume you had a prescription for your Truvada. Most prescription bottles have an expiration date printed on their label. Does yours? In general expiration dates tend to be conservative and medications remain active even beyond their expiration date most. Precisely how long beyond the expiration date they remain active is unknown but a few months should be fine. Generic truvada should be just as effective as the brand name product.

3. For HIV prevention taken as PrEP Truvada alone is highly effective but the two drugs in Truvada are not sufficient for for treatment HIV treatment unless taken with another medication. In general the combination medications used as PEP (post exposure prophylaxis) also include more than just truvada. There are many drug combinations which are used as PEP.

I hope this information is helpful. If there are further questions or any of my responses are unclear please use your up to to follow up questions for clarification. EWH

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50 months ago

Thank you for your response Dr. Hook. You asked if my Truvada pill had an expiry date. Yes, it did. It was July 2021. So there is still over a month left. I was mostly worried about it not being stored at proper temperature. I traveled a lot in last year and took the pills with me in case I needed them. Some of the places I traveled to were hot.

I have some follow up questions and will really appreciate if you answer them:

(1) For on demand PrEP, is it better to take both pills at the same time 2 to 24 hours before sex compared to what I did (taking one 14 hours before sex and one 2 hours before) ? I realize that there probably studies investigating the question that I asked, but the dosing I used still includes 2 pills within 24 hours.

(2) Since I used condom (which probably worked despite breaking at the base) in addition to PrEP, should I worry about testing at all for HIV? I don’t know the HIV status of the women I had sex with but she is at a very high risk of acquiring it. Also, I am uncircumcised.

Edward W. Hook M.D.

50 months ago

Thanks for the clarification on the dates. I suspect that despite your travels the Truvada you had was fine. It is clearly stable in temperature is up to 100°F. I would not worry. In answer to your follow-up questions:

1. In the studies of PrEP on demand the participants took their two Truvada pills at the same time. The rationale for this was to achieve higher drug serum levels to assure effectiveness. There are few data regarding taking the two pills separately but I suspect they would work as well. As a matter of convenience going forward however, as well as to correspond to the way the drug has been studied, In the future I would recommend taking your first two pills at the same time.

2. Even most commercial sex workers and other high risk partners do not have HIV. Testing is a personal decision. Personally, between the use of a condom and your use of prep on demand, I would not strongly feel the need for HIV testing.

Hope this helps. EWH

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50 months ago

Thank you for your help Dr. Hook. After reading your response, I feel like there isn't any need for testing. I will forget about this incident and move on with my life. Have a great day.

Edward W. Hook M.D.

50 months ago

Thanks for your thanks. This will complete this thread. Take care, stay safe. EWH---