[Question #8308] HIV + PEP

46 months ago

Good afternoon,

Thank you for having this forum available to us. My case is as follows: MSM Unprotected anal sex, me being the insertive partner, for a duration <4 minutes with a male that stated he is undetectable, accordingly for the last 3 years, and on current HIV tx (Dolutegravir.) Immediately after finding out, I seeked medical care. PEP given > 2 hrs post-exposure at 2300 (Truvada + Isentress.)

Here is where the problem arises: Labs were drawn. Following day, LFTs are elevated ( not critically and I do have a history of fatty liver.) I tried contacting my PCP to ask if PEP treatment should continue. No answer. PEP taken again at night, again with Truvada + Isentress @ 0030. I’m on day two of treatment.

The questions are:

What is your assessment on my exposure risk?

What is the possibility of PEP failure (Truvada daily and Isentress BID) taking into consideration the initial dose right after exposure, the lapse of 24 hrs between doses, but still less than 36 hrs post exposure?

Thank you for your time and reply.

H. Hunter Handsfield, MD

46 months ago

Welcome to the forum and thanks for your question. I happened to log in a few minutes after you posted: most questions don't get nearly real-time replies!

I have good news: you are not at risk of HIV from this event. When an infected person is on effective anti-HIV treatment, with suppression of blood virus to undetectable levels, there is no chance of HIV transmission: such treatment is 100% protective. You could have unprotected sex daily for 20 years with such a person and never be infected yourself. You do not need PEP on account of his event. (Apparently your PCP also may be unaware of the data on the effectiveness of HIV treatment in preventing transmission, otherwise s/he probably would not have prescribed PEP.)

Abnormal liver function tests are a well established side effect of Truvada, so it might be logical to withhold treatment (or use other drugs) in persons with such test results before treatment. But you don't need PEP anyway, so the logical plan would be to just stop treatment. We don't provide direct medical care on this forum, which means I am not specifically advising you to stop treatment. But this is something to discuss with your PCP. If I were in your shoes, or advising one of my patients, I would not have started PEP and certainly would stop it now, especially with the abnormal LFTs.

Those comments pretty well cover your specific questions, but to assure no misunderstanding: 1) This event was risk free in regard to HIV. However, you could be at significant risk of other STIs, although of course this depends a lot on your partner's sexual lifestyle. But to be safest, you should have a urine gonorrhea/chlamydia test a few days after the event, and a syphilis blood test in a few weeks. 2) If there had been HIV risk, the 24 hour delay between the first and second doses probably would not significantly raise the chance of PEP failure.

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

HHH, MD

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46 months ago

Good evening,

Thank you so much for your time and prompt response. I know you cannot “hear” it in my previous inquiry, but I’m actually pretty nervous. But your reply has given me much needed reassurance that everything should be alright.

One more question in regards to PEP:

I did request for this person to show me his HIV meds (which he repeatedly assured me he is taking) and his proof of being undetectable (he did show me lab results with his data showing he was undetectable as of one month ago.) But let us say he was not being as compliant as he told me or that he happened to have a higher viral load at the time of the encounter, what would be the new assessment for my risk (again, MSM, me being the uncircumcised insertive partner with a < 4 minute intercourse)?

As for my LFTs. Just this:

The ED physician did say I could take PEP for 15 days, recheck my LFTs and then discontinue the meds if the results were still elevated (continue the full 30 days if the opposite if found.) What do you think if this recommendation?

And,

Can you go into liver failure from one month course of Truvada/Isentress?

H. Hunter Handsfield, MD

46 months ago

Your opening statement is interesting: that you are highly anxious about all this was obvious from the start! But that sort of anxiety doesn't justify unscientific or unwarranted treatment decisions. Most people don't lie about HIV status, and I do not accept your premise that your partner wasn't being truthful. (I certainly understand his reticence to give you more proof than his word. That would have been most people's response to your request, including my own if somehow I were in that situation. In the future, you should plan on having a discussion about mutual HIV status with a new partner before having sex with him, not afterward.)

For an HIV infected partner not on anti-HIV drugs, the risk to the insertive partner from a single episode of unprotected anal sex with that person is around 1 chance in a thousand. (Actually calculated at 1 in 975, if I correctly recall the data.) That certainly would be high enough to warrant PEP. But as I said, I think you should not assume the worst about your partner.

To the best of my knowledge, the ED physician's advice is fine. I don't know that Truvada or Isentress ever cause overt liver failure. In any case, you already have my more important advice, that PEP isn't warranted and you should not be taking it.

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