[Question #9208] High risk exposure

35 months ago

Good day, here I am again. Anyways, possible high risk exposure. I’m a heterosexual man in a heterosexual relationship. I’m currently visiting Manila. Went for a night of heavy drinking and met from what I thought was a girl. Not a CSW from what I saw but im still not sure. Went back to my hotel and when we got back I found out that it was a transgender. I was so drunk that I went for it anyway. Prior engaging I made sure to ask if she was clean. She said yes. She has not had any exposure but was not clear if she was tested. Engaged in unprotected oral both ways and had unprotected anal (giver) and she was the receiver until finish. It’s been 2 days but I’m freaking out as always. I did not think of the risk all the way nor did I take in consideration of my actions. She looked healthy no sores. One thing that stood out was she took some asthma pills while we were in the club. I messaged her again to make sure she’s clean and she said that she always watches for her health and that she would’ve known or seen some changes if she had any type of STI. I’m mostly concerned about HIV or Hepatitis. Do you recommend going in for PEP? And I don’t know where to get PEP from here in Manila.

H. Hunter Handsfield, MD

35 months ago

Welcome back. Thank you for your continued confidence in our services. I reviewed your earlier discussion with Dr. Hook and agree with all he said.

As I think has been discussed previously, oral sex is safe sex in regard to HIV -- perhaps not completely free of risk, but even if your partner had untreated HIV, CDC has published risk calculations of one chance in HIV transmission for every 10,000 episodes of fellatio penis to most and 20,000 mouth to penis. Those figures are equivalent to one transmission from giving or receiving BJs with infected partners once a day for 27 years or 55 years, respectively, before virus transmission might be likely. The episode of condom protected anal sex was statistically riskier than the unprotected oral events, but still very low. You don't mention your partner's HIV status: did you ask her? Recent test result? If positive, on effective anti HIV drugs? (If negative or on effective treatment, there was no risk, even if you had had entirely unprotected anal sex.)

I would not recommend PEP in this situation. That said, PEP decisions always should be based on local epidemiology and other circumstances. There are sophisticated STI and HIV clinics and prevention services in Manila, which should not be difficult to find. If such a facility considers these events sufficiently high risk (and perhaps especially if you learn your partner has untreated HIV, or if the experts advise that rates are high in Manila transgenders), perhaps they would recommend PEP. Personally, I don't think it is necessary, but local expert advice always is best.

These comments apply in general terms to all STIs, including viral hepatitis. The only hepatitis for which there might have been risk is hepatitis B virus (HBV), but the large majority of Asian countries -- including, I believe, the Philippines -- have nearly 100% rates of childhood immunization against HBV. Contrary to popular beliefs, hepatitis C virus (HCV) is not a risk in this situation, especially since there was no condom failure for oral sex.

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

HHH, MD

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35 months ago

Thank you very much for the replies. Unfortunately I should’ve clarified a couple of the events. The Act of giving anal was not condom protected. I’m circumcised not really sure if that makes a difference. I asked her if she’s clean pertaining to any type of STIs and she said yes but like what I said she was not very clear if she was tested. I think I need to go in for PEP. And I need to get it today.

H. Hunter Handsfield, MD

35 months ago

Thanks for clarifying; sorry I misread about condom use. PEP now makes sense; hesitation or obfuscation about HIV status probably is a bad sign. The decision still should be local, but I agree you should look for suitable PEP resources ASAP. Good luck.---
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35 months ago

Hello again, thank you very much. My final question is. I’m not familiar with the PEP regimen. How long after finishing or taking the PEP will I be able to go back to my normal sexual interaction with my partner.

H. Hunter Handsfield, MD

35 months ago

PEP regimens are 4 weeks in duration. In the unlikely chance you caught HIV and PEP doesn't work, it is exceedingly unlikely you would be able to transmit the virus while on treatment, but I cannot say it is 100% certain you would not be able to infect your wife by unprotected sex. If somehow I were in your situation, I likely would continue unprotected sex with my wife. However, my relationship and our mutual trust is such that I would discuss the situation with her so she could participate in that decision. In theory, the greater risk of transmission might be not while on PEP, but in the first couple of weeks after completing treatment.

Follow the advice of the clinic or doctor that prescribes PEP, but standard advice would be for you to be tested for HIV (with an AgAb test, i.e. 4th generation test) at 2, 4 and 6 weeks after completing PEP, and many experts would add a PCR test for viral RNA at 2 weeks. Only after a negative result at 6 weeks (10 weeks from now) will you be completely certain you were not infected. However, negative testing (AgAb plus PCR) at 2 weeks will make it extremely unlikely you were infected, and many couples would resume sex at that point. But there are no black/white answers to these decisions; it's going to be up to you, depending on how you like these odds. They are greatly in your favor, but that's the best I can say. Good luck in all this.

That completes the two follow-up exchanges included with each question and normally would end this thread. But I'll leave it open for one more round if these comments trigger any additional questions.

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35 months ago

Hello, thank you very much Dr. HHH. I received my first dose of PEP today and I will be taking it for the next 28 days. Is there any other STI that gets cured by PEP? Or is it solely just an antiviral for HIV strain? They did a quick test for me today HIV 1/2 to make sure I was clear before giving me PEP and it came negative. They gave me 2 different pills that I need to take for the next 28 days. Is it true that I cannot miss a dosage even one day as it will not do its job. I was also told that PEP has only 80% effective is that true? Does it matter that I’m starting PEP regimen a little over 48hrs of possible exposure? Thank you again!

H. Hunter Handsfield, MD

35 months ago

PEP protects only against HIV, no other STI. Probably the clinic was just emphasizing the point to assure you don't forget, but it is an exaggeration to say missing an occasional daily dose makes PEP infective. It does not. While I certainly encourage you to take the pills as directed every day, missing a day here and there will make no significant difference in effectiveness.

There has been no research in humans on PEP effectiveness, only animal studies. (It is ethically impossible to randomize exposed persons to PEP versus placebo, which would be the only way to definitively study effectiveness.) Effectiveness is believed to depend strongly on how soon after exposure PEP is started; the consensus among experts is that it is at least% if begun within 48 hours. I have never previously seen an estimate of only 80%, but that could be the case if PEP is not started until after 48 hours. At "a little over" 48 hr, I would think 90% would be an appropriate estimate. That doesn't mean there is a 10% chance you will be infected. If your partner has untreated HIV, your anal sex event had a risk of infection around 1 in a thousand. 90% reduction means your risk becomes one chance in 10,000.

That will have to end this thread. Please do not start another about this exposure, your PEP treatment, etc. From here on out, you'll need periodic testing (as I discussed above). Assuming you soon will return to your home country, you should find an experienced HIV/AIDS clinician (or an infectious diseases specialist) for follow-up and to guide you on the details. We do not provide direct medical care or more detailed advice than I already have given.

In the 15 years of this and our preceding forum at MedHelp, Dr. Hook and I have had thousands of questions from people potentially exposed and worried about HIV infection. So far, not one has reported they acquired HIV, and you are not likely to be the first. But in the chance it happens -- i.e. if PEP fails and you turn out to be infected -- we would like to know. So here is the deal I will offer: Please return with a new question to let us know the outcome, once you have been finally tested, probably 6 weeks or more after completing PEP. In that event, we will reverse your posting fee.

I hope the discussions have been helpful. Best wishes to you.

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