[Question #9365] testing after pep and hiv concern

33 months ago

hello, i am a 24 year old male. On aug 24th i had a possible hiv exposure with a female sex worker. i had used a condom but it broke. immediately after it broke i pulled out, within seconds. now i am concerned becuase of the condom breaking and the fact that i am uncircumsized. i also do want to note that i had shaven 1hr prior to this encounter and i couldve possibly had a few shaving nicks/cuts, i didnt personally see any blood from said shaving cuts or nicks so i dont know if i did have any to begin with. but i know i did have some vaginal fluids around the area. 65 hrs post possible exposure i had my first dose of pep however it was only truvada for the first day, the next day i had truvada again at the same time and 5 hrs later took my first dose of tivicay and proceeded with truvada and tivicay from then on for 30 days. i was able to contact the sex worker and asked if she could get tested but she was reluctant to do so and never did. she kept saying she didnt have HIV but i dont know how much i can trust her word, so ive been really worried this whole time. i took a combo test a day after PEP and it came back negative and another 28 days after that 29 days post PEP with a combo test, again negative.

1. how much risk do you think i had for my exposure?

2. is my PEP regime ineffective because i only had truvada within the 72 hrs and my first dose of tivicay well after the 72 hrs?

3.. how confident can i be with these test results?

4. when can i get conclusive testing after my PEP regime?

5.if pep was unsuccessful when would a test be positive? how long does pep stay in your system suppressing any virus?

6. is loss of voice (hoarseness) and coughing with a bit of a weak feeling symptoms of ars? no other symptoms. the coughing has been going on for 6 or 7 days.

H. Hunter Handsfield, MD

33 months ago

Welcome and thanks for your confidence in our services.

This was quite a low risk exposure and I'm not sure I would have recommended PEP -- although it certainly was not unreasonable, especially if local data suggest a high risk of female sex workers having HIV in the setting where this occurred. In most settings in the US, there would be under one percent chance she is infected, and perhaps under one chance in a thousand. And despite her reluctance to be (re)tested, most sex workers know their status and are not likely to lie when asked directly. The brevity of the exposure after condom breakage also is strongly in your favor. Neither the shaving nor your circumcision status makes much difference. (In Africa, being uncircumcised roughly doubles the risk if exposed. But if the risk starts at, say, one chance in 100,000, the doubled risk to one in 50,000 remains minuscule.)

As for your PEP, Truvada alone is highly effective; the additional benefit from Tivicay is small. In any case, combining the inherently limited risk of the exposure plus PEP started within 72 hours, the chance you have HIV is extremely low. So although you need more testing to be certain, you can definitely remain mellow in the meantime. Perhaps you'd also like to know that in the 15 years of this and our preceding forum, with thousands of questions from persons concerned about possible HIV exposures, nobody has yet turned out to have been infected. I'm confident you won't be the first!

Those comments answer some of your questions at least in part, but to be explicit:

1. Even without PEP, the chance you caught HIV probably is under one in a million. (If you would like, I'd be happy to give you a numerical/statistical analysis.)

2. You had very effective PEP. The only imperfect aspect is starting at 65 rather than 24-48 hours after exposure, which is still more effective.

3. I'm afraid your current test result is meaningless. The window for testing when people take PEP starts when PEP is completed.

4,5. Same question twice, in different words. While it is clear the window is extended by PEP, there are no good data on exactly how long. This is an almost impossible thing to study with reliable patient numbers and statistics. Clearly negative AgAb (4th generation, "combo") tests at 2-3 weeks are pretty good evidence, but most experts believe it takes 6 weeks for conclusive results; and some even say 3 months. So I would advise another AgAb test 2-3 weeks after your last dose of drug, at 6 weeks (which you can consider very probably conclusive), and maybe 3 months to be on the very safe side.

6. These are not ARS symptoms. ARS doesn't cause cough at all.

A final point, less for you than others who might be considering PEP and read this thread: A major downside of PEP is often disregarded, and you may suffer that downside. The cost of greater assurance against infection is the delay in knowing for sure. Instead of conclusive HIV AgAb testing 6 weeks after the exposure, the time after completing PEP extends the period of uncertainty -- and often anxiety -- to as long as 4 months after exposure. This is one of the reasons the most knowledgeable experts tend to be conservative in recommending PEP, i.e. advising it only when the exposure is especially risky.

That said, I'll repeat what I said above: I believe there is well under one chance in a million you have HIV. (If somehow I had been in your situation, I would never have stopped having unprotected sex with my wife. That's my level of confidence you don't have it.)

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

HHH, MD

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33 months ago

Thank you Doctor. So a conclusive combo test would be 6 weeks after PEP? and 3 months to be on the safe side? would i be able to infect someone while on PEP?

H. Hunter Handsfield, MD

33 months ago

Correct about timing and meaning of your test results. If you had acquired HIV, it is exceedingly unlikely you could have infected a sex partner while taking PEP. However, if you had sex during that time, you should inform your partner so s/he is aware.---

33 months ago

once PEP is over i know it takes around a week for the meds to get out of your system, but after theyre gone and they didnt work would the virus begin to replicate like it would from the moment of exposure or would it replicate slower because of the effects of the meds or would it not matter. i see the UK has some places where a combo test is deemed conclusive by 2 months after exposure, 1 month after PEP. for example " better2know". is there any difference between our testing procedures? why are the US guidelines stretched out to 3 months post PEP?

H. Hunter Handsfield, MD

33 months ago

I'm not aware of data on how quickly HIV starts replication after completing PEP. Your analysis makes sense, i.e. maybe not until PEP drugs have been cleared entirely. OTOH, they may not need to be completely gone for replication to resume.

I have already explained why advice varies from one expert source to others; carefully re-read my original reply above. As I said, there simply are no data on the required time to conclusive testing after PEP and therefore advice varies. As I also said, most experts advise 6 weeks as sufficient, but some estimate 3 months. Two months is equally reasonable. (There are no "US guidelines"; or for that matter, official guidelines from any country's public health agencies, as far as I know. Different providers in any country may have advice that varies between 6 weeks and 3 months.)

In any case, I suggest not obsessing about the details. Just get tested at least out to 6 weeks after your last dose, at which time the negative result probably will be conclusive. But you're also free to be tested one last time in addition to that, at either 2 or 3 months. I'm sorry the data do not permit a more precise reply, but that's the state of the science.

That completes the two follow-up exchanges included with each original question and so ends this thread. If you remain concerned, that's another reason to re-read my main reply above, which was intended to be highly reassuring. It is almost impossible you have HIV. Stop searching about the details testing after PEP: you will never find more conclusive or consistent information than you have already seen.

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