Last night I had unprotected anal sex ( I was bottom) with a "high class" TS escort. This occurred in Dublin, Ireland.

It was a misjudged encounter and she told me before that she had been tested in the last month and is on PreP. In the cold light of day I asked her again of her status and she says she cares a lot for her personal health and gets tested monthly.

I enquired about her PreP regime and she said she was on it daily but had liver issues, so now takes it situationally. She said she took two pills yesterday and showed me the bottle which read "Emtricitabine/Tenofovir disoproxil Mylan 200 mg/245 mg film".

I have little (zero) knowledge and despite reviewing previous questions, am unsure if her having taken this in any way reduces my risk as the bottom or if it simply protects her. I have no reason to doubt that she is telling the truth, but am seriously anxious and wondering does this encounter present significant risk that would lead me to seek PEP today?

Grateful for a risk assessment here and your view on whether I should be seeking PEP.

Many thanks

Compared with the exposures discussed in your previous threads, which were highly safe, in this one you were playing with fire. (I'm very glad you recognize it as "misguided".) The highest of all sexual risks for HIV is unprotected receptive anal sex with an anatomic male (which your partner is) who has sex with other men. It's good your partner apparently does not have HIV. Her PrEP does protect you, primarily because it protects her from catching HIV -- although it probably would protect you to some extent if indeed she were to be infected herself. On the other hand, apparently she does not take it consistently, in which case she could still be at high risk for HIV. In the event she were infected, it would reduce your risk as well. Still, I hope that if similar exposures are in your future, you have a discussion about HIV etc before proceeding, and for goodness' sake, use condoms!

All that said, it seems unlikely she has HIV at this time, but it may be possible. Decisions about PEP are best made with the advice of a local expert who understands the epidemiology and frequency of HIV in that geographic area. It would be reasonable for you to visit a government genitourinary medicine (GUM, i.e. STD/sexual health) clinic; there are excellent ones in Dublin. Or an urgent care facility with HIV experience. Then follow their advice about whether or not to proceed with PEP.

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

HHH, MD

Am filled with regret and anxiety and certainly this would be the most risky sexual thing I’ve ever done.

I was prescribed PEP yesterday and started same day (about 12 hours post contact).

Might I ask the views on effectiveness of PEP generally and in light of this situation?

Many thanks

From the relatively low chance your partner has HIV plus taking PEP, I would estimate the chance you will turn out to be infected is one chance in hundreds of thousands, probably all under one in a million.  So you really can be relaxed and confident going forward. The additional downside, however, is that PEP delays the time to conclusive testing, prolonging the duration of uncertainty. You probably were given advice about testing timing and frequency, but basically the clock starts with your last PEP dose, so conclusive testing with an AgAb (4th generation) blood test will be 6 weeks after that at the earliest, and some experts advise final testing 3 months after the last dose, i.e. 4 months after the exposure. (Personally, I am confident 6 weeks (10 weeks total) is sufficient.

Finally, the other option -- perhaps also discussed with your PEP prescriber -- is to contact your partner and ask her to be retested at this time. If negative, you will know for certain you were not exposed and it might be possible to stop PEP (with the approval of your prescribing doctor or clinic).

Many thanks for the helpful advice.

Managed to get in contact with the partner in question. Incident occurred on 12th December and the partner got tested via her routine prep clinic appt on 16th and received results all negative inc HIV. I’m assuming this is reasonably good news.

The not so great news is that after 7 days of my PEP, the airline lost my luggage with the PEP in it and I was unable to source replacement in the country I was in.

I just got the news from the partner today and my plan was to get an early HIV screen 14 days after my last PEP dose then at 21 and 28 days also.

Curious for your view on all the above, appreciate its multi factorial now and even more complex!

Thanks

Now off PEP, I would suggest you stay off. It is almost impossible you were exposed:  you should believe and trust your partner's negative test result. The window period of potential transmissible infection, before a positive AgAb test, is only 2-4 days long. Therefore, his negative result 4 days after exposure is virtually 100% proof he did not have transmissible HIV at the time of that event. If you had known of his negative test result before starting PEP, I would have advised against it. At this point, just have follow-up HIV testing roughly 2 weeks and 6 weeks after your last dose of PEP. You can be confident of negative results.---
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