[Question #9756] PEP after brief high risk situation

29 months ago

Hello, married to a pregnant woman, had my first gay experience. Mutual unprotected oral, then switched to bottom no condom. I know the oral portion can lead to STIs and I am planning to have those tests run. The bottom portion is leaving me anxious, the whole process took less than about 15-30 seconds with maybe 4-5 actual attempts to insert and push. Limited lube and realizing there was no condom, I quickly left. Prior to meeting he confirmed he'd been tested a month previously and come away with no positive results, tended to top, circumcised and had his next test scheduled as well and reiterated afterwards being clean and the event was very short. I see frequently here that trusting people when they share their details like this makes sense but I still find myself tempted to get PEP. I know there is no guarantee that this question will be answered in time for the PEP window to still be open. I know I am scared by the 1 in 72 no condom HIV rate, but am hoping that perhaps I haven't made the biggest mistake or will harm wife/kid.

H. Hunter Handsfield, MD

29 months ago

Welcome to the forum. Thanks for your confidence in our services.

Your temptation is valid: I do believe PEP is a reasonable consideration. Unprotected receptive anal sex ("bottom") is the single highest risk sexual exposure in relation to HIV risk. It is unlikely your partner has HIV, given his negative test result only a month ago, and that makes PEP optional. However, we do not make conclusive PEP recommendations; that always should be between the patient and his or her health care provider, in person. Such a doctor or clinic is more likely to have a sense of HIV prevalence and risks locally; and other individual considerations are in play, such as other health conditions, risks for side effects from the drugs, and the like. Also, taking PEP for a month prolongs the duration of potential anxiety, because conclusive HIV testing is delayed until at least 6 weeks after the last dose -- which would be about 10 weeks from now instead of 4-6 weeks.

There is an out, and it's an important one to consider: if your partner agrees to be retested for HIV and is negative, you can safely forego PEP. Same thing if he is adamant about his last test, and if he hasn't had any high risk exposures since then (and if you believe him; you're a better judge of that than i can be, of course).

The ideal source for PEP advice is a provider with lots of experience in HIV and STDs, such as an ID specialist, public STD clinic, etc; but many urgent care centers have lots of expertise as well.

Effectiveness of PEP depends partly on time since exposure. You don't say exactly when this event occurs. All the above assumes the timing allows you to start PEP within 72 hours of the event, preferably under 48 hours, and ideally 24 hours.

I hope these comments are helpful. Best wishes and stay safe. Let me know if anything isn't clear.

HHH, MD

---

29 months ago

I have scheduled an appointment in regards to PEP, it will be around 59 hours after the fact due to my waffling. In regards to the out, just so I understand correctly, his regularly scheduled testing at the beginning of the next month would allow me to stop the PEP if his results are negative? An item I was hesitant to touch on was the short time span anything was occurring with the whole ordeal lasting fewer than 10 minutes, maybe a minute oral and then the very abridged bottom portion, I don't remember pre cum or anything approaching climax. I'm hoping that that tips things in my favor but I assume it is difficult to put into numbers what those items might do to risk? Finally, I have been confused in regards to PEP testing, I've read a variety of items indicating a test at the beginning, then 4-6 weeks (essentially the day you finish the PEP), and then testing either 4 or 6 weeks again? or in the scenario you mention, the 6 weeks is conclusive 10 weeks out from initial run in? Thank you so much for the answer

H. Hunter Handsfield, MD

29 months ago

Thanks for these additional comments. Before you sent them, I was planning to add -- forgot to include originally -- that if your partner is retested and negative, or if you otherewise become completely certain he doesn't have HIV, you can stop PEP if it already has been started before you have thar result. But this assumes he is tested immediately, not waiting another two weeks. Once you've taken PEP that long, some experts would advise continuing the full 4 weeks of treatment. These are issues to discuss with your PEP provider.

The brevity of the exposure probably reduces the risk of HIV transmission, but it's hard to know how much. The risk also is lower if he didn't ejaculate in your rectum. Still, it doesn't eliminate the risk entirely. There are no data by which to estimate a numerical risk for these scenarios.

Others on the forum have reported online information suggesting a negative HIV test immediately on completing PEP is useful and valid. I am unaware of any data to suggest this, and it really doesn't make much sense biologically. Even if PEP fails to prevent HIV entirely, almost certainly it completely shuts down viral replication while taking the drug. Virtually all experts advise that the clock on testing starts with the last dose of PEP; and after that, the timing is pretty much the same as for exposure without PEP -- that is, valid PCR testing around 2 weeks and conclusive AgAb (4th generation) at 6 weeks (i.e. 10 weeks following the start of PEP). Some experts actually recommend final testing 3 months after the last PEP dose, although personally I am confident it isn't necessary.

---

28 months ago

Hello again, the public STI clinic got me on PEP, 7 days of 2 x Doxy 100mg and a shot of Ceftriaxone. My nurse and doctor argued the exposure was low risk without ejaculation. I forgot to mention to you but did mention to them the small amount of blood I discovered while cleaning myself after the fact which they also felt was low risk. That combined with my anxiety in the room pushed my doctor in my opinion to give me the PEP. As they said "Low risk, but so is PEP and that's what it's for." I've tried to read through the answers on this site, with the shot and doxy I am hoping that chlamydia and gonorrhea are accounted for, do those two also likely head off syphilis or did I need the Azithromycin as well? Without symptoms do I need to worry about Mycoplasma or Trich? I know I'm unable to test for HPV, am vaccinated for it so I hope that allows me some peace? Also vaxed for Hep A/B

As I attempt to move on from my event:

1. Due to the short period of genital to genital time exposure, am I able to consider the event lower risk for HSV2? After 11 days I've not noticed anything like the sores associated with an outbreak

2. I will be finishing out my course of PEP and then testing 14 days after conclusion by RNA. You mention 6 weeks post PEP by 4th gen can be considered conclusive but wondered if there were value in a 28 days post PEP RNA+4th gen? I thought I had seen you mention that combo being extremely promising at that time frame but you had also excluded high risk situations although I am now struggling with what to consider my event. Like many others the goal is to return to unprotected encounters with my wife.

3. Is there anything else I should be addressing testing wise?

Thank you for this service and your answer

H. Hunter Handsfield, MD

28 months ago

Thanks for the follow-up information. (I was logged in when these comments arrived. Most users shouldn't expect nearly real-time replies!)

I'm glad to hear your medical management is in the hands of an obviously knowledgeable clinic and nurse. While not all STI/sexual health clinics would have administered ceftriaxone and/or doxycycline, it is a reasonable approach and seems to have been done thoughtfully and professionally. Same for PEP. You definitely did not also need azithromycin: either the ceftriaxone alone or doxycycline alone is 100% effective in aborting incubating syphilis. (Azithromycin isn't reliable against syphilis; at least half of all syphilis bacteria are resistant to it.)

1. The risk of HSV2 from any single exposure of this sort probably is under one chance in several thousand. I wouldn't worry about it; and absence of herpes symptoms within a week is strong evidence against newly acquire HSV2.

2. Yes, AgAb testing (i.e. 4th gen) 28 days after completing PEP is highly useful, in addition to RNA at 14 days. That combination probably is nearly 100% reliable. Still, most experts advise a final AgAb test at 6 weeks as well, just for a margin of safety. Having received ceftriaxone and started doxy and anti-HIV PEP, you can safely resume unprotected sex with your wife, in my opinion. However, you might check back with the STI clinic and consider their advice as well.

3. I see no other need for testing for anything.

That concludes this thread. Thanks for your thanks; I'm glad to have helped.

---
---