HIV - Prevention Expert Forum
Advice on Possible Exposure & PEP
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This forum is limited to prevention of HIV and to safe sex in general. All questions will be answered by H. Hunter Handsfield, M.D. or Edward W Hook, MD.

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Advice on Possible Exposure & PEP

Hi Dr. HHH,

I am a healthy, young HIV negative male (last tested December 19) and over the weekend had insertive anal sex with another apparently healthy, young male. We made out and I was wore a condom when I penetrated him, for probably a cumulative total of 20-25 minutes. The sex wasn't rough and I used a lot of silicone based lube with the condom. I pulled out of him a number of times and checked the condom each time, it appeared to be intact each time.

I had asked him twice before if he was negative and he confirmed yes. I asked again during a break from sex, and it turns out he is actually positive - says he takes Stribild daily and his last labs 3 months ago showed that he was undetectable. I left immediately, really not happy that he would place me in a position of risk like that.

Approximately 12 hours after the possible exposure, I visited a local STD clinic and they started me on the first 4 days of PEP taking Truvada 1x daily and Kaletra 2 x 2 daily. On Tuesday I am supposed to go in and pick up the remainder of the 28 days.

I am concerned that at points during that encounter without the condom on, I believe that my urethra was exposed to his anus, but not penetrated, and therefore I may have come into contact with his rectal secretions, which by all accounts are possible to be infectious even with an undectable plasma level.

What level of risk do you believe I have placed myself under, in the event that his rectal secretions did come into contact with my unprotected urethra, especially given that he claims he is undetectable? Also from deep mouth kissing?

Given the level of risk, would the PEP (apparently 90% success rate) virtually cancel out any of the remaining probability that I could have contracted HIV?

In your opinion, could I only continue to take the Truvada and not the Kaletra?

When is the earliest after finishing the PEP course that I could get a NAAT or p24 test to obtain a reliable indication of my negative status?
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Welcome to the forum.  Congratulations on your understanding and apparent commitment to safe sex -- including discussion of HIV status with partners before having sex.

You describe an entirely safe scenario, even with your partner's HIV positive status, and I don't understand the decision for PEP.  Even if your partner were not taking anti-HIV therapy, the use of a condom that remained carried little risk of transmission.  And the research data shows that when HIV infected people are taking adequate therapy -- i.e. with documented low or undetectable viral load -- they are minimally infectious if at all.  In my clinic, if the information about your partner were believed to be reliable, we would have strongly recommended against PEP.

The minor exposures other than anal sex -- i.e. brief exposure of your urethra to your partner's anus -- doesn't change anything.  And kissing has never been documented to result in HIV transmission, regardless of anti-HIV therapy.

We don't advise on this forum about details of treatment. Whether or not you should continue PEP, and which drugs and for how long, are issues for the clinic that prescribed treatment.

Finally, there are no data on the extent to which the testing window should be prolonged after PEP.  Most experts extent testing after PEP to around 6 months, but you're going to have to rely on the prescribing clinic for specific advice about it.

Having said all that, you really shouldn't be at all worried. Even without PEP, you were at no measurable risk of infection.  All will be well -- after, of course, a period of uncertainty until reliable testing can be done.

Regards and good luck--  HHH, MD
7 Comments
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Avatar_m_tn
*Dr, to clarify = I mean that at points when the condom was not on, I may have brushed or pushed the head of my penis against his anus. This was before and after the actual protected sex.
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239123_tn?1267651214
I saw this before I replied.  It doesn't change my opinion or advice.
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Avatar_m_tn
Dr., thank you for such a quick response - I appreciate it.

I understand you don't provide treatment advice but if you could comment on the following I would appreciate it:

Given that you believe the situation I was in was a very low/no risk one, do you think that adding Kaletra to the Truvada is not necessary and that if I was the one to push to continue the PEP for the next 26 days, that Truvada alone would be ample to satisfy the (in your opinon) non-existent need for PEP anyway? Or does Kaletra play a necessary part in the PEP process?

I say this because even though I understand you have said the situation was entirely safe, there is a side to me concerned that 1) the guy could have been not accurate about being undetectable and 2) that the condom may have been ruptured or otherwise damaged at some point which means I would have had a higher risk of exposure than you believe. I know these could be classed as 'what-ifs' but they are possible as it was dark and I dont know him very well at all.. - if he was willing to lie about his status to begin with, why should i expect him to tell the truth about being consistent on his meds..
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239123_tn?1267651214
Sorry.  Once someone has been prescribed specific treatment, no distant expert should interfere.  This remains a question for the prescribing provider.  And in all honesty, I really don't know the relative contributions of these drugs in a PEP setting.

Yes, I suppose it is possible the information about your partner was wrong.  But treatment decisions have to be based on the best info available.  Anyway, in this instance I would not have recommended PEP even if you knew your partner were not treated and had a high viral load.

Your profile says you're in San Francisco, which arguably has the world's highest concentration of top level HIV/AIDS experts.  If for some reason you are reticent to discuss these issues with the STD clinic, I would recommend you seek out an infectious diseases/HIV specialist to advise and follow you.  But whether you do or not, this forum has nothing more to offer.  Good luck with it.
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Avatar_m_tn
Dr. HHH, thanks for the advice. If you wouldn't mind, as a last question, could you please let me know your thoughts on the window or eclipse periods for HIV NAAT PCR DNA/RNA testing?

From what I have read, an HIV infection starts to replicate rapidly after exposure, so does this mean that tests completed at either 7 or 10 days post exposure would have a very high accuracy in detecting any infection? If so, what degree of accuracy?

I am not referring specifically to my situation (with PEP), but wonder if you could give general information regarding those specific tests and the window periods.

Thank you again.
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239123_tn?1267651214
Your research has found the right information.  The NAATs for HIV DNA/RNA pick up at least 95% of infections by 10 days.  However, PEP could delay it -- as well as the development of measurable antibody.  One of the reasons PEP decisions should not be taken lightly is that it delays the time to definitive testing; most experts don't consider negative antibody tests completely reliable until the 6 month mark, whereas without PEP the exposed person can be reliable reassured within a few weeks that s/he wasn't infected.

That will wind up this thread.  Take care.
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