To pep or not

[Samiam2014]

I am visiting singapore and had sex with a commercial sex worker that was not licensed yesterday
We used a condom but continued for a few minutes after that as well

When I withdrew my penis came out without a condom which was hanging out of her vagina. I am guessing it slipped during withdrawal. It was intact and didn't break

I panicked and went to see the Department of STD center and consulted a doctor for pep
She told me that I was a low risk case and most of the risk was around the history of the unlicensed worker and if my condom slipped during intercourse or withdrawal

She said that since. PEP had less but still potential risks round liver and heart issues she would advise me to let it be but left the choice to me since I was eligible given my blood test result

Need a second opinion

I guess for me the big if is what if I lost it during the session and not withdrawal someone told me that if I lost in the session it would be sticking out

[Edward W Hook, MD]

Final answer.  your earlier condom protected encounter with another CSW in no way changes my opinion or advice.  

It is time for this thread to end.  Take care.  I am confident you will be fine. EWH

[Samiam2014]

Doc last question I held back some information because I was feeling guilty
This was my second encounter in a 3 hour window

My first was with a CSW worker as well but the condom did its job

Sorry but I was ashamed and this is a side of me that I deeply regret and is not typical behavior

Does that change the assessment sir

This is my last post on this thread and would appreciate a reply

[Edward W Hook, MD]

You are over reacting.  You have my assessment. It will not change.  EWH

[Samiam2014]

Doc let me clarify my question about the case study I posted above. I went to the same area and had the near same experience except that my condom slipped but was intact chances are we went to the same group of workers given the ethnicity


I am freaking out to see a near same experience end in infection

[Edward W Hook, MD]

My advice is to stay off of the internet.  PEP does fail occasionally- I have told you that but for you to fuel your anxieties by searching the internet where you are likely to find horror stories and misstatements is not a wise thing to do.

Nothing more to say. EWH

[Samiam2014]

Dear Dr Hook - I came across this post which has an eerily sounding story similar to  mine can you please see this

http://blog.askdrtan.com/a-case-of-pep-failure/

[Edward W Hook, MD]

Your additional comments do not change my opinion or advice.

1) how effective is PEP
Very effective but precisely how effective is a bit hard to calculate since even if sexually exposed only 1 in 1000 (1/10th of 1%) get HIV.  We know that at least a small proportion of persons still get HIV despite PEP and the PEP is not effective if started more than 72 hours after exposure.  

2) what are chances of long term damage from using PEP
These are not clear- probably low.

EWH

[Samiam2014]

And the CSW was Vietnamese

[Samiam2014]

3)Did your comment on condom hanging take into account my description of the act

I am leaning towards forgetting and moving on what say?

[Samiam2014]

Thanks Doc. Just three follow ups

1) how effective is PEP
2) what are chances of long term damage from using PEP
3) did ur c

[Edward W Hook, MD]

Welcome to the Forum.  Your exposure is not an exposure for which PEP is strongly recommended.  PEP is recommended for UNPROTECTED exposures to persons KNOWN to be HIV infected.  In your case, while your partner was unlicensed and therefore somewhat more likely to be infected, the fact is that most unlicensed CSWs in Singapore do not have HIV.  Further, that the condom you used was hanging out of your partner's vagina after you withdrew is more consistent with it coming off as you withdrew than during sex.  Had it come off during sex, it would not have been hanging part way out but would have been deep inside the vagina.  If your exposure been infected and your partner had HIV, your risk for infection from a single sexual encounter would still be less than 1 infection per 1000 acts of intercourse.  For these reasons, as well as the fact that PEP has its own side effects and is expensive, you are not in a group for who PEP is strongly recommended.  PEP however, as the other doctor told you, is a personal choice- I have provided the data.

If you choose to try to find someone to provide you with PEP, please hold them accountable for all that goes with it (i.e. follow-up, answering your questions, etc).  Sadly, there are all too many health care providers willing to provide it, thinking that their jobs are done when the prescriptions are written.  This is not the case.  In my opinion, it is essential that anyone who provides PEP also provide follow-up and a commitment to answer their patient's questions about risk, side effects, etc.  Often this is not done.

I hope these comments are helpful.  EWH

[Samiam2014]

Condom came off !!

[Samiam2014]

Sorry to  keep adding but the act started with her putting on the condom though I was not fully erect and she started riding me I came too soon but still did multiple thrusts and changed position from girl on top to me lifting her

I not know if  this made the condom come off at one point my penis went total
flaccid and she withdrew and we ere shocked to see the condom hanging from her

Sorry for the gory details but I am stressed out and leaning on taking PeP given the high incidence in CSW in Asia  the fact she was unregulated and the cond

[Samiam2014]

Just to clarify what is bothering me is her unlicensed status and I don't know when the condom slipped because I was doing it after I came