Do I need PEP

[marcusshoren]

Hi Doctors,

I'm a guy who earlier today had an encounter with a male escort - this is the first time I've had sex in a year - my last HIV test last month was negative. I decided to try something new so I hooked up with a dominant master and we had vigorous sex for around two hours. During this time I performed oral sex on him several times and we had anal sex (I was passive) 4 times. We used a fresh condom for each round of anal sex  (which was vigorous and  rough, using poppers - Im a bit sore) and to my knowledge none of the condoms broke or failed - I managed to test three of them with water afterwards and they were intact. The escort gave me several enemas to make things cleaner and more hygenic (using his douche which he hadnt used recently and he smeared it with antispectic gel first), he performed watersports on me (urinated on me) and spat on me - the urine and spit both went in my eyes, they stung a bit - there was quite a lot of it. There was also a lot of kissing and exchange of a lot of saliva. In terms of oral sex I have chapped lips and a tingling spot on my lips which seems inflamed i.e stingy but doesnt appear to be bleeding or open - I also bite my cheeks unconciously - this has me worried although I dont think I have any open wounds as such. I have a scratch on my arm from being tied up.

He did not ejaculate at all.

After the session was finished we were talking and I asked the escort his HIV status which he told me he was positive - on treatment and currently undetectable. He told me not to worry as he didnt put me at risk of HIV and he works in healthcare advice. My questions are:

1) Are any of the details above worrisome in terms of hiv infection?

2) Is the oral sex and anal sex detailed above a huge risk?

3) Is saliva/urine in eye an HIV risk?

4) Would you recommend that I seek PEP?

5) If you were me would you be concerned? Would you take PEP in my circumstances?

6) Do I need an HIV test?

[Dr Mervyn Tyrer, MB BCh; Dip HIV Medicine, Freedomhealth London]

Thats what comes with PEP sometimes - if you want to take PEP then you may end up with diarrhoea etc. We've done your risk and I don't want to go over that allover again. Your further info doesn't make any difference. My work here is done ... I wont be coming back to this question. all the best Merv

[marcusshoren]

Hi Doctor,

Thanks for your response - I decided to start PEP for my own peace of mind. I started at 18 hours post event and have so far not missed a dose. My only question is that I've had pretty bad diarrhoea (shocking actually) although this has died down now - it happens maybe an hour or two after my first dose of truvada and kaletra in the morning - will this affect its effectivness?

Also - I managed to check two of the three condoms - no tears or rips or leaks - does this lower my risk?

Thanks

M

[Dr Mervyn Tyrer, MB BCh; Dip HIV Medicine, Freedomhealth London]

Good Morning Marcus, Merv here this time. I've ahd a look at your exhcnage with Sean above and have repeated your extra questions beneath with my comments.

Thanks for your response. Can you clarify one or two points for me?

1. You say I may have been inadvertently put at risk due to the energy used - do you mean that the rough sex was risky even in light of using condoms?  

He means ...I think because I'm not him but obviously we work together...that the sex was vigorous and involved a lot of energy or "aggression" ..that will put your rectal and anal mucosa under some strain and may cause tears etc. The douching, fingers and penile penetration together for such a long time mean that there is potential for hazard. It seems unlikely but sean was pointing out that although your recollection was good there may have been a breach. Obviously we weren't there so we don't know - he's just highlighting a potential

2. You say that an undetectable viral load makes the risk of transmission barely above that of the normal population - I don't understand what you mean, can you explain?

When we treat HIV the aim is to achieve some key results.....we want to reduce the amount of HIV virus circulating in the blood = the VIRAL LOAD ..to undetectable levels and we want to increase the specialised T cells ...CD4 cells to high levels. When we get to undetectable levels of virus then it seems from some good studies that the risjk of transfer of HIV from an infected perospn to an uninfected person is near zero..not quite but very near...which means that the chancces of you contracting HIV from an effectively treated HIV positive person are barely above the "normal" uninfected population.

3. You said you would be easy in recommending PEP- does this mean you would recommend PEP?

He means that he's easy about it - no strong views in your case. We do have people who touch a doo handle and think they've caught hiv because they didn't like the look of the person who touched it before and they want PEP..clearly not appropriate in any sense. In your circumstance if it makes you feel better then because of the prolonged sex session with an HIV positive escort then I think Sean says yes, ok, you can have it but equally he's not that concerned to really push it

Sorry if I'm being more than a bit dumb  - the escort said we did nothing risky and that the sex was safe and that even if an accident did happen the fact that he produces no pre-cum, did not ejaculate and has an undetectable viral load makes risk minimal. He assured me that to the best of his knowledge no condoms failed (apparently it would be obvious to him).

Well look sweetheart, although what he says is probably very true about HIV and Sean and I and everyone else by the sound of things agree on that a quick wipe of a douching kit with antiseptic is not hygienic. If he's been popping that baby up other peoples butts and giving it a wipe then sure there'll be apotential hazard of something...I DO NOT think HIV but lots of other bacterial conditions may be lurking. So I buy the statement from him taht hiv was not a significant risk but I don't like the grubby little douche.
I became a bit concerned as last night I had some bleeding so I started PEP this morning (18 hours after the incident), I lied at the clinic and said a condom tore to get the drugs (which I feel awful about) and they said it was low risk.

Well thats much what Sean has said and I've said ...the clinic seem to have been "easy" about PEP too...ultimately I think this will turn out to be a bit of a distraction but nothing more.

I also spoke to a councillor at the terrence Higgins trust and explained the incident (truthfully) and they said I have nothing to worry about?

Well again, Sean, I and the THT and your local clinic seem to all agree.

I'm freaking out even though everyone says I have no need to be, i feel so bad about what I've done - the guilt and anxiety are killing me - should I stop PEP?

Not sure I understand...guilty about having sex with an escort???...forget it...far too many things in life to feel guilty about already. Guilty about taking PEP....forget it...if it makes you feel safer then its worth it.

Am I high risk? I though sex with HIV positive people was fine as long as it was protected and safe?

Youare not high risk..everyone has told you that including Sean. Sean has not seen or spoken to you and neither have I...we relying on what you have said and Sean has carefully picked over it and told you what he thinks...very clearly.Merv

[marcusshoren]

Hi Doctor,

Thanks for your response. Can you clarify one or two points for me?

1. You say I may have been inadvertently put at risk due to the energy used - do you mean that the rough sex was risky even in light of using condoms? 

2. You say that an undetectable viral load makes the risk of transmission barely above that of the normal population - I don't understand what you mean, can you explain?

3. You said you would be easy in recommending PEP- does this mean you would recommend PEP?

Sorry if I'm being more than a bit dumb  - the escort said we did nothing risky and that the sex was safe and that even if an accident did happen the fact that he produces no pre-cum, did not ejaculate and has an undetectable viral load makes risk minimal. He assured me that to the best of his knowledge no condoms failed (apparently it would be obvious to him).

I became a bit concerned as last night I had some bleeding so I started PEP this morning (18 hours after the incident), I lied at the clinic and said a condom tore to get the drugs (which I feel awful about) and they said it was low risk.

I also spoke to a councillor at the terrence Higgins trust and explained the incident (truthfully) and they said I have nothing to worry about?

I'm freaking out even though everyone says I have no need to be, i feel so bad about what I've done - the guilt and anxiety are killing me - should I stop PEP?

Am I high risk? I though sex with HIV positive people was fine as long as it was protected and safe?

Sorry to bother you again doc.

[Dr Sean Cummings]

Golly Marcus, you had a bit of a session didn't you! You've given rather a lot of detail and your questions are:-

1) Are any of the details above worrisome in terms of hiv infection?

Not really - all sounds a bit energetic and I'm not surprised you are sore - but it seems that the penetrative sex was protected and he is HIV positive with an undetectable viral load. The "energy" used may have inadvertently put you at risk. The evidence so far is that in HIV positive individuals who are otherwise well and with undetectable or very low viral loads that the risk of transfer is barely above that of the usual population.

2) Is the oral sex and anal sex detailed above a huge risk?

I've more or less answered this above - I think not.


3) Is saliva/urine in eye an HIV risk?

No

4) Would you recommend that I seek PEP?

Very individual question - I think the circumstances described are clear; he was an HIV positive person with an undetectable viral load and you used condoms. I think it might be best if you get concerned about these things to chat through HIV status BEFORE a 2 hour session. On balance, I would be easy about recommending/issuing PEP - I don't belive there is a signifcant HIV risk despite your description.


5) If you were me would you be concerned? Would you take PEP in my circumstances?

As per my answer in 4 above


6) Do I need an HIV test?

All sexually active adults with multiple partners/contact with random individulas/contact with sex workers should have HIV and STD testing as far as my opinion is concerned. You should also consider being immunised against Hepatitis A and B and also Human Papilloma Virus. In respect of this particular episode I don't think you need to rush to test.

best regards, Sean

[marcusshoren]

I should just mention that when I say a lot of urine got in my eyes I mean a lot - he urinated on my face - so it was a constant stream for maybe over a minute.

Apologies for being so graphic.