CSW Unprotected Vaginal Intercourse

Hi doctor,
First of all thank you for a great forum with plenty of useful information. Now to my dilemma. I engaged in unprotected vaginal intercourse this morning with a London escort and am obviously now regretting this. Having spoken to the woman in question, aged 40, she has assured me she gets tested on a regular basis and is healthy. She tells me she was last tested 3 months ago for HIV and all clear, and does not usually engage in unprotected intercourse. Obviously the latter claim may be a little dubious. She tells me she is due for testing on the 11th of this month. Me on the otherhand, have been tested 3 months ago and am HIV negative (Insti Rapid test), but uncircumcised.
Her claims have comforted me a little, but regardless I am still feeling rather anxious. I am asking what action should be taken and whether PEP is necessary. I understand a one off encounter such as this is relatively low risk from reading other posts, but any guidance would be greatly appreciated.

Many Thanks and a Happy New Year

[Edward W Hook, MD]

Welcome to our Forum.  I'll try to provide you with some information which I hope you will find helpful.  

For better or worse, I am sure that if you want PEP you can get it.  Decisions about PEP are a personal decision in which one should consider the likelihood that infection will occur, the likelihood of drug side effects, one's personal anxiety and the cost of the drugs (expensive, typically in the neighborhood of $1000).   The risk from the exposure you describe is low and If you were my patient, while the choice would be yours, I would not encourage PEP.  In general few commercial sex workers have HIV, and your partner's reassurances make the risk lower than average. further, even if she did happen to be infected, the risk of becoming infected following a single unprotected encounter is less than 1 in 1,000.  Thus since the probability that your partner had HIV is 1% or less, on average, and the probability of infection is, on average less than 1 in 100,000 you mathematical risk of infection is about 1 in 100,000 or less.  On the other hand, side effects of PEP are sufficiently high that less than 40% of persons who start PEP finish it.  As I said, I would not encourage PEP in your case but it is up to you.  If you could get your partner tested sooner than later and her test was negative, your risk of infection would be still lower and too low to recommend PEP at all.

I hope these comments are helpful.  If you choose to try to find someone to provide you with PEP, the PEPE should be started within 72 hours of exposure and please hold the person who prescribes the PEP accountable for all that goes with it (i.e. follow-up, answering your questions, etc).  EWH

[bassmanx]

Thank you very much Doctor Hook for your reply. You have somewhat allayed my anxiety. Just a quick question about the PEP. Are side effects experienced in all subjects? Would it be correct to infer that the low rates of completion point to these side effects being extremely severe?

[bassmanx]

Again, many thanks

[Edward W Hook, MD]

Both the frequency and severity of sie effects due to PEP vary from person to person.  There is no way to predict who will or will not have side effects, nor how severe they will be.  EWH

[bassmanx]

Thanks for all your help doctor. Well today I began the course of PEP. Fingers crossed I will be able to get through the course. Assuming I do complete it successfully, how would my odds of avoiding infection look? I'm sorry but the anxiety is still there.
Also, the doctor did say a duo HIV test immediately after the course of PEP would probably be enough to determine my status. Would you agree?

I will post the results of my test at the end of the month, hoping they will be all fine. This will be my final question. Thank you so much.

[Edward W Hook, MD]

Your mathematical risk of getting HIV to start with, as I mentioned was less than 1 in 100,000.  Taking PEP would decrease the risk at least 90T making the risk now less than 1 in a million.

I would not expect a DUO test immediately after  completion of PEP to tell the whole story.  I woul suggest waiting until at least 4 weeks following completion of th medication.  EWH

[bassmanx]

Hello again Dr.
I would like to thank you again for all the information you have provided. I hope this post is not excessive per comm guidelines.
At the moment I'm a little confused about the situation as regards post pep testing. I have delayed testing due to the information you have given, but have also received opinions that a test shortly following PEP is quite reassuring, if not definitive. From the information i have received, the DUO in particular would detect the p24 antigen after a month post exposure, therefore whilst pep would delay antibodies, if infection did occur due to pep failure, the p24 antigen would still be detectable. Would you agree?
Of course i do intend to follow testing as per recommended guidelines, but your thought on this would be much appreciated even from an academic perspective.

Many Thanks

[Edward W Hook, MD]

You should be discussing this with your doctor.  As you point out, the recommendations vary and we try not to get between our clients and their doctors in such situations.  While a DUO result would be reassuring that is not the recommended assessment which is to test at least three months following completion of PEP.  As you know, I feel comfortable in most instances at four weeks.

the thread is now over. EWH

[bassmanx]

Thank you for your time