Refused PEP - don't know why.

[jacobsquestion]

Dear Doctor,

I asked you a question last year and you were nice enough to answer.  I have another, and this one is making me scared.  I met someone through a personal ad (a man - I am a gay man as well).  We had two dates.  We kissed on the first date (which I know is zero risk).  On the second date, I asked him his status and if he has any STDs he said no.  I asked him again later in the night and he said, I am fine (I always ask my partners every time)  We made out again and I gave him oral sex - NOT to ejaculation, but I did taste precum.  He did the same.  When we were done he said that he was indeed positive and he said he was sorry.  I was so angry I run out of his place and drove to two hospitals for PEP and was denied both times.  These hospitals were both in a major city.  They said the risk was so low that my chance were beyond remote.  I don't by it.  I begged and pleaded but each hospital refused flat out.   Now I have been freaking out for 24 hours and can't sleep, eat or even drive.

What are my chances that I am negative?
What is your opinion on PRECUM and HIV exposure?
Should I try another hospital - it has been 14 hours since the exposure

The doctor, a ID specialist at one of the hospitals said if he gave pep for every exposure like mine, even though they guy was positive, a large percentage of the gay and straight world would be on pep.  He told me to relax (gave me ativan) and said to get tested if I was worried, but "don't loose sleep over this."

I know you typically don't answer oral sex questions, but since this was a confirmed exposure I thought it may apply.

I would love your opinion.

[H. Hunter Handsfield, M.D.]

Among gay men, the most common circumstance for PEP is unprotected anal sex with a known infected partner, or with a partner at especially high risk, such as an anonymous bath house partner.  Ditto for sharing injection equipment with an injection drug user.  Oral sex is generally too low risk, because the chance of a serious (even life-threatening) side effect from treatment is higher than the risk of HIV transmission.

[jacobsquestion]

Just a question, when does one get pep?

[jacobsquestion]

Thanks for your response. I think I overreacted a bit, as the ID doctor at the hospital said I could beg as much I wanted but he wasn't going to give me PEP as  it was medically not needed and rather unethic for him to do it based on my oral without ejac risk.

I will be actually doing both of your suggestions.  Waiting until I am in a monogamous LTR with another men and test 3 months out and see a therapist.  I have a huge fear of this disease dispite the fact that I only have had protected sex and the occasional oral sex without ejaculation.  It's not normal to have these worries based on the risks - I guess I have a better chance of getting hit by a lightening bolt or meteor.

I do wish, however, that people would be honest with their STD illnesses and not lie.  It just makes me thankful that I have never had unprotected anal sex in my life!  

Thanks for being blunt....I appreciate that.

[monkeyflower]

When you have an actual risk.

[H. Hunter Handsfield, M.D.]

Each health care institution has its own policies on PEP, generally based on rcommendations of the local or state health department.  I agree with the medical advice you have had from two different hospitals and your ID specialist; the exposure you describe does not warrant PEP, and it would not be given if you had come to my health department or to Madison Clinic, the main HIV/AIDS clinic in Seattle.  'Don't lose sleep over this' is exactly my advice.

I don't know where you came to think that I 'typically don't answer oral sex questions'.  I answer them all the time, with the consistent advice that oral sex is very low risk for HIV infection.

My further advice is that if you're going to get this freaked out over such exposures, you have only 2 realistic choices:  1) Forego all sex with other men until/unless you forge a permanent, mutually monogamous relationship, with no sex until you both have been tested and negative 3 months after your last sexual exposures with anyone else.  Or 2) seek counseling to help you find a balance between some reasonable (low) level of risk and your sexual needs.  At the moment, you clearly cannot handle the stress that comes with anything other than 100% sexual safety, and that is not psychologically normal or healthy.   I suggest this out of compassion, not criticism.

Best wishes--  HHH, MD