Concerns over PEP after brief condom breakage.

[ben485]

Hello Doctor,

Condom broke during vaginal intercourse with a CSW in Malaysia of unknown status. Most likely had unprotected intercourse for approx 2 - 3 mins before realising broken condom and then immediately stopped. Prescribed PEP - [Tenvir-Em (300mg) & Strocrin (efavirenz - 600mg) at 14 hours post incident.

2. Is Tenvir-EM taken in the Morning and Strocrin in the Night before sleeping an effective, and internationally recognized method of PEP, and is it effective in inhibiting HIV seroconversion? How effective would this combo be, administered 14 hours post exposure?

3. My biggest concern - for 2 weeks, I kept my PEP meds in my laptop bag in the front pocket. It says on the meds that they should not be exposed to direct sunlight or moisture - which they were not. But what I am worried about is the fact that I am sure that at time the bottles/packaging in my bag, may have been in the boot of my car for a maybe a few hours at a temperature higher than 30 degrees. On the PEP meds it says that these medications need to be stored below 30 degrees - my question is that if these meds have been exposed a few times to higher temperatures - would it mean that these tablets are rendered useless as effective PEP? I'm now on the 27th day of PEP, coming close to an end. I called up my doctor a week earlier, and he said that there's nothing really to worry about, as the tablets were in their original bottle/packaging, inside the laptop bag - therefore the temperature change wouldn't have been drastic inside the bottle, and hence the tablets wouldn't have been compromised. Would you agree with this assessment? Is there any way I can find out if my medication was compromised?

4. Other experts I've asked about my risk, say that following a momentary condom breakage, for an insertive partner on PEP - the risk is even lower than 0.01% for me to end up positive. Would you agree with this assessment?

Thanks

[Edward W Hook, MD]

This is a silly question.  Basically, you are asking if PEP, a therapy proved to reduce the risk for acquiring HIV would lower your risk of getting HIV if exposed.  The answer is yes.  Precisely how much is hard to say, in particualry becasue your risk was so low tostart with.  

This will end this thread.  EWH

[ben485]

Thank you very much sir. In conclusion, given the fact that you said that if I were your patient, that you wouldn't have warranted PEP at all, given my low risk exposure - but now that I have almost completed it, would you say that my risk of being infected drops even lower now?

This is my final question and I will no longer ask anymore after this sir. Thank you.

[Edward W Hook, MD]

The general statments about PEP are that the sooner it is started, the better it works and there is no reason to start it later than 72 hours following exposure.  These are the best statements that can be made because of a number of scientific reasons, as well as the fact that most people who take PEP, like you, are not in the group for whom the therapy if recommended (i.e. person KNOWN to have been exposed to an HIV infected person).  EWH

[ben485]

Thank you for your patience doctor. I was merely trying to clarify the effectivity of PEP once started before the 24 hour mark. Also a quick clarification on No.2 - "I am not positive but I think not" as in yes it would drop the efficacy of PEP, or not most likely it would not?.

[Edward W Hook, MD]

You are asking "what if" questions at a time when there in nothing you can do to change things.  This is not a good use of your time or mine..  Your exposure was low risk to start with and were you my patient I would not have recommended PEP at all.  You got it however and have taken it for nearly 4 weeks,  Time to stop with the "what ifs" and move forward with your doctor's gidance in testing.   I will briefly answer these questions but no more.  

1. Have you seen an insertive condom break like mine, on PEP, end up positive before?
No.

2. I am unable to swallow tablets due to a phobia since I was a child. I asked some other experts on whether chewing and then swallowing the tablet with water would lower the efficacy of PEP, and was told that it would not. Would this be correct?
I am not positve but I think not.

3. Have you heard about the Tenvir-EM (Truvada) and Stocrin (Efivarenz) combo before? Is this less effective than other PEP combos?
There are many PEP regimens.  This is not one I have used.

4. With PEP being started 14 hours post exposure, what is the percentage of success against seroconversion?
There are no data of this sort, providing results on a hour by hour basis.

EWH

[ben485]

Thank you Dr. Hook.

Just a few quick follow-ups:

1. Have you seen an insertive condom break like mine, on PEP, end up positive before?
2. I am unable to swallow tablets due to a phobia since I was a child. I asked some other experts on whether chewing and then swallowing the tablet with water would lower the efficacy of PEP, and was told that it would not. Would this be correct?
3. Have you heard about the Tenvir-EM (Truvada) and Stocrin (Efivarenz) combo before? Is this less effective than other PEP combos?
4. With PEP being started 14 hours post exposure, what is the percentage of success against seroconversion?

Thank you.

[Edward W Hook, MD]

Welcome to the Forum. when a person starts PEP, they should have a relationship with the physician who prescribed it and work with him/her to address any concerns that might come up. These are questions for you  and your doctor.  I will provide brief answers but I do not want to get between you and your doctor.

As for your questions:
2.  Typically we give antiretroviral therapy at night, before going to bed.  This is done to minimize side effects. There should be no problem with you taking the medication in the manner you describe.  The medications you have been provided should be highly effective as PEP.

3.  I agree with your doctor.  It is unlikely that the temperatures your meds encountered damaged them.  Typically the recommendations given by drug companies about their medications are broad generalizations for which there is substantial lee-way.  Further, I should point out that at this time, there is nothing you can do about the meds you have already taken- what's done is done  I would just move forward

4.  The figure you list is correct. IF your partner had HIV (and you do not know that she did- statistically she did not), then your risk for infection from an unprotected exposure is, on average, between 1 in 1000 and 1 in 2000.  

I hope this helps.  I suspect you have little to worry about at this time. EWH