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PEP: an ethical question?
Oct 12, 2007

First, great site! 2 days ago, I had a sexual encounter with an ex-boyfriend. After sex, we talked and told me that he got HIV from an unfaithful ex (sadly, the 3rd person in a "monogamous" relationship I know who got infected through their partners, scary!!) Anyhow, I question him and found out that it's been about a year and half since the positive test and that he is not on any meds because of healthy labs, I assume. He is a healthcare professionnal so I assume responsible. My question to you is that even with a rationale head, I was really concerned about my risk of getting infected. The source of my concerns; he is a HUGE precumer and he is not on any meds. There was no anal sex but some fooling and poking around there with possible slight insertion (and I mean maybe the tip of his penis went in a bit, not more) and plenty of oral sex. I went to see my doc and told him the same thing I'm telling you and he decided to put me on PEP (Truvada+Lexiva) for a month. 1) Do you think PEP was warranted in this situation? I won't think of less of my doc if you think not. I'm just really wondering. Definitely anxious on being on these meds for a month 2)How do you as doctors, make a decision on wether PEP is warranted or not. Apart from the obvious no risk at all, when there is even a slight risk or low risk, aren't you ethically obligated to prescribed PEP? How do you deal with this? Thanks again for your good work Stephan

Response from Dr. Wohl

Dear Stephan,

I do agree with your doc's actions. You did not practice safe sex, your partner is HIV infected (and not on meds) and there was potential for infectious fluid to have come in contact with the thin mucus membranes of your anus/rectum that could lead to infection. As you presumably do not want to become HIV infected, this was a prudent decision.

The choice of meds was also fine.

The decision about whether to start PEP or not is largely based on the severity of the exposure. Exposures that are very minimal and carry a very low risk of transmission do not warrant PEP. This is because the risk of serious side effects of the meds vastly outweigh the risk of infection. In cases where there is a low risk but the individual is freaking out with worry, many clinicians will prescribe PEP. Clearly, with exposures that carry a higher risk, the enthusiasm for prescribing PEP increases.


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