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PEP (Truvada & Dolutegravir)

Sep 24, 2017

Hello - I had a question regarding PEP treatment after possible exposure.

Late Saturday night I decided to visit a bathhouse and had unprotected anal sex with an african american male (that claimed to be HIV neg) where I was the bottom - right after I went home looked up on the internet about PEP and went to emergency room where I was prescribed both Truvada (200-300mg) and Dolutegravir (5oMG) and had taken first does with 5 hours of incident. -- this is a one time incident meaning that I do not regularly sleep with men let alone in high risk situations , which I do not plan on doing again - more of an exploratory mission that went horribly wrong (or at least potentially)

Am I at high risk for contracting HIV? Should I feel confident that PEP will work if needed? Are you able to just take PEP for three weeks (21 days) or is it absolutely essential to take 28 days? Should i have been prescribed three pills instead of two? What is the earliest HIV test available?

Response from Dr. Young

Hello and thanks for posting.

First off, contrary to a popular misconception, any single sexual exposure isn't high risk, it's low risk for HIV. For example, in this well done study among heterosexuals, the estimated "per coital" transmission risk was estimated to be 1-2 in 1000; and in a different analysis, the per coital risk for condomless anal intercourse in the range of 1 in 100. There is significant variability in the point estimate of the risk, and many factors affect risk. Most importantly, viral load dramatically influences risk and there have been no documented cases of HIV transmission with viral loads less than 1500, and none among over 75,000 documented instances of condomless sex when the positive partner had an undetectable viral load in the Partner study and Opposites Attract study.

PEP is recommended to be taken for 28, not 21 days, and there is little clinical science to tell us if three instead of four weeks of modern PEP is effective. The first dose of PEP should be (as you did) within 72 hours of the exposure.

It's my strong opinion that if your sexual partner was on HIV treatment and virologically suppressed, or if you were taking (and adherent to) HIV pre-exposure prophylaxis (PrEP), that PEP would not be indicated, nor add anything to risk reduction.

The regimen that you've been prescribed (Truvada + Tivicay) is two pills taken (together is perfectly fine) once-daily.

HIV testing is recommended before and at 1- and 3-months after the exposure.

Should you have ongoing risk of HIV exposures, I'd suggest considering PrEP. It's been shown to be very effective in preventing HIV infection in diverse settings- including our own APEX Family Medicine clinic in Denver, Colorado where we have upwards of thousands of person-years of PrEP use without a single case of HIV transmission.

I hope that's helpful. BY



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