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Condom Break and PEP
Oct 11, 2009

Hello my one and only Dr. Bob,

2 weeks ago I had an episode of condom break during insertive anal intercourse with another guy in my college. I knew him for a while now and before sex he told me that he had tested negative 3-4 months ago and he hadnt been unsafe since then. The condom broke during penetration after we changed positions. As soon as I realized I pulled out and I was inside him for maybe 5-10 seconds. After removing condom, we then continued with mutual masturbation. After this, again he insisted that he is negative and hes been safe.

Immediately after this, I rushed to the ER and the doctor put me on Combivir which I took my first dose at around 6 hours. He mentioned that my risk in low (6.5 in 10000) and he would not recommend PEP but since I asked for it directly he will give it to me anyways. He also mentioned that he is not giving me a PI since he believes that combivir alone should be enough.

3 days later, and based on your recommendations in archives, I met with HIV specialist and he insisted that I finish combivir even though the risk is not big. Also, I specifically asked for a 3-drug regime by adding a PI and he also refused to do so. Now my questions are: 1- Ive read many times that the majority of condom breaks do not result in HIV transmission. Given the brief nature of my exposure and PEP, how would you asses my infection risk? 2- Would you recommend PEP in my situation? 3-Is 2-drug therapy going to be effective? Its now 14 days after my incident, do you recommend to see a third doctor to change my plan to a 3-drug regime? 4-Ive read papers suggesting that combivir alone will result in resistance after a while. In case of a possible infection, is there a chance of resistance development due to combivir therapy for only 28 days of PEP?

Thank you for your time. H.S.R. from Canada

Response from Dr. Frascino

Hello H.S.R. from Canada,

Condom failure during anal sex does place you at some degree of risk for STDs, including HIV; however, your exposure was extremely brief (5-10 seconds). The statistical estimate you quote (6.5 per 10,000 exposures) refers to unprotected insertive anal sex with a partner confirmed to be HIV infected. Your estimated statistical risk would be less, because we do not know the HIV status of your bedmate (even though he claims to be negative). PEP would not be recommended for this limited potential exposure.

To specifically address your questions:

1. Extremely low.

No.

3. No one can predict whether PEP will be effective or not. Even when appropriately prescribed and begun immediately after a a significant HIV exposure there are still PEP failures. Yours truly is an example of that! I would not have recommended PEP for your level of potential exposure. Consequently I certainly would not advocate for adding a third drug to your regimen.

4. No. Combiver is not my first choice for a PEP regimen; however, using it for 28 days will not cause drug resistance.

Good luck.

Dr. Bob



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