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Does brief dipping warrant PEP ?

Question: 

Hello,

Today I met a guy online and we agreed we would meet for sex (I'm also male) Even before meeting, I inisted that we would be using condoms. At some point, after we touched and kissed, he sat on me, and rubbed my penis between his buttcheeks. I told him again, if he wanted to go ahead, that we would need a condom. He told me he was just teasing, and that there would be no actual penetration. Yet at some point I did feel my penis head stretching his anus, maybe even penetrating him with just the head, I can't be sure. I asked him to stop immediately and he did.

Later on, he was moving his penis near my anus, he was saying again : "I'm just teasing, I'm not penetrating". Yet at some point I definitely felt his penis head stretching my anus. That's when I said : "Ok, this is too much, either put on a condom or go". He finally put on the condom.

I'd like to know what risk there is for HIV transmission in these circumstances. I'd also like to know if such an exposure would warrant PEP.

Also, as a side note, I would like to mention how I'm sick and tired that even though I am always extremely clear about wanting to have protected sex, guys often seem to try, at some point, either to penetrate me without a condom or have me penetrate them without a condom. It's like the pressure of minimizing transmission risks always fall on my shoulders only, and I have to be careful not to have too much fun, because I need to stay alert in case the guy I'm with tries doing something to me without protection. I find this to be an utter lack of respect.

Thank you for your time.

Answer: 

Hello and thank you for your inquiry.

We understand that you would like a risk assessment for an incident in which your penis may have partially penetrated another guy's anus, and his penis partially penetrated yours. The other guy's HIV status in unknown and you are also wondering if PEP would be warranted in this situation.

Unprotected anal sex is automatically classified as a High Risk activity for transmission of HIV, regardless of depth or duration of penetration.

When it comes to PEP, the guidelines are more nuanced. It is important to note that PEP drugs need to start working against HIV as soon as possible after the virus enters the body, meaning that PEP should be started as soon as possible after a potential exposure and not more than 72 hours afterwards. (1) While it would not be beneficial for you to seek PEP now for this particular event, we can still explore whether it would be worthwhile to do so if you have a similar incident in the future.

In 2017, The British Columbia Centre for Excellence in HIV/AIDS published HIV Post-Exposure Prophylaxis (PEP) Guidelines, intended for healthcare providers dealing with patients such as yourself who have potentially had a high risk exposure to HIV. Based on theses guidelines, risk assessment is divided into three categories:

  1. Assessment of exposed person (you). (2) This assessment would include a baseline HIV test, probably some questions about your own sexual history and an inquiry into the potential presence of any other STI's (gonorrhea, chlamydia, syphilis)

  2. Assessment of event/exposure type. (2). Some factors which can influence the risk of transmission from sexual exposures include:

    -The presence of a sexually transmitted infection (especially genital ulcer disease) in either the source or the exposed individual

    -Circumcision status for insertive male partners

    -Condom use

    -Degree of physical injury (e.g. mucosal or skin break) associated with the sexual act

  3. Assessment of the source person. (2) In a case where the source person is known, but their HIV status is unknown, they would be contacted for an interview and point-of care HIV testing if available.

After this process, if the degree of risk is calculated to be significant, PEP will be initiated and must be adhered to for a 28 day course. With the particular details you have provided, I suspect that PEP would not have been indicated based on these guidelines, but only a health care professional can determine this definitively.

Your use of condoms is commendable so keep that up. I agree that for a guy to try to have unprotected sex with you after you have explicitly stated your intention to use a condom is at the very least a lack of respect. You are wise to stay fully alert unless you are with a partner you known and trust. As a man who has sex with other men, you might qualify for Pre-Exposure Prophylaxis (PrEP) to further reduce your risk. Discuss this with a doctor if it interests you.

Recommendation: Refer to a health care professional for HIV testing. Fourth-generation HIV tests can detect HIV infection in 50% of people by 18 days after infection; 95% of people by 34 days after infection; and 99% of people by one and a half months after infection. These tests have a sensitivity of about 99.9%.

Regards, AIDS Vancouver Helpline Volunteer, Dyson