Anonymous
Hello, here is my case: I had sex with another man I met online. Before meeting we talked about our safe sex habits and we both said that we never practice unsafe sex (for what it’s worth this was very clear in his profile by the way). He brought condoms and lube the first time we met which is always a great sign. We met a second time a month or two later. Again before meeting he asked if I had condoms at home (again great). This second time unfortunately the condom broke towards the end (I check often to make sure it is fine), and I only noted when we were finished. I had an exposure of about 2/3 minutes at the most. I’m top only but uncircumcised.
I totally panicked even though I don’t honestly have any reason to think that my partner engages in risky behaviors as he seemed concerned about bringing and using condoms (but he is bottom only and accidents with condoms happen). He was also upset but he did not panic as much as I did which made me even scarier. We talked about the incident and he said that he got tested about 2 months before and that everything was fine and that he hadn’t been with anyone since (but who knows right?).
After he left I decided to go to A&E and get PEP. The doctor prescribed Truvada+Ralgetravir (all STD baseline tests were negative) and I took the first dose about 8 hours after the exposure. I took all doses exactly as prescribed – or so I thought - for the full 28 days. As it happens I had to visit relatives so I took medication for the 10 days I was with them and hid it in my bag (this was between days 6 and 16 of PEP). The morning pills were easy to take (2 pills) because nobody was home but the evening pill was harder so I sometimes kept it in my pocket and then went to the bathroom when it was time to take it. As it happens a few weeks later (after completing the course of PEP) when I returned to my family’s house I found a Ralgetravir pill in one of my jeans and I panicked. I could swear I didn’t miss any dose but now I’m not sure whether they gave me one extra pill of if I missed one. Anyway, I’m absolutely sure I took every other pill as prescribed (I’ve been really stressed and not sleeping well so I may have missed that one).
2 weeks after completing PEP (and 6 weeks after the exposure) I went back to the clinic and got an insti hiv1/hiv2 rapid test which was negative. I was quite happy with the outcome as I read that the test is very sensitive and detects both Igg and Igm antibodies and is now therefore considered a 3rd generation test which is useful in detecting early seroconversion. The New York State Department of Health AIDS Institute has a test comparison sheet where it says that the window period for the INSTI is 4-6 weeks. So here are my questions
1) would that 1 Ralgetravir pill I may have eventually missed lower the efficacy of PEP? I hear that some people take truvada only as PEP and I didn’t miss any of those. I also read that experts aim for a 95% adherence rate but I’m not sure whether that applies to PEP.
2) What can I take from this 6 week negative result? Have you ever seen a case where someone who took PEP and got this result would later seroconvert?
3) I’ve read a lot about delayed seroconversion after PEP. The revised CDC guidelines ask for testing up to 3 months post-exposure (not post-pep) and the revised UK guidelines ask for tests 4-6 weeks post PEP (which is basically the same). The experts at thebody.com say that delayed seroconversion is a myth. I have searched the academic journals and found reports of older cases (1990s) where the timing of testing was not always clear and a report of a monkey in an animal study. I also found an interesting report reviewing seroconversion cases among health care workers. Though not all cases were offered PEP there didn’t seem to be a noticeable difference in the time of confirmation of seroconversion between PEP and non-PEP takers. What is your view on this?
I’m still waiting to go back for my 12 week test. In the meantime, I managed to talk to my partner through the dating site to tell him that I got tested. He replied saying that the got tested too and was fine. I know I should probably be happy with this but I’m totally paranoid and that is only a modest comfort for me.

Many thanks for your help!
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Anonymous
Hi there, and thanks a lot for contacting the AIDS Vancouver Helpline for your HIV/AIDS related health information. It seems you're concerned about the possibility of HIV transmitting during an encounter, and the accuracy of some tests you've had since finishing a PEP regimen. We're happy to answer your question for you.

First off, it's great that you decided to seek out PEP, as if the condom breaks during sex it is indeed considered a high risk situation, meaning that most transmissions occur due to activities such as these. This doesn't mean transmission occurred in your case.

As for your question about how potentially missing a dose of PEP may effective its effectiveness, we'd say this is probably a question for your healthcare provider. It's great you adhered so strictly to the regimen as indeed, adherence to PEP regimens is extremely important for them to be effective.

Canadian guidelines still state that PEP extends the window period of tests for as long as you take it. So if you had an exposure on day 1 and took it for 30 days, your "exposure" date then becomes the date you completed the PEP regimen. You then need to wait for the window period of the test in question for it to be considered accurate. So for the RAPID test (the test you've had), you'd need to wait 12 weeks (or 3 months) since the date you finished PEP for it to show your status conclusively. The test you had 2 weeks after finishing PEP was a bit soon to show your status accurately. It may be that the CDC and UK guidelines differ on this. If you have questions about these potentially inconsistent guidelines, we'd encourage you to speak with a healthcare provider about them where you live.

Thanks for contacting the AIDS Vancouver Helpline with your questions, we hope they have been answered fully.

Trevor

AIDS Vancouver Helpline/Online

helpline.aidsvancouver.org
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