Question
PEP – why do some doctors wrongly prescribe PEP
20 November 2021. Related: All topics, HIV transmission, PEP/PEPSE, Sexual health.
Hi, I have a few questions about PEP – even though I know you are mainly about HIV treatment. Please help if you can.
Last Saturday (13 Nov) I paid a women to have sex with me. We used the condom provided by the sex worker. I didn’t pay much attention to the quality of condom at that time and the next day, having doubt on the condition of condom, I consulted a doctor. Also I continued the intercourse till 30 seconds after ejaculation and the protection did not slip out after 30 seconds, but this caused more paranoia.
The doctor recommended PEP with TDF 300 mg, emitricitabine 200mg, efivarenz 600mg.
I took the first dose after 20 hours of suspected exposure and could not tolerate it as I was feeling drowsy, stomach ache and problem in balancing myself, so I stopped after that. Then I had a gap of 3 days till I could consult another doctor as the previous doctor insisted on taking the drug which I couldn’t tolerate.
I consulted another doctor and he recommended TDF 300 mg, emitricitabine 200mg, dolutegravir 50 mg and suggested to continue PEP. After 3 days gap I took new medicine and did not face side-effects. I have taken 2 more new doses till now without gap.
But I was again doubtful about effectiveness of PEP after 3 days gap, so I consulted another doctor from school of tropical medicine in our state, even she recommended to continue PEP saying DTG does not have so much resistance.
All 3 doctors are specialists in Infectious diseases. But Im still doubtful that if PEP fails and if the test to be done 3 months after PEP shows +ve, the virus might develop resistance by then and I might be forced to take other medicines with side effects for lifetime, as I\’ve heard HIV +ve people need to take medicines for lifetime.
I’m so worried that the whole day I’ve just googled for answers but failed to get any. Could you please advice what should be done with a good reason ? Would be very much thankful for your suggestions on this.
Answer
Hi there
You are right that the i-base service is really about HIV treatment. This is because we have already posted information online about PEP.
https://i-base.info/pep-and-prep
I will answer this question online though because we get many questions like this. It includes situation when doctors are not using latest guidelines. The information you were given by all three doctors was wrong. PEP would not have been used in the UK.
Firstly, you used a condom throughout. This means that you were not at risk for HIV. The doctors should have told you this. Unless there is a real risk of HIV, PEP should not be given.
Secondly, using efavirenz for PEP has never been recommended in the UK. Efavirenz has a high risk of difficult side effects during the first few weeks, so is not a good drug for PEP. There have also been reports of serious side effects to the liver when used by people who are HIV negative. The UK uses raltegravir as the third drug. Dolutegravir is also okay but not by anyone who might become pregnant during the month using PEP.
Thirdly, going on and off PEP for three days will have made future use unlikely to work. This is even if you had been at risk.
Here are links to the 2021 UK guidelines. The summary on pages 2-3 supportes the information I gave above about you not needing PEP.
https://www.bhiva.org/PEP-guidelines (download page)
https://www.bhiva.org/file/6183b6aa93a4e/PEP-guidelines.pdf (PDF)
It really makes little difference either way. You are obsessing about tiny risks and whatever you decide will be okay :)
I totally understand that i-base Q&A is solely on HIV treatment and not PEP.
Just wanted to know your thoughts on it if it fine with you. Also to mention that I myself will be responsible for whatever decision I take :)
Hi, Big thanks for your reply but I guess my query got misunderstood a little. My guess might be wrong also but still wanted to clarify 2 points below :
1. I did use the condom throughout but I had the doubt that the condom was broken, maybe that’s why the doctors recommended pep.
2. I was off on pep for 3 days just once after the 1st dose of TDF, Emtricitabine and Efavirenz, after which there is no more gap.
Requesting your suggestions on what should be the better option i.e. whether to continue further with pep or not ? Maybe a good reason would help pacify my much troubled mind.
Would be really very much grateful to you for your reply on this. I’m writing this to you as I’m still in doubt after consulting 3 doctors and too much research for a week.
What I’m thinking now is that continuing with PEP may still have a chance of getting rid of HIV that I might be exposed to by possible condom break, even after a 3 day gap. But if I test positive even after PEP, the virus might develop resistance.
On the other hand if I discontinue PEP, then I’ll surely become positive if I’m exposed to hiv by possible condom break. The advantage might be that the virus will not develop resistance but still doubtful on that as I’ve taken 3 continuous doses of TDF/Emtricitabine/DTG after the 3 day gap.
I’m confused between the above 2 options :(
I’ve consulted the NACO counselling in India also but they were not able to answer some of my questions which left me unconvinced with them also.