Is PEP for you? A case of wrong decisions.

Posted on June 24, 2015 by drtan
As the old saying goes “you aren’t an expert until you have had things go wrong”.
Our clinics deal with many patients with potential HIV exposures every day. Most are low risk events where all we need to do is to reassure the patient that his/her risk is low and follow up with a test for HIV and other STDs at the appropriate window period. Sometimes, we come across cases where the risk is high enough to warrant the use of PEP. Most of these patients take their pills diligently and “dodge the bullet” as they say.
Then there is the case of Mr. M. He was a young and successful executive in the aviation industry. He was also a proud gay man and absolutely not shy about his sexual orientation. He was smart, held a degree in aviation engineering and being an active member of the gay community, he was very knowledgeable about all things to do with HIV. He even volunteers with organisations to help spread HIV awareness.
Mr. M was also a regular patient of mine. He sees me regularly for HIV and STD screening and other minor health issues. One day, Mr. M came to see me at my clinic. He was out last night and met someone he really liked. One thing led to another and they ended up going back to his place. He used a condom but unfortunately, it broke.
“Do you know his status?” I asked Mr. M. “Yah, He told me he was positive. I suspected it right from the start! I really should have known!” He replied.
“OK. Don’t worry.” I said “But of course given that your partner is HIV positive and the condom broke and you were bottom, you are a candidate for HIV PEP. It’s been less than 24 hours so we really stand a good chance.”
“But doc,” added Mr. M “I also read that the risks are actually not that high. I saw him taking some tablets that he told me are for treating his HIV. I read that if he is treated the risk is not high. Also he pulled out immediately after the condom broke. He was inside for 5 seconds at the most and also did not cum. You really think I need PEP?”
“Being on HIV treatment reduces the risk by about 87%. Since he did not ejaculate the risk is also probably lower but there is really no good statistics for this.” I explained, “also, there is really no studies to tell us how much lower the risk is if he is in you for 5 seconds compared to let’s say 10 seconds or 1 minute. Honestly, you go and read any PEP guideline, in your kind of case, everybody will recommend you to take PEP.”
“I don’t know leh.” Mr. M continued “You know I volunteer at HIV testing places. I also see a lot of such cases and they are all negative what. I also read somewhere that the risk is actually less than 1%. It’s not the money you know. I just don’t want to take 1 month of medicines for nothing.”
“OK you really cannot look at it this way” I said, “Statistics for receptive unprotected anal sex puts the risk at anywhere between 0.6% and 30%. That is really significant. I am not trying to push you the drugs. But really your kind of situation is really dangerous.”
“You mind if I go and think about it? I want to call my friend also.” Mr. M said shortly before leaving the clinic not giving me a chance to say anything more.
The next time I saw him was 2 months later.
“How’s things going?” I asked casually as he sat down.
“Good good.” He replied.
“Any symptoms?” I asked.
“No. I feel completely normal.” He said.
“So no fever, no throat ulcers, no rash?” I asked.
“No, no, no. Completely normal” He replied.
“That’s great. Let’s do the Combo test OK? Just to make sure.” I said.
“Sure! That’s what I’m here for.” He replied.
I pricked his finger and placed a drop of blood on the test cassette. We started to chat casually about his work. I personally really like aeroplanes so we had a lot of chat about.
But out of the corner of my eye, I saw the positive line appearing on the HIV test cassette.
“You test is not good.” I said.
“Oh.” That was all he said. There was no anger, no surprise, no emotional outburst. He looked very sad and very lost.
We had a long discussion about HIV. He remained a patient at my clinic and I am currently treating his HIV infection. I am glad to say he is doing well. His viral load is undetectable and his CD4 cell count is very healthy. He will live a long, productive and healthy life. Despite what, in hindsight, was a rather poor decision.
Learning points:
–          Not all cases are straightforward. Sometimes it is difficult to really ascertain your risk. Have a detailed discussion with your doctor about the pros and cons of HIV PEP for your particular exposure. Read up on PEP guidelines published by the WHO, US CDC, BHIVA and ASHM.
–          If you feel the doctor is pushy, don’t be afraid to seek a second opinion.
–          The decision to start PEP is never easy. Make sure you have a detailed and frank discussion with your doctor first. Know all the risks and benefits.
For more information on PEP at our clinics, CLICK HERE.