Truvada missed doses and possible exposure

[Lex]

I have scoured the internet for Truvada or HIV hotlines available 24hours or on weekends and it seems it’s been a bust so I’m hoping you guys can help me.  I apologize if this isn’t the right forum.

I am fairly new to anal sex and have found condoms to hurt me as a receptive partner even with lots of lube. Maybe from a lack of experience. I am not very sexually active but I decided to go to an infectious disease doctor to get put on truvada and I’ve been on it since February. I’ve been taking it daily up until very recently. I’ve had an issue with my pharmacy that caused a delay in getting my prescription so for about a week, I’ve been taking the pill every other day to try to extend my current bottle. I took a pill Wednesday night at bedtime and skipped Thursday night. Friday I got my 30 day refill so I am back on a daily schedule. Friday night, I had a sexual encounter with someone I have known briefly. We talked beforehand and he believed he was STD free. Since I don’t know him well, I asked him to wear a condom anyways but it was extremely painful. In the heat of the moment and knowing I'm on Truvada, I allowed him to go bareback. He ejaculated inside me. When he left, I went to take my bedtime medications, including Truvada, and it struck me how this was the first pill I’ve taken in 48 hours. This got me to thinking and I would like to ask advice:

1. I know Truvada is highly effective even at just 4 days a week but how long does it stay in your system? After 48 hours, was my system basically Truvada free and I had no protection?

2. I know Truvada used to be given as PEP alone. I took Truvada less than a hour after the potential exposure and now that I have my month supply, will be taking it daily for the next month. Would that be efficient for a PEP treatment in this scenario? Since I am within the 72 hour window, should I seek out the 3rd anti-viral medicine included in the current PEP regiment?

I see my infectious disease doctor in about 3 weeks for my PrEP 3 month testing. She also does a full STD screening too. She has told me the blood test she does can detect HIV as early as 2 weeks from infection (unless I misunderstood) so I should know fairly soon. I am just worried that the few missed doses this week may have been a huge mistake.

Thanks in advance for all advice.

[Jim Allen]

Hi

So if part of your safer sex plan is having unprotected intercourse in part based on someone's last test results its a sure way to catch HIV and/or other STI's.

Anyhow as for the Truvada as PrEP you are on, it takes time to build up the levels required in the tissue to provide the high level of protection PrEP offers. That said it does require following the dosing to maintain that high level of protection in your system and tissue, so having "gaps" would or could reduce the overall level of protection offered.

If you are thinking about switching to PEP than make sure to do this as soon as possible no later than 48 -72 hours post exposure. The decision is up to you and your Doc at the end of the day.

Jim

[Jim Allen]

I moved your thread to "How Can I Prevent HIV" so others might chime in on this.
Just do stay within this section of the forum.

Jim

[Lex]

So if part of your safer sex plan is having unprotected intercourse in part based on someone's last test results its a sure way to catch HIV and/or other STI's.

My safe sex plan is to be on Truvada, talk to my sexual partners about their statuses, and use condoms as often as possible. Last night, condoms were used initially but removed during sex. In the moment, I thought it would be fine for HIV prevention since I am currently on PrEP. The recent missed doses is what is given me concern. I have missed approximately 3 doses in the last 7 or 8 days, typically on a day on day off pattern until my insurance was fixed.

[/quote] If you are thinking about switching to PEP than make sure to do this within the 48-72 hours post exposure and the decision is up to you and your Doc at the end of the day. [/quote]

I am considering switching but I am wondering if Truvada alone for the next 30 days is sufficient. I feel I would have had at least some medicine in my system from almost 2 months of daily use. And after the 48 hour gap, I did take truvada less than a hour after potential exposure.

Do you have any kind of hotline I can call that would be available 24 hours or on weekends?

[Jim Allen]

The safer sex part of it, well I guess you already know what I think about that part of your plan. Enough said.

Look if you only missed 3 doses in the last 8 days but have been taking the Truvada as PrEP correctly since February you should have some level of protection. The Ipergay study shows us that even with planned gaps some level of protection is offered, however the level of Truvada dosage was different in that study. (I'm not recommending taking PrEP this way but it's just as example)  http://www.aidsmap.com/Pre-exposure-prophylaxis-also-stops-86-of-HIV-infections-in-Ipergay-study/page/2947854/

Look your situation is not ideal. I mean it's prescribed as a daily dose and you did miss a few doses so i would say that does not mean no protection but it could very well affect the level of protection.  It's up to you if you want to switch to PEP to be sure following your exposure. 

Now I don't know of any hotline that is open myself. Others might know depending on your location. This forum has members from all over the world, so all I can recommend is for you to talk to your Doc.

Jim

[AusShep]

PrEP on Demand seems to be pretty successful.  But it calls for a double dose 24 hours before sex, then for two days after the initial dose.  You were at lower blood levels when having sex, not higher. 

Even though you're nearing the end of the on demand window, you may see if you can get your ID doc's after hours number and see if a double dose now is worthwhile.   

Also, start filling your Rx 3 or so days earlier every month and build up a bit of surplus to hold you over if you have another insurance mix up.  I had a weird situation that left me unable to fill Truvada for a month last year, but my backup supply held me over.

Here's one article and snippet about PrEP on demand:

http://betablog.org/demand-prep-shows-high-efficacy-ipergay-trial/

"In contrast to how PrEP is now prescribed—as a once-daily pill—men in the IPERGAY study were instructed to take two tablets of Truvada two to 24 hours before sex, and then one Truvada tablet 24 hours later and one final Truvada tablet 48 hours later."

[CaveyUK]

If I were you I would also get to the bottom of your fear of condoms. You say that as a receptive parter condoms 'hurt' you? I don't understand this bit. Other than an extreme latex allergy (which wouldn't likely hurt at the time and could be avoided by non-latex condoms), I can't think of one reason using condoms as the receptive partner would be remotely painful.

Sounds like some psychological issue going on here too

[Lex]

PrEP on Demand seems to be pretty successful.  But it calls for a double dose 24 hours before sex, then for two days after the initial dose.  You were at lower blood levels when having sex, not higher. 
Even though you're nearing the end of the on demand window, you may see if you can get your ID doc's after hours number and see if a double dose now is worthwhile.   
Also, start filling your Rx 3 or so days earlier every month and build up a bit of surplus to hold you over if you have another insurance mix up.  I had a weird situation that left me unable to fill Truvada for a month last year, but my backup supply held me over.
Here's one article and snippet about PrEP on demand:
http://betablog.org/demand-prep-shows-high-efficacy-ipergay-trial/
"In contrast to how PrEP is now prescribed—as a once-daily pill—men in the IPERGAY study were instructed to take two tablets of Truvada two to 24 hours before sex, and then one Truvada tablet 24 hours later and one final Truvada tablet 48 hours later."

I actually did take a double dose of Travada less than a hour after the possible exposure. I had an extra pill from my conservation efforts so I took it. I am trying to fill my prescription at the absolute earliest I can. That was what happened this time too but my only option was to conserve until I was sure I could get the medicine.

I did find this article that eased my mind some:
http://www.aidsmap.com/Intermittent-PrEP-may-be-a-robust-strategy-for-anal-sex-vaginal-much-less-certain/page/2986809
"In terms of stopping PrEP, after 30 days of daily dosing, the estimated protection offered by the PrEP remaining in the body from HIV transmission via anal intercourse was 97%, 24 hours after the time of the first missed dose, 96% after three days, 93% after five days, and was still 90% a week later."

I've taken Truvada daily since February and have missed 3 doses in the last week so at worse I am at 96% protection. And I took the double dose right after the possible exposure. I did go to the ER before finding this article to get more info. It was my only option to talk to a doctor on the weekend. They believed I was okay too but gave me raltegravir for worst case scenario and asked me to talk to my doctor monday morning to see how to proceed.

If I were you I would also get to the bottom of your fear of condoms. You say that as a receptive parter condoms 'hurt' you? I don't understand this bit. Other than an extreme latex allergy (which wouldn't likely hurt at the time and could be avoided by non-latex condoms), I can't think of one reason using condoms as the receptive partner would be remotely painful.
Sounds like some psychological issue going on here too

I experience a friction like pain. An HIV counselor said it could be from my lack of experience and is wanting me to experiment using toys as even condomless sex is not easy for me either. Looking back on Friday night, I think my partner wasn't putting enough lube further down towards the base of the condom.

[mecch]

This is completely unsolicited feedback but I have the same thoughts as CaveyUK. 

A sexually inexperienced person, such as yourself, taking PREP because condoms "really hurt", throws up red flags to me, imo, as to what is really going on here. 

I guess PREP is prescribed pretty easily nowadays and I guess your prescribing doc told you the "official" way its supposed to be used - with a condom.  Why a newbie needs it to avoid the "pain" of condoms perplexes me.

Maybe you should ask yourself if you simply want condomless sex.  There are plenty of sexually experienced guys going on PREP because that is what they want. That is the informed and protecting decision they make, after consider experience with their sexuality and other men.

Also what happened with your top is a fairly typical scenario we oldsters with a lot of experience have heard many times. 

1) Something like "I don't have any STI that I am aware of" is a pretty unreliable safer sex screen, as you are aware.

2) Sex that is negotiated to be protected, ending up being bareback, might mean the bottom needs more negotiating skills to stick to his guns.  The top is an opportunist.  And really maybe the bottom wants to bareback and might just affirm that and go from there.