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Nelson, what would you do?
May 17, 2013

Nelson, my best friend just called me to say he woke up from partying with friends after drinking and he feels that there is semen in him. What would do if you were him besides get tested? I am poz but he is neg

Response from Mr. Vergel

This email is about what I would do and in no way is a recommendation.

I would provide a sample of my blood and then start HIV medications right away (that is a challenge for most people due to lack of access, unless you have a friend who is taking them) and get tested using a PCR test to measure viral load. But viral load may not show up until days later. You can see in this graph how there are 6 stages of HIV infection as determined by what is called the Fiebig stage I- VI. After a few days (10 days in this graph), viral load is detected (stage I). Then p24 antibody is detected (stage II)using the ELISA test, and so on.What are Feibig stages during HIV infection?

The problem with this approach is that you never really know if you got infected if your early blood sample shows nothing during the first few days. But knowing what I know now, I would take the chance taking medications like Isentress plus Truvada or Stribld (integrase inhibitors are much better at tissue penetration and at driving HIV viral load down fast). Who knows?, this way I would be betting to be part of the small number of people who have no viral load after they stop HIV medications months after initiation. Starting HIV treatment right away may prevent spreading HIV into different hiding reservoirs.

Luckily, some researchers have been looking at immediate treatment even before we learned about the baby that was cured when her doctor put her on HIV medications within the first 30 hours of birth. Dr Jintanat Ananworanich from SEARCH and the Thai Red Cross AIDS Research Center in Bangkok and colleagues are investigating the relationship between Fiebig stage and levels of HIV unformed particles (DNA instead of RNA) in blood cells and gut tissue. They presented a study at CROI-2013 that found that people at the earliest stages of infection had extremely low reservoir size, and that starting treatment this early appears to restrict "seeding" of long-lived central memory T-cells. Hopefully, we will see more data from this Thai cohort and others around the world looking at early treatment.

This is a complex subject with emerging data that may not be practical to implement in most settings, but I am just answering you about what I would do knowing what I know now about early treatment.

Getting back to what to tell your friend: he can call local AIDS Service Organizations that provide primary care to find out who offers post exposure prophylaxis and/or early treatment and PCR tests for diagnosis (HIV/AIDS Hospitals and Clinics ) . And if he is not infected but not going to change his risk-taking behaviors and likely to find himself in this situation again, tell him to seek out pre exposure prophylaxis either through a study, or from his doctor. Gilead will pay for Truvada for this use if his insurance won't. Gilead's PrEP Patient Assistance

I am sure I will get a few emails about this reply. Good luck to your friend. I am sure he learned a lesson. Blacking out when drinking or drugging is certainly a good way to lose control of your actions.

Nelson



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