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On Pep for the 2nd time - Please respond- sleepless
Aug 12, 2006

Hello, PLEASE HELP ME UNDERSTAND. I have been posting my question everywhere without a response from anyone. This is my story. I am was involved with a man who was very promsicious, & did not know his HIV status. But for my sake let's assume he was HIV positive. I was on PEP for 26 days, on the 26th day, 1 hour after taking my combivir I had sex & the condom popped & the guy came inside my vagina. I finished taking my last 2 days of combivir & my doctor put me on another 28 days of PEP, except this time with Combivir & Sustiva. What are my chances of contracting the virus? Could I have developed a resistance to the drugs? I've been taking each dose faithfully everyday on time from the beginning. I am so scared b/c I can't believe I am in the same predicament again. I've posted my question on mixed couples forum & the treatment & prevention forum without a response. Could you please help me, respond to me? I'm very scared, I hear about PEP failing because of resistance. I've read the different thing s on resistance, but I still don't really fully get it. I'm sacred that since I was already on PEP that my chances of contracting the virus is higher if this guy was infected. I'm rambling on. It would be easier for me to tell him lets go get tested together, but he insist that he already has been. I'm sorry but this day in age a person just can't believe anything that comes out of everyones mouth. Please write back doctor.

Response from Dr. Sherer

OK. I think you have a serious problem for which you should seek counseling: AIDS phobia. And I think you need to figure out what to do about this guy; my advice is to dump him.

AIDS phobia is very common. Anyone who has faced the possibility, even if remote, that they have acquired HIV has known some measure of it. HIV infection is a fearful disease - but one of the solutions available to you is the knowledge that its very different than it was before the new treatments became available. I will argue below that you need to actively change your thinking (and actions) related to HIV from this dreaded paralyzing fear to a healthy respect for HIV that leads to simple actions to protect yourself, and frees you up from this paralysis.

First, even if I assume the worst - your boyfriend is and was HIV positive, and you have acquired HIV infection - this is not the end of the world, not the end of your life, far from it. HIV clinicians around the world see patients with new HIV infecion every day, and, where there is treatment available, they are able to provide very reassuring information and counseling.

But there is NO REASON to assume the worst here. Estimates for the likelihood of transmission after vaginal intercourse with ejaculation from an HIV positive male to an HIV uninfected female are around 1 per 500 exposures. Even without the prophylaxis that you have taken, the odds were strongly against transmission of HIV.

We have credible evidence with health workers following needle stick exposures that PEP reduces the risk of HIV transmission, and that it does not eliminate the risk completely. There is less available data for non-occupational PEP, but it is reasonable to expect that you have lowered your risk further by taking these medications.

OK? So far, so good. Next, there is no reason to think that resistance to the medications that you have taken will occur as a result of the PEP itself.

It is possible that the effectiveness of the PEP could be reduced by the presence of pre-existing mutations; in the current era in the US, around 10% of new HIV infections have resistance mutations to at least on HIV medication. Still, you have done well to take all the PEP doses faithfully, and you've done everything possible to maximize its effectiveness.

My biggest concern from your story is that the fear of HIV could overtake you, and impair the quality of your life. I strongly advise two steps: 1) Get some medical answers and make some important decisions about this guy; and 2) Get some counseling to help you walk through this territory.

1) Get some answers and make some decisions: By this I mean confront both your fears and your boyfriend with this problem and get the answer to the central question here, i.e. does he have HIV infection, or any other sexually transmissable infection that you should be aware of? Go with him and get him tested; if possible, ask for a rapid HIV test, so that you leave the doctor's office or testing center with an answer. Tests for syphilis, gonorrhea, chlamydia, and hepatitis B and C should also be done. Have him come with you for your next tests after the PEP. (If he says no, dump him).

Your question says that "I am was involved". What does that mean? Are you still involved or not? It sounds like you are.

I also mean make up your mind whether staying in relationship with him is worth the emotional toll that its taking. From your brief description, written at a time when you were clearly distraught, it sounds like the answer is no. Why stay with a guy who you have reason to mistrust? Rather, why not make the decision to get rid of him and seek a relationship that is based first on trust and honesty?

Your second exposure occurred due to a broken condom; what happened the first time? Did you forget? Were you drinking or using drugs? You also need to decide to reduce future risk as much as possible by following the ABCs of HIV prevention, i.e. always use a condom (accepting that they are highly effective and not perfect, as your own experience confirms), or find a partner who is not infected and being faithful - all in order to help to deal with this fear by keeping the risk of infection as low as possible.

One problem with the fear of HIV: No amount of testing, doctor visits, etc. can completely 100% eliminate the possibility that you acquired HIV infection. You will have to live with the exceptionally small and remote possibility that you have acquired HIV. However, it is equally important to understand that after a negative HIV test after 3 and 6 months following the exposure, the chances of having HIV are well below 1%, and you will need to accept that information as conclusive that you do NOT have HIV infection.

Back to your partner for a moment: If he IS worth it, and you and he intend to continue a 'promiscuous life style', whatever you and he mean by that, then get a grip! Live with that decision and accept that periodic regular HIV testing is going to be a fact of life. If you choose this route (which I would discourage you from doing), then I would just hope that you both find a way to have multiple partners and to follow safe sex guidelines as much as possible. Can you make such a commitment and follow it yourself? Do you think he can also?

2) Ongoing counseling will help in two ways: First, to sort out these risks, and to offer a non-judgmental sounding board for the results of the next sets of tests - both yours and his. And secondly, it will help you to replace this dread and fear of HIV infection for a healthy respect for HIV. HIV prevention is not rocket science, you can protect yourself with relatively simple measures.

Ask your doctor to refer you for counseling, or seek help from the local AIDS support organization in your area.

Here's my summary: 1) your risk of HIV infection is extremely low, less than 1/500 2) your fear of HIV is in danger of getting out of control - you should seek counseling right away 3) you need some medical answers from your boyfriend right away: Is he HIV positive? 4) you need to make some decisions now about this relationship and how your going to handle the risk of HIV infection for the rest of your life. If you choose to stay with this guy, then he needs to be part of these decisions.

Is resistance inevitable?

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