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Why Do You Ignore The Tough Questions, Dr. Bob
Jun 15, 2004

Dear Doctor: I love you, but lately I've been a little p/o by you. I notice that you never answer any truly unique and TOUGH questions like the one I have below. What happened to the Dr. Bob that used to tackle the truly difficult questions? (But I still love you). Here's goes once more.

Dear Dr. Bob:

Since you have not responded to me, I have gotten two opinions from two GPs. Unfortunately, the opinions are very conflicting. See below the facts. The first GP said that given the facts below, and assuming the sex worker were HIV+, my risk for contracting is essentially non-existent. The second GP said that every time the integrity of the skin is broken in any way, shape, or form, (even superficial cuts such as my cut), there is a risk for transmission.

I respect your opinion more than either one. Please settle this once and for all, and help me get a good night sleep.

I fingered a sex worker of unknown status for approximately 10 seconds. (Additionally, she performed protected oral sex on me. The condom remained in tact). That was the ONLY sexual contact. Please note that I talked to my Primary Care Provider (GP) last week, and he said that I am at among the highest risk and should have started a PEP.

My Concern: I fingered her with my index finger, which had some THIN skin peeled off (away from the finger nail). Basically, it was a VERY THIN layer of skin peeled off. That part of the finger appeared red in color. In terms of depth, the cut was much less deeper than a standard paper cut. In other words, a paper cut usually penetrates more deeply than this cut was.

This cut on my finger occurred approximately 12 hours before. It was not bleeding at any time, and there were no gashes. But I could not determine if this cut satisfied the definition of fresh cut that puts someone at extremely high risk when fingering.

Now, I hope you can handle the following tough questions.

1. ASSUMING that the sex worker was HIV+ (she was not bleeding), how risky was my 10-second fingering episode. Note that my fingers did not go deep inside of her, nor did I finger her forcefully so as to tear any linings.

2. You stated in prior e-mails, that fingering, even with a small cut is not considered risky. What is the basis for this, Dr. Bob. Is there a physical or anatomical basis for your statement? I would venture to guess that the majority of people who become HIV infected through sex also engaged in fingering. Thus, how can we be so sure that fingering was not the actual route of transmission in those cases.

3. Can a cut be an OPEN cut, yet not be a FRESH OR DEEP cut? In this instance, would this lessen the risk? It makes sense that a fresh (i.e., bleeding) and deep (well, thats common sense) pose some theoretical risk. However, what about an open cut where a THIN piece of skin is missing. When I say thin, I mean VERY, VERY thin so as to not even justify a band-aid of any sort, and so as to not even sting when I was with soap in the shower.

4. Pls. HELP, Dr. Bob. I know Im HIV-infected and I am freaking out. My blood pressure has gotten to be so high because of this. My symptom of ARS have been: Five days after the fingering episode, I started to feel a tight neck and my armpits and upper/inner bicep hurt slightly off and on. The pain went away for 5 more day, then has returned again for an entire week. The pain was very slight (scaled of 1-10, about a 1 or 2 MAX). I am at week three after my high-risk exposure. NO other symptom of ARS, except for these slight pains in the upper-inner arm and armpit region. One doctor examined me twice, and another once time and found no lymph nodes swollen at the armpit, neck area, behind the neck, etc. No other symptoms. But the pain near the armpit region persist, and sometimes, it shoot into my triceps and elbow. It's a pain that I never noticed before this high-risk exposure.

Please try to answer me as detailed as possible. I feel like Im in a box, doctor.

Response from Dr. Frascino

Hello,

I "never answer any truly unique and TOUGH questions???" Really? Re-read the entire archives of this forum. Go ahead. We'll wait . . . . . . . Now, would you like to apologize for that comment?

"What happened to the Dr. Bob that used to tackle the truly difficult questions???" Well, at the moment, I'm at 38,000 feet, winging my way to Athens. Where are you?

OK, now let's look at your "truly difficult, TOUGH question" . . . . You had protected oral sex and fingered a hooker for 10 seconds. WOW! No wonder you are so worried! After all, how often would a risky situation like that come along? That's right about a gazillion times every day!

But what about the extenuating circumstances? The "VERY VERY THIN" layer of skin that peeled away from your fingering finger's fingernail? It was 12 hours old, didn't sting when washed with soap and water, wasn't bleeding, and was much less deep than a standard paper cut. Am I missing something here??? I can tell you one thing that's definitely missing here a tough (or even mildly reasonable) question! Dude, read the archives or just use a bit of common sense. Your risk is so slight that its' essentially nonexistent. I'm delighted to be the tie breaker between the warring G.P.s.

G.P. #1 feels your risk is essentially nonexistent. I agree.

G.P. #2 feels that if the integrity of the skin is broken, there is a risk for transmission. I also agree.

Primary Care Provider G.P. #3 feels your risk is among the highest, and you should have started PEP. I totally disagree!

So, PCP (G.P. #3) is in drastic need of an HIV/AIDS refresher course and G.P.s #1 and #2 are both correct, except that G.P. #2's idea of skin integrity may be a bit too strict. Your type of superficial peel and minimal potential exposure to secretions that may or may not have contained HIV constitutes an essentially negligible risk. HIV can be absorbed across mucous membranes (like the lining of the vagina, urethra, or rectum); however, skin is not a mucous membrane. If you don't have blood or fluids leaking out, how do you expect HIV to "leak in?"

OK, on to your very specific (and ever so tough) questions:

1. As indicated above, I believe your risk was essentially nonexistent.

2. The physical/anatomical basis? Reread the paragraph above about skin vs. mucous membranes, and leaking in vs. out. How can we be sure fingering is not an actual route of HIV transmission? Well, 20 years of HIV scientific research for a start.

3. Fresh, deep, open, thin . . . stop already! If I quoted you nanometers of thickness, would that really help? Keep it simple, dude! If you've got a cut and it's bleeding, it's fresh enough and it's deep enough, OK?

4. You "know" you're HIV positive and you are "freaking out?!?" Well, I'll agree with 50% of that statement! You are definitely freaking out! Did you realize #4 really doesn't even contain a question? Just a bunch of high-anxiety gobbley-gook about transient "symptoms" that do not bear even the slightest resemblance to HIV ARS.

Sorry pal, your questions do not qualify for difficult or tough. In fact, they are quite a bit below average for what gets routinely submitted. I'll have to give you a C- or D+ at best. But, your anxiety level is undoubtedly an A+, right up there with the best of them! Congratulations!!

My advice to you is as simple and straightforward as your questions:

1. Your HIV risk is essentially nonexistent for the episode you describe.

2. If you're worried, or if you feel you've placed yourself at risk, get tested three months or more after you gave her the finger!

3. Consider getting some counseling to help you cope with your irrational fears.

4. Get a new primary care provider.

OK? Are we buds again? I still love you, too.

Dr. Bob



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