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Re: a mad med student
Jun 12, 2005

Dr.Bob: I know you're busy helping everybody but I just wanted to thank you for answering my email. First, you're obviously right;people do have their own set of rules but you know, where's personnal responsability on stopping spreading HIV...We have to wake up seriously!! Now, I have to tell you I got really sick from the PEP therapy (constant nausea/vomiting and right abdominal pain) and stopped the meds on my own (so I only did 5 days on it which of course makes me very insecure now about seroconverting). And now of course I find myself making it worse by self-diagnosing symptoms I'm experiencing. I do try to stay rationnal but after experiencing the PEP, you can understand that I have a hard time imagining myself on HAART for a lifetime and it makes me very anxious. Now I have 2 more questions I hope you can answer.

1. The doc who prescribed the PEP to me did so because he suggested that oral sex with ejaculation with a man who have sex with men is in the same risk cathegory as anal sex without condom...what are your thoughts on that. 2. I know you don't like PCR as a "diagnostic" tool for HIV infection but if I was to have one (doc I don't know if I can wait for Elisa, I'm really worried) when do you think is a reasonable lapse of time I should wait after doing the 5 days of PEP?

Thank you so much Still mad student and now also worried

Hello Mad Med Stud,

1. First off, not everyone plays by the same rules when having sex. Consequently, you should make it absolutely clear to your tricks that you are not looking for a high-protein snack before you start sucking on a penis Popsicle. OK?

2. Next, PEP (post-exposure prophylaxis) is generally recommended only for very significant HIV exposures. If PEP is warranted, the treatment should be for 28 days. HIV testing during PEP should not include PCR testing, as antiretroviral drugs could decrease the viral load (PCR) to undetectable levels, thereby rendering the test useless for diagnostic purposes. Perhaps your doc is a bit confused on some basic HIV testing and treatment concepts. I'd suggest you consult with an HIV specialist to better evaluate your HIV risk, need for PEP and, if necessary, PEP treatment and follow-up.

3. PEP does not delay the immunologic response to HIV infection, i.e. the production of anti-HIV antibodies. It can, as I mentioned above, decrease HIV viral load. That, however, is not an immunologic response, but rather a direct measure of viral replication.

Hope that helps. I'm here if you need me. Good luck.

Dr. Bob

Dr.Frascino, as a med student, I could have a more honorable HIV exposure excuse but here it is: I somewhat engaged in unprotected oral sex with an anonymous guy. I do allow myself to take the risk but absolutely do not include ejaculation in that equation!

SO No. 1: I JUST HAVE TO SAY; IN TODAY'S WORLD, YOU GUYS ARE RUDE AND CRIMINAL TO COME IN PEOPLE'S MOUTH WITHOUT PULLING AWAY OR ANNOUNCING SO, I AM SO MAD!!!!!

No.2: My doc decided to put me on a post-exposure (40 hrs) prophylaxis of Combivir and Viracept for 14 days and then get tested. Now, I read that for sexual exposure, tx is usually 1 month...is that possible and can a test (even PCR) reveal anything after 14 days?? Shouldn't I do 1 month? I'm a little confused!

No 3. Also, isn't it logical to think that let's say I got infected, that PEP would delay immunologic response because of supression of viral load?? Hence my worries about obtaining a valid test that early (even though I understand tests are getting better at early detection)

Please, please, I respect your forum and really hope you can make sense of all of this...If I'm going to do this PEP thing, I want to do it the right way.

Many thanks

A mad & confused Med student

Response from Dr. Frascino

Hello Mad Med Stud,

I agree with you: many folks do need to "wake up" to the risks associated with their behaviors; however, I also believe "personal responsibility" is indeed personal! That means you are responsible for protecting your HIV-negative status. Each individual decides for himself or herself what level of HIV-transmission risk is acceptable for him or her. Some may have decided that oral sex is for them an acceptable risk; others obviously would disagree. The new prevention program, "HIV Stops with Me," focuses on HIV-positive folks; however, I believe it applies equally to HIV neggies as well. So unless you only plan to stay home by yourself and "burp the nephew," remember to set the ground rules before "trick-or-treating!"

Your experience with PEP is not uncommon. Having taken HAART for a decade, I do understand. It's also a good reminder to our readers that PEP is not a simple "morning after" pill for routine indiscretions.

Now on to your questions:

1. What are my thoughts about your doctor's believe that oral sex has the same HIV-transmission risk as anal sex without a condom???? That's easy. Your doctor is either woefully misinformed or a complete idiot.

2. You are correct I do not recommend PCR for routine HIV screening. Consequently, I don't believe there is a "reasonable lapse of time to wait," because I don't recommend it in the first place.

Mad Med Stud, my advice to you remains the same: consult an HIV specialist if you need to better evaluate your risk, need for PEP therapy or management of PEP/PEP-related side effects. For HIV screening, I recommend an ELISA at three months followed by a confirmatory Western Blot if the ELISA is repeatedly positive.

Good luck!

Dr. Bob



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