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Let's hope this does not change your opinion
Dec 1, 2006

Dear Dr. Bob, Kind thanks for your light-speed reply ! ( from Steve, the fellow Bay Area "Tequila I.V." WW guy ) Not the risk experince you referenced, but entirely hetero here ( not that there's anything wrong with that )- one episode of unprotected vaginal for about 5-6 min, also due to way too much tequila, with a later confirmed hiv+ stripper. So perhaps higher than the 1 in 10,000, and I'm "uncut", so could be even worse.. Did not have any HIV tests because I'm scared s***less, and the only reason for the lymphocyte subsets count was to determine if there was anything unusual about the consistent drop in absolute lymphocites over the last 4 years.. My symptoms aside, which you wrote are not indicative of hiv, I was trying to see if the specialist's assertion that I cannot possibly be infected and maintain a positive 1.5+ cd4/cd8 ratio at this stage.. he said hiv is classically characterized by an inverted ratio which remains troughout the course of the illness, unless medicated.. Still worried, but you're right - greater risk in driving on 101 or 280, especially the wway I do, voting republican ( did that once when I was young and stupid ), etc., etc..

Response from Dr. Frascino

Hello Steve,

The estimated per-act risk for acquisition of HIV for insertive unprotected vaginal sex is 5 per 10,000 exposures to a partner confirmed to be HIV positive. Not getting a simple definitive HIV test (results available in 20 minutes!), because you are scared shitless, and instead prodding multiple physician specialists to hypothesize whether a CD4/CD8 ratio is consistent with changes seen in CBCs over four years and possibly indicative of a HIV disease, thereby explaining a number of vague symptoms, makes about as much sense as Dubya explaining his strategy for ongoing victory in Iraq. Dude, snap out of it. It's time to grow-up and get real! Get an HIV rapid test and stop acting so Republican. If you're in the Bay Area, you can even make an appointment at the Frascino Medical Group (650-917-1357). We'll make sure you don't freak out during the 20 minutes it takes for the test to process and then we'll even WOO-HOO with you. But we can't guarantee you won't be run over by an errant bus on your way home. So you can worry about that if you want, OK?

Dr. Bob

Your compassion for the WW is amazing Nov 30, 2006

Dear Doctor, A million stories in the naked city, and from the tens of thousands of emails you must receive you still find the time , the energy and especially the compassion to respond to so many who are sickened with worry...and often do so with a GREAT sense of humor. Remarkable ! Thank you on behalf of so many WWs, a group which I am now also joining. So from a fellow SF Bay Area resident, here's one more of those stories adding to the mix, to which I can only hope you will chose to reply, but if you can't, it's entirely understandable.. I am a 50 year old male, generally very healthy who had a potential exposure four years ago. A 1 in 10,000 probability, reading various other of your responses here, but nonetheless, a distinct possibility. Never gave it much thought, in spite of a variety of very mild but inexplicable symptoms over these last 4 years ranging from three days of light night sweats which started the constellaton of worries, to a bout with IBS a few montsh later, to a stiff neck yet a few more months later, to some occasional malaise, to what is now, four years later, the appearance of solitary infalmed and also non-painful papules ( never pustules ) here and there, on buttocks, side of trunk, under arm pits, shoulder, etc. SO naturally I'm in a state of panic. But what componds the problem is my annual CBC results which show a steady decline in lymphocytes, by an aggregate of 25% over this 4 year span. So now there is empirical evidence to support my symptom-induced panic. DAMMIT !! BTW,I sent the subset results to Dr Mark, but might as well reference here, because clearly this transmittal is not long enough, and it seems on on track for the longest letter ever.. CD4 536, 37% CD8 345, 24% CD3 932, 64% CD19 169, 12% My doctor, AFTER consulting with an infectious diseases specialist and a hematologist conveyed their assertion that four years post an hiv infection I could not have those type of results, PARTICULARLY since the CD4s outnumber CD8s by a margin of 1.5. But does that give me sufficient reassurance so as to lower the tequila IV hooked to me which I need to cope with the stress - NO, it doesn't ! ( ok, I would not reduce the tequila regimen regardless, but you know what I mean..)

Please, any words of wisdom from you would be so much appreciated. It's one thing for a I.D. or hematologist specialist to issue an opinion, and that's great, but that's not nearly par with the thoughts of an HIV expert on the matter.

Donation on the way ( not because of an anticipated response, but because it's a good cause and the support you provide for countless of concerned individuals )

Kind thanks for reading all of this, unless you deleted it half way into the novel I wrote here, and all the best wishes to you. Steve

Response from Dr. Frascino

Hello Steve,

How could I refuse to respond to a fellow S.F. Bay Area resident with a Tequila I.V. drip? As for the million stories in the naked city, well it's not always naked around here; just on Halloween and at Folsom Street Fair. The other days we are only semi-naked.

OK, on to your question. You put your estimated risk at 1 in 10,000. Consequently, I'm assuming you tasted a tallywhacker. Yes, the risk may be real, but does it warrant your degree of anxiety? Do you worry equally as much when you drive on Highway 101 and/or 280? Ride an elevator without looking at the inspection certificate to see if it's current? Get into a taxi without checking the cabbie's driver's license? Eat sushi? Swim in the ocean? Vote Republican? All of these activities also have associated risks as well. And some of those risks are greater than your estimated HIV risk, which, by the way, is far less than 1 in 10,000 if you do not know the HIV status of the gentleman attached to the tasty tallywhacker.

Next, symptoms. Symptoms, no matter what they are, do not equal HIV disease. Your symptoms are not suggestive of or worrisome for HIV ARS.

Next, lab work. A decline in total lymphocytes over a four-year span is not "empirical evidence to support" anything, particularly your "symptoms-induced panic." You did not provide actual numbers, but chances are your "steady decline" in lymphocytes on your annual CBC was totally normal and/or completely inconsequential. If you're worried about HIV, you need an HIV-antibody test, not serial CBCs. I'm assuming you've had one (or, most likely, multiple) HIV-antibody tests and they are negative, right? If not, you should get a single HIV-antibody test, see that it is normal, yell woo-hoo, and put all this unwarranted fear permanently to rest once and for all. But, assuming you've had negative HIV-antibody tests and you're still a nervous Nellie, you now have T-cell subsets to perseverate on. First, I should mention I see absolutely no reason why you had this test performed. There is no clinical indication for it from what you've written in your post. Next, I absolutely agree with the hematologist and infectious diseases specialist: your counts are fine.

So, to sum up. Your risk: negligible. Your symptoms: not suggestive of HIV. Your labs: not suggestive of HIV. In other words, HIV is not your problem. No way. No how.

So, why all these irrational fears? In general, I feel it's most likely because HIV infection is so very different form the other fears and risks I mentioned above. HIV is still stigmatized and, in the subconscious minds of many, may be equated with punishment for a sexual behavior that is associated with a lot of guilt. I strongly urge you to stop fearing and chasing an illness you do not have and to begin focusing on your anxiety and irrational HIV fears.

Good luck!

Dr. Bob



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