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Risk and PEP (nPEP)
Dec 10, 2006

Hi. Thanks so much for what you do. this site is amazing. i did search on here and got some valuable information in the past and yet today, but i do have some questions. I know you are busy with these, but i really really really hope to hear from you - and i am scared.

I had an unprotected anal receptive experience with someone i dont know who claims to be negative and tested 'a few months ago'....but who can really know. And I am in NYC where the infection rates are higher. The experience was letting him put his penis all the way in side me and then me pushing him out 3-4 times. So, no 'fucking' per se, but he was in me. We then put on a condom and had sex with a condom from that point on. I know there is risk is what transpired. I would guess it was lower risk in a high risk category but would like to best understand the risk associated with this. I also went on PEP and have some questions on this. Here goes...

1. I dont fully understand transmission. I know this was risk behavior but is there a now a high probability i would be infected?

2. while i dont think he lied about hsi status i am willing to bet he just doesnt know. and i am willing to bet he does this with others. if he had a recent infection, how much higher are my chances of infection?

3. I went on PEP 15 hours after the experience. A doc put me on 600 mg of Sustiva (god help me) at that point, and then at 24 hours i took Truvada. The Truvada is very manageable....the sustiva makes me freak a bit, super cloudy head and i am certain i will have a hard time functioning at work for these 28 days. Do you think this PEP regime is effective? I have heard i could maybe just be on the Truvada, but not sure how to think about this? And why is it 28 days? should it be longer or can it be less?

4. I would like to get a DNA PCR test like next week (about 5-6 days after the experience) and if that is negative for virus, discontinue, but i dont know if PEP masks the test?

5. Finally (sorry), does PEP delay infection so a 6 week test wouldnt give me the piece of mind i need?

Dr Bob - please help.

thank you. and how do we make a donation?

- freaked out

Response from Dr. Frascino

Hello Freaked-Out,

"The experience was letting him put his penis all the way inside me and then me pushing him out 3-4 times." But "no fu**ing per se . . . ." Hmmm . . . . Dude, the old in-and-out is indeed f**cking per se! The best you can say is that your unprotected receptive anal sex was brief and did not include ejaculation. Those two factors would indeed "lower the risk in a high risk category." How much lower? No one can really answer that question, as there are far too many variables to consider viral strain, viral load, concurrent infections, host immune response, etc., etc., etc.

To answer your specific questions:

1. "High probability?" No. However, was there HIV risk? Yes.

2. Again, this is way too hypothetical to address with specific numbers, as there are multiple confounding and interrelated variables.

3. I'm not sure why the Sustiva was started first and then Truvada, later, but there is no doubt that combination is potent PEP. Yes, some HIV specialists may decide to use other PEP regimens and yes, one of those regimens can be Truvada (Viread plus Emtriva) on its own. Based on our current understanding and the current meds we are using for PEP, a full PEP course is 28 days. No, it should not be shorter and there is no reason to lengthen it either.

4. DNA PCR testing is not recommended for this purpose.

5. "Delay infection" is probably not the best term. I would recommend you follow the post-PEP guidelines for follow-up HIV testing (out to six months). You can read all of the guidelines at the following link: www.cdc.gov/mmwr/PDF/rr/rr5402.pdf. Also see the posts from the archives below.

6. Finally, donation information for The Robert James Frascino AIDS Foundation can be found on our foundation's Web site at www.concertedeffort.org. Tax-deductible donations can be made by credit card, PayPal, personal check, money order, direct-wire transfer, appreciated securities, etc.

Good luck. Please note the odds are astronomically in your favor that you did not contract HIV from your brief in-and-out experience.

Dr. Bob

Hey Doc, please respond!! please! Oct 31, 2006

Hey Dr. Bob,

Quick question. I was with a friend of mine who is HIV+, she was trying to grab my cell to see who I was texting. While we were playfully scuffling, she scratched my hand in a few areas. One of the scratches bled. Is this a risk for transmission? I called a local clinic and they recommended nPEP, but that seemed extreme to me, what do you think?

Thank you tons, I hope you will please answer and help me decide what to do.

Thank you again Doc, take care.

Response from Dr. Frascino

Hello,

Your local clinic recommended nPEP because your friend scratched you??? Oh my, my, my . . . this was one of the fears in making nPEP widely available: it would be used inappropriately. I'm sure your clinic means no harm, but their advice was not only "extreme," it was wrong and potentially dangerous. PEP and nPEP are not benign treatments. They carry some degree of risk. Taking them without proper justification can lead to significant medical problems (drug toxicities and side effects). The risk of HIV transmission from being scratched is nonexistent. I'd suggest you refer your clinic to the Health and Human Services guidelines for nPEP (www.cdc.gov/mmwr/PDF/rr/rr5402.pdf) and advise them you were given inaccurate advice!

Finally, just who were you "texting" by the way?

Stay well.

Dr. Bob

started PEP around 41 hrs post exposure! Nov 25, 2006

Dr. Bob-

Well, I had a possible exposure to HIV from the guy I've been seeing briefly. In a horrible lapse of judgement mainly due to alcohol-we had unprotected anal sex (I was the receipient) and even more worrisom was that he only used spit and it hurt alot-but I was pretty out of it. Yes, I'm kicking myself. Anyways-he says he gets tested every 6 months but he never actually said he's negative or positive. I went to the E.R. and they started me on Combivir and Viread for 4 weeks. I've taken two doses so far with minimal nausea. I didn't start the meds though until around 41 hrs after possible exposure-will the meds still be effective??? Thanks for your time and advice signed, worried and waiting

Response from Dr. Frascino

Hello Worried and Waiting PEPer,

Post-Exposure Prophylaxis has the best chance of preventing HIV transmission when it's begun as soon as possible after a significant HIV exposure, i.e., minutes are better than hours and both are better than days. Beginning PEP beyond 72 hours is generally not recommended. Even when PEP is started promptly and a full 28-day course is taken exactly as directed, it is not always effective in aborting an HIV infection. There are PEP failures even under the best of circumstances. (Yours truly is an example!) Will your PEP be effective? No one can say for certain; however, it was begun before 72 hours; consequently, we can all certainly hope for the best. I'll repost some PEP questions from the archives that give additional information.

Good luck!

Dr. Bob

Me again Oct 11, 2006

Hey Doc- First off, you really are a wonderful man. It is me of the previous two days posts entitled "Hello again old friend" and "thanks." Day three on PEP after the popped condom with the girl I met at the club. A few questions. First off...side effects. As you recall, I am on Atripla. The side effects have not been too pleasant. After I take it at night I get a kind of stoned feeling. In the morning I am groggy and have been pretty crabby until after lunch time. My mouth has also been very dry. I can't wait for this to be over! I just have a few questions. First off, I know that the normal testing window is three months. Would taking PEP affect the amount of time before I can see a conclusive test? Would PEP be likely to cause false positives or negatives? Secondly, Can I count on the side effects to wear off. Lastly, my mensch of a doctor prescribed PEP for 30 days. Can I stop after 28, or must I go all 30? Is there a difference? As you can tell, I am very eager to be done with this, and hope that after three months, find out all is ok. Very much because of you, I have been able to keep a pretty cool head throughout this, and I am very grateful.

Response from Dr. Frascino

Hello Me Again,

Your questions about nPEP (Nonoccupational Post-Exposure Prophylaxis), nPEP side effects and post-nPEP HIV testing are extremely common to almost everyone undergoing this treatment. That is why I have repeatedly encouraged all folks who have had an exposure significant enough to warrant PEP to hook up with an HIV/AIDS specialist. See my response to your original question below that anticipates your current concerns. The same advice still stands.

To briefly address your questions:

1. The guidelines for testing after nPEP call for HIV-antibody testing at 4-6 weeks, 3 months and 6 months.

2. nPEP side effects vary considerably in severity and duration. Your HIV specialist should be able to help evaluate and manage your symptoms.

3. A full course of nPEP is 28 days.

If you would like to read more about nPEP, I suggest you download the recommendations from the U.S. Department of Health and Human Services report entitled "Antiretroviral Post-Exposure Prophylaxis After Sexual, Injection-Drug Use or Other Nonoccupational Exposure to HIV in the United States." It can be easily accessed on their Web site.

Good luck! I'm continuing to send my good-luck karma that your follow-up HIV tests remain negative.

Dr. Bob

Hello again old friend Oct 2, 2006

Dr. B- Long time reader and many time donater here. I finally thought I got it right and have been exclusively using condoms. On Friday, I met a girl at a club and she came home with me. We had both been drinking. I put a condom on before sex, and it was feeling to good. After roughly three minutes, I noticed that the condom had completely broke. It has been about 48 hours, and because it is the weekend, I have not found an open clinic to get PEP. I am very upset. I know all the stats, but have two questions:

1) Assuming the condom broke immediately, the time of exposure would have been 1.5-3 minutes. Would this be considered a brief exposure (as oppossed to full on sex), and if so, would a brief exposure carry less likelihood of transmission than a long exposure.

2) I am going to look for a clinic tomorrow, but most of the clinics are closed due to Yom Kippur. Assuming the worst, that this woman was positive (she stated that she tested negative in March, but who knows), would you recommend PEP in this situation?

Thanks

Response from Dr. Frascino

Hello,

Welcome back to the forum. Sorry it has to be under such stressful conditions!

To answer your questions:

1. Certainly the briefer the exposure the less the overall risk of HIV transmission. However, even a brief exposure is an exposure and therefore carries some degree of risk.

2. PEP would be offered in this type of situation, but not necessarily strongly encouraged. There are many factors that come into consideration in ultimately deciding whether to PEP or not to PEP the likelihood that the partner is HIV positive, exposure to menstrual blood, the level of concern/worry of the exposed individual, etc.

Regarding PEP availability, any emergency room should be able to evaluate your risk and prescribe PEP, if warranted, to get you started ASAP. If PEP is begun, I would recommend you see an HIV specialist over the next few days to more carefully evaluate your exposure risk, optimize the PEP regimen, handle any PEP-related side effects or toxicities and arrange for post-PEP HIV testing.

One final thought: if you are still in contact with your club-gal, you might ask her to get an HIV rapid test now. If negative, that would very dramatically reduce any chance you contracted the virus.

I'm sending you my best good-luck/good-health karma, OK?

I'm here if you need me.

Dr. Bob

brief encounter with a masseur Jul 25, 2006

Hello Dr. Bob.

I am a recent reader of your forums, and I found some of the articles very informative. However, I have some specific questions of my own after I got stupid and got myself exposed to unprotected sex with someone who offers massage with release.

I went and got his services thinking, how unsafe can a massage get, the worst that can happen is he'll give me a massage, and stroke me and then I pay him, that's it.

Wrong. when I got there, things got out of hand, we both got carried away, but before we did anything I asked him if he plays safe, he said "always", but as I learned the hard way, that doesn't mean anything. So we proceeded, he gave me the massage, started to rub his stubbles on my anal area, used spit to lube me up, he tried to push his penis inside my rectum, but he didn't go all the way through, I gave him oral stimulation, but he didn't cum inside my mouth, and he did the same to me in return. I think I tasted precum on him. I then penetrated him anally, thrusted 3 times then realized i shouldn't be doing it so I pulled back and just jacked off until I came. He came on my chest. I started freaking out when I realized he had had some hiv+ clients before, but he said he only gave them massages and nothing else, and he didn't have sex with all of his clients, like I really believed him at this point.

My questions are:

1: Is it possible that his rubbing of his stubbles on my anal region caused breaks on the skin where the virus can enter? 2: Will this have led to the possibility that he might have infected me (if he was lying about his hiv status) by using spit to stimulate my anal region?

3: Precum in the mouth during oral sex: I only did it for probably a minute or two. Does that make a difference on my risk?

4: He tried penetrating me, but didn't go in entirely. Am I possibly infected by his pushing his penis inside me? He didn't thrust in and out or anything because I asked him to stop.

5: I topped for him, thrusted thrice, with him on top, me lying on my back. It was gentle thrusting. How does this affect my risk? Could I have gotten the virus (granting he's positive and lied about his status) even if I pulled out after thrusting 3 times?

5: I went to my doctor on the 3rd day ( the encounter happened on a Friday night, saw my doctor that following Monday morning) and inquired about NPEP. He said it was too late (I thought it was 72 hours?) to start it; besides he thinks the risks/side effects of taking it far outweigh the benefits in my case. How is this so?

He did test me for HIV and VDRL as baseline, I'm still waiting for those results. In the meantime, what can I do? The anxiety is killing me. Thanks for your answer in advance. I can't tell you enough how grateful I am for people like you. Where can I send my donation? I'll be waiting for your answer. Thanks again and more power.

Response from Dr. Frascino

Hello,

So Rub-a-dub-dub guy tells you he "always" plays safe and then he tries to bareback your backside like Jack and Ennis on Brokeback Mountain and subsequently allows you to go commando on his buns???? Hmmm . . . I'm not sure Mr. Rub-a-Dub understands either the word "always" or "safe." OK, on to your questions:

1. No. this would be highly unlikely, even if he had Jake Gyllenhaal's stubble!

2. No. HIV is not transmitted via spit.

3. Less exposure means less risk.

4. If he got in, there is a potential risk; although, because it was so brief, again the risk would be minimized.

5. Unprotected sex is unprotected sex. Your risk would be "insertive anal sex with a partner of unknown HIV status." Could three thrusts be enough to transmit HIV? Theoretically yes.

6. PEP and nPEP work best when started as soon as possible after exposure, i.e. minutes are better than hours and hours are better than days! Beginning PEP beyond 72 hours is not recommended. PEP is generally advised only after a significant HIV exposure. Taking PEP is not easy and there are indeed risks associated with these potent medications.

7. What can you do while suffering through the window period? I'd suggest volunteering some of your time at an AIDS hospice or other AIDS service organization. Helping others who are much less fortunate than ourselves is an excellent way to keep our own problems and challenges in their proper perspectives. If HIV/AIDS organizations are too stressful, try a pediatric cancer center or read to the blind or hand out meals to the homeless.

Thank you for your willingness to donate to The Robert James Frascino AIDS Foundation. Donation information can be found on the foundation's Web site at www.concertedeffort.org. Our address is:

The Robert James Frascino AIDS Foundation 1000 Fremont Ave., Suite 145 Los Altos, CA 94024

In return, I'm sending you my very best good-luck karma that your HIV tests remain negative.

Good luck.

Dr. Bob



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