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Double Edged Sword?
Mar 20, 2008

Thank you so much for these forums. It is nice to have a more "human" answer to questions as opposed to textbook info.

I recently had a brief unprotected insertive anal sex ans receptive oral sex (without ejaculation) exposure to a man who after the fact identified himself as positive. I immediately went to an academic center and within 6 hours of exposure was placed on AZT, 3TC, and indinovir (needle stick kit). After talking with an infectious disease specialist, I was switched at 48 hours post exposure to Kaletra and Truvada (since resistance patterns for my xourse were not available) and now have a 28 day course.

Clearly I used poor judgment and am glad that the exposure was not any worse. I am confident I have gotten the best care possible at this point and am grateful to the MDs who acted swiftly.

The doctors have been reassuring -- stating that my risk to begin with (insertive, brief) was significant, but relatively low and that the administration of nPEP within 6 hours of exposure all work in my favor. This seems to be confirmed by the information I found in your frequently asked questions.

One MAJOR concern, I have learned that the "source" recently learned his status (5 months ago) and has not been treated with antiretrovirals. From what I've read, this is troublesome because viral load could be very high... although he symptomatically does not seem to be in the acute phase.

On the flip side, one physician I talked to stated that untreated individuals were more likely to have "wild type" virus which might be more responsive to PEP regimens. She stated that it is very rare on RNA analysis to find highly resistant strains in individuals who have been untreated.

I know this is all a coin toss... but curious on your thoughts? How does exposure to an untreated source weigh into the risk equation?

I probably shouldn't even ask the question.. because I am doing exactly what you say not to... trying to apply population statistics to my individual case -- ecological fallacy? But, I'm sure you understand my anxiety.

Your thoughts, comments, concerns, etc.. on this entire situation is appreciated.

I'm trying to keep a sound mind. Thanks for being there!

Thanks,

A grateful reader

Response from Dr. Frascino

Hello Grateful Reader,

You've essentially responded to your own question by explaining both sides of the coin (which may be a better analogy than the "double edged sword").

I am somewhat surprised the "academic center" started you on AZT/3TC/indinavir. That's a relatively outdated regimen. I agree with the revised regimen, Kaletra/Truvada.

As for your risk assessment, the statistical odds remain very much in your favor. Insertive partners are always at less risk than receptive partners and wild-type virus may indeed be more responsive to PEP intervention. However, it's also true that folks not on antiretrovirals may have high HIV plasma viral loads and that could increase the risk of transmission. Finally I agree that population statistics cannot be used to give an actual statistical risk assessment for a specific case, as there are far too many variables to consider. The bottom line is that you are doing everything you can at the moment. Worrying or trying to calculate specific statistical risks won't change the outcome of your situation. So I would suggest you try to avoid both activities. Qué será será. And whatever the future brings, I do believe you've learned a valuable lesson about the need to always use protection. I hope those reading this post will take that lesson to heart as well.

Good luck.

Dr. Bob



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