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Petrified of what ifs PLEASE HELP
Mar 21, 2008

Hello to my favorite doctor! I pray you and the rest of your family are doing well. I miss very much hearing from you but always appreciate what I learn in your forum. I desperately need your help. I recently had a LEEP procedure done and after almost three weeks, my husband who was acting like we had not had intercourse in a year, was asking for us just to "cuddle" and needless to say, had intercourse. What happened next is why I am sick to my stomach. When I wiped, I found some blood and although he said he did not see any on his penis,obviously he came in contact with it. I AM PETRIFIED he is now sick as well. I immediately that very moment contacted the clinic where I get my care and left a message for the social worker to call me. I spoke to her that very morning and explained what happend. She said that she would have the only doctor that would be in call me as soon as he could. He never did. She called me back today to tell me it was now too late to do anything and that he should be tested in three months. I was seething with anger. I did not take him to my local ER because the couple of times I was there and was honest enough to tell them my status, they treated me like I was an alien from another planet and wore space suits just to take my vitals. They had no idea how to handle me or my situation and blamed me for getting myself into my situation. They quickly then proceeded to state that the reason I had been there was for a stomach ache and discharged me immediately so as not to have to deal with me anymore. I am so sick of this doctor. You have advised me in the past to be brave and go out there and make them have to deal with me, but I keep running home with my tail in between my legs praying that no one in my neighborhood finds out I am sick. What are the chances he is sick doc? How high are the percentages? I have been undetectable for over 6 months and have a T-Cell count of over 1000, but I figure that the risk is double as bad because he came in contact not only with blood but fluid. I know that he still runs a risk and that even if it is 1% it is a risk but as far as statistic with the information I have provided, what are the chances? He will not get tested and all I keep thinking about is losing him like my previous husband who knowingly infected me but did not tell me he was infected. He died in my arms and... I cannot take this stress. PLEASE. Will you bless me with a reply? Looking forward to hearing from you and wishing you a wonderful day. Mommy of Three

Response from Dr. Frascino

Hello Mommy of Three,

I'm assuming the "cuddle"/intercourse was unprotected. The estimated per-episode risk for HIV acquisition from unprotected insertive penile-vaginal sex with a partner confirmed to be HIV positive is 5 per 10,000 exposures. The presence of blood might increase that risk somewhat. However, that you have had an undetectable viral load on antiretroviral medication for over six months would significantly decrease the HIV-transmission risk. I should also point out that population-based estimated-risk statistics should not be interpreted as an actual risk statistic for any one specific coupling. (See below.) At this point the statistical odds are certainly very much in your husband's favor that he did not contract the virus; however, HIV testing at three and six months is warranted. Your degree of anxiety is a reflection of your previous loss and not really warranted based on the actual degree of real risk associated with this recent exposure.

Regarding your local hospital and their staff's unprofessional behavior, I would recommend you write a letter to the hospital CEO and send a copy to your congressional representatives. Such discrimination should not go unchallenged. If they treat you that way, they are likely to do the same to others. Demand that the offending physician and/or ER staff be counseled or disciplined.

One other thing to consider is talking to your HIV specialist. You can mention your experience at the ER. If the specialist is on staff at that hospital, he or she may help in educating their colleagues on the ER staff. Also ask your specialist about a PEP starter pack for your husband in case of accidental significant exposures. PEP is most effective if started as soon as possible and no later than 72 hours after an exposure.

Finally I encourage you not to live your life in fear. Being HIV infected is challenging enough without adding all the negativity that comes with constant fear and anxiety.

Good luck. Be well (not petrified!).

Dr. Bob

HIV STATISTICS Sep 13, 2007

Doc,

Ive written to you many times over the past 3 years and youve answered several of my questions. Thank you! What I really need to know now is how accurate are your statistics about oral and anal sex. Is it really 1 per 10,000 for oral and 50 per 10,000 for anal? Im trying to explain to my negative partner exactly what our specific risk is. Neither one of us are math whiz-kids but this seems reasonably straight forward. He could expect to become infected once for every 10,000 blowjobs. Right?

Thanks Dr. Bob

Response from Dr. Frascino

Hello,

"He could expect to become infected once for every 10,000 blowjobs. Right?"??? Well actually no, that would be a wrong conclusion to draw from those statistics!!! I've covered this topic numerous times in the past, but I know HIV statistics can be a confusing topic. So even though this questions has now become a QTND (question that never dies) with an ATNC (Answer that never changes), I'll try to explain the limitations of these statistics once again.

The statistics I quoted are "estimated per-act risk statistics for acquisition of HIV by various exposure routes" published in a CDC document. These statistics were generated by combining a variety of published reports and did not control for many different potential variables that occur in different populations and among individuals. In other words, these statistics are primarily useful in determining relative risk, but not specific risk or actual risk for any individual. The reason for this is that any specific sexual coupling has a wide variety of variables to take into consideration when attempting to quantify specific HIV-transmission risk. These would include both viral factors, such as viral strain and viral load, as well as host factors, such as immune integrity, concurrent illnesses, circumcised/uncircumcised, genetic susceptibility, etc. Add to this nonspecific factors/extenuating circumstances, such as roughness of the encounter possibly causing trauma to mucous membranes, menstruation, etc., and perhaps you will begin to see the difficulty in providing transmission-risk statistics for any specific coupling. Also I should point out we cannot conduct prospective controlled epidemiological studies to try to account for theses variables, as that would be unethical. There are some published reports that address risk associated with specific sexual practices that control for some variables, but these studies usually have relatively small sample sizes and again are not applicable to everyone's specific situation. Another reference that I quote frequently is http://hivinsite.ucsf.edu/InSite?page=kb-07-02-02 (SAFER SEX METHODS). If you review the specific epidemiologic studies in this well referenced report, you'll get a better understanding of the complexity involved in these issues.

So why do I quote the statistics that I do? Good question! The main reason is that I am constantly barraged by anxious wrecks desperately trying to quantify their risk. I use the CDC statistics, because CDC is a very conservative organization and the numbers they generated are an amalgamation of many studies. They also standardized the relative risk to a common denominator ("10,000 exposures to an infected source"), which allows us to discuss relative risk. For instance, unprotected receptive anal sex is approximately 10 times more risky than unprotected insertive penile-vaginal sex, which in turn is approximately 10 times more risky than unprotected insertive oral sex.

I hope that this will help clarify the limitations of these estimated HIV-transmission risk statistics.

The bottom line is really much more concrete and easy to comprehend. If someone has placed himself or herself at risk for HIV, he or she should be HIV tested. Period. End of story.

I can just about hear all the paranoid panicky worried wells beginning to type away furiously, providing me with a blow-by-blow of their latest blow-by-blow and begging for me to quantify their specific risk. But unfortunately, unless the other person they were having sex with was me, I will not have enough specific detail to give them an accurate response. Hell, even if it were me, I still might not be able to give a completely accurate risk quantification!

Dr. Bob



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