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Am I eligible for PEP?
Sep 2, 2008

Hello Doctor,

My situation is this:

Wednesday afternoon, I had sex with a random male partner and the condom broke. I was the insertive partner and my penis was completely exposed. I went to the bathroom to wash with soap and tried to piss, but couldn't. I ran water into the condom and found a small tear, but apparenty my penis just went straight through it. My partner sat me down and revealed he has been HIV+ for over 10 years and is on a cocktail that has kept his viral load undetectable. He said I shouldn't worry about contracting the virus for that reason. I asked about his vascular legs and bloated body-builder-like stomach, and he said it was lipothropy.

I don't know him well and, even though he seemed honest, I find it hard to take a random sex partner's word at face value.

I called the local STD clinic and was told that in order to receive PEP, I had to know if my partner was HIV+ (I know that), and what drugs he was taking (I don't know that). Without meeting both criteria, they would not see me and could not administer PEP, which they say is very costly to begin with.

I found that alarming. When a medical worker gets stuck by a random needle and there is no way of knowing who the needle is attributed to, I would guess PEP still is administered?

Taking a responsible first step, I finally was able to get an HIV test today and tested negative (using OralSure), as expected. I don't have any past encounters over the past three months that I'm concerned with -- other than what occurred on Wednesday -- but I wanted to make sure the whole PEP debate wasn't a moot point.

I don't have any open sores or other diseases that would make HIV transmission easier, but still am a bit concerned.

Two HIV workers have told me I pose low to moderate risk, while an Infection Disease doctor I spoke to on the phone seemed to err on the side of caution, but said he could not be of service because I was not a patient at his hospital.

The sex wasn't messsy. The other guy had an extremely clean rectum/anus, and I didn't find any abrasions or cuts after carefully inspecting my penis in full light after washing up after the act.

I'm closing in on 72 hours, and have roughly 15 hours to take my first pill or wait it out for 3 months.

As best you can tell, what is my risk? Are the odds with me to simply wait 3 months, or should I be all over trying to get approved for PEP at the emergency room at all costs?

Does my not knowing what drugs my random partner is taking rule me out of receiving PEP all together?

If I find a way to become eligible for PEP, is there any type of service that helps cover the costs?

Thanks for your time, Concerned

Response from Dr. Frascino

Hello,

Let me start with the PEP issue first. Your experience at "the local STD clinic" is shocking and certainly not customary! Your exposure insertive anal sex with condom failure with a partner confirmed to be HIV positive would warrant a recommendation for PEP. The requirement that you know what drugs your partner is taking is preposterous! Yes, PEP is costly; however, preventing an HIV infection is priceless! PEP is covered by all insurance plans and should be available free through your local health department, if you don't have insurance. (47 million Americans don't!) All emergency rooms, urgent care centers, STD clinics and public health clinics should be ready, willing and able to get you started on PEP emergently, if you've had a significant HIV exposure. (Your exposure would qualify.) PEP is most effective when started as soon as possible (and no later than 72 hours) after exposure. If you are beyond the 72-hour widow, your only option is to get HIV tested at three months. Since your exposure was significant, the CDC recommends a follow-up test at six months as well.

Despite the fact your exposure would warrant a course of PEP, the statistical odds that you did not contract HIV from this condom-failure episode remain strongly in your favor. The CDC's statistical estimate of the HIV-acquisition risk per episode of unprotected (or broken-condom) insertive anal sex with a partner confirmed to be HIV positive is 6.5 per 10,000 exposures. I would suggest you check with your local AIDS service organization regarding the rules and requirements for PEP that you encountered locally. They are totally unreasonable. I'm also shocked the infectious diseases doctor would not help you because you were not a patient at his hospital! He should have realized the gravity of the situation and the time-sensitive nature of PEP and at least given you a starter dose while helping you find follow-up HIV specialist care. The health care system in this country is severely broken. Situations like yours should never happen. All the more reason we must all vote for Barrack Obama and the Democrats in November. Enough is enough!

Good luck on your upcoming HIV tests. I'm here if you need me, OK?

Dr. Bob



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