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Follow-up to Started PEP- Is it necessary in my situation??? (Resubmitted from the Fatigue and Anemia Forum)
Sep 11, 2008

Dr. Bob, Thanks for getting back to me on my initial question. I apologize that I originally posted to the wrong forum. I started the course of PEP with Truvada and Kaletra about 36 hours out from my hook-up... I should also note that I have an abnormally HUGE fear of HIV, sometimes to the point of irrational where it affects my day-to-day life. I am also a huge hypochondriac and I tend to punish myself if I ever party, or do things that are normally against my values and morals... I would imagine that it would take a pretty screwed up person to fuck me bare while I am passed out. I am absolutely sure that I didn't have sex with the guy I hooked up with initially; he didn't even cum, and he is negative. He also told me that I fell asleep after he and I were done... But my fear is that the third guy from the other threesome in the next room fucked me while I was passed out. I was assured by close friends that this didn't happen, and that he left after the other three were "done". I have taken the PEP faithfully up until now, and have managed the side-effects with Imodium for diarrhea and gas, and the occasional aspirin for a slight headache, but other than that it hasn't been horrible. I have NEVER had unprotected anal sex in my life, except with a long-term boyfriend when we had both tested negative out to three months. I wonder if my fears are unwarranted and if I freaked out over the phone to my doctor to the point of him prescribing PEP... He did not see me in person before prescribing the PEP, and he has never seen me in person before as my old doctor moved to New York. I go to Pacific Oaks Medical Group in Beverly Hills, and they are renowned as an expert HIV-specialist practice, as well as general practitioners. While I can handle taking the pills for the 28-days, I really don't want to if I don't have to. I am out of town right now and can't see my doctor. I would like your opinion on this additional information I have shared. You are so knowledgeable and are so comforting. I really hope you have time to respond to this message as well. Again, I have donated to your foundation and really appreciate and admire the work you do. Thanks again, Dr. Bob.

-Scared Shitless Dave

Response from Dr. Frascino

Hey there S.S. Dave,

As I mentioned in my initial response, "I may not have recommended PEP . . . ." This is still my position based on the limited information provided. Certainly, now knowing (1) you have a history of "irrational" fears of becoming HIV infected, (2) you are a "huge hypochondriac" and (3) your close friends "assured" you that you were not used or abused while in your cocaine and tequila induced coma, I would tend to lean even more toward not recommending PEP. However, before deciding one way or the other, I would need to have a conversation where I could ask questions and try to pin down more accurately your true HIV-acquisition risk. This is why a face-to-face visit with an HIV specialist is desirable. Since you are tolerating your PEP adequately, I'd suggest you continue it until you can have a one-on-one visit with an HIV specialist. I anticipate there's a good chance he or she may advise discontinuing PEP.

Dave, you might also consider getting some counseling to help you confront your HIV fears and tendency to party until you black out. Addressing these issues now could benefit both your mental and physical wellbeing going forward.

Good luck to S.S. Dave!

Dr. Bob

Started PEP- Is it necessary in my situation??? (Resubmitted from the Fatigue and Anemia Forum) Sep 10, 2008

Dr Bob, I wanted to ask you about PEP in my situation. I just began a regimen of Kaletra and Truvada after an unknown potential exposure over the weekend while in Laguna Beach. I performed oral sex on a male friend of mine who is a physician the first night. I know he is HIV negative. The second night, I was among the same group of friends, all of whom are upstanding, responsible individuals. We were all rather drunk and had used cocaine. I ended up hooking up with a different man- I do not recall us fucking, and he also said the next day that we didn't, and that he is negative. At the time we hooked up, I was rather intoxicated, and ended up passing out in his bed. There was another threesome in another bedroom hooking up at the same time. I know two of the others are HIV negative, but I didn't know the third, but he seemed like a normal california twenty-something. My friends all said that he left after the other little escapade in the other room, but I don't know this other kid, so I am not sure. I have the somewhat irrational fear that after I passed out, someone fucked me without me knowing it. I called my doctor to see if I should start PEP and he said that when cocaine is involved, sometimes people don't recall what happened, so he would recommend PEP. I just tested negative two weeks ago, and want to stay that way. What are your thoughts here, and how horrible are the side effects of PEP with Truvada and Kaletra? I so appreciate your expertise here. This is so not normally how I behave. I am beating myself up over what went on this weekend, which might explain my urgent call to my doctor asking for PEP. It was prescribed over the phone without a doctor visit or urgent care checkup... I am donating to your foundation as well. Thanks again for all you do.

Sincerely, Scared Shitless Dave

Response from Dr. Frascino

Hello Scared Shitless Dave,

"S. S. Dave," I'm delighted your question finally found its way to the proper forum. I agree with your doctor that cocaine (and other stimulants, like crystal meth) can increase the risk of unsafe sex, due to the concurrent lowering of inhibitions (common sense) and the raising of one's libido, a perfect storm for increasing STD risk. As for being fucked without knowing it, that's a bit more unlikely. Generally speaking, one would still feel the backdoor effects the next day.

As with all HIV exposures thought significant enough to warrant a course of PEP (post-exposure prophylaxis), I recommend you see an HIV specialist. That specialist would review and document your actual HIV-acquisition risk, review and optimize your PEP regimen (or stop it, if it is not warranted), evaluate and manage all PEP-related side effects and toxicities, evaluate and manage all symptoms that arise during the course of PEP to ascertain if you are experiencing acute retroviral syndrome and finally arrange for and interpret post-PEP follow-up HIV testing.

S. S. Dave, from the limited information you provided, I may not have recommended PEP. (I would need additional information before making a final determination.) PEP needs to be started as soon as possible, and no later than 72 hours, after the exposure. (You don't mention how long your interval was.) Truvada and Kaletra are a recommended three-drug regimen for PEP. Side effects and toxicities vary from person to person. Some folks feel "reasonably" okay while on these drugs; others have a very difficult time tolerating them for the full 28-day course. There is no way to predict how well you will tolerate this treatment. However, the HIV specialist can help get you through a full course of PEP.

Dave, I'm glad "this is not the way (you) normally behave." I was particularly worried about the cocaine use and the alcohol abuse leading to a blackout. Use this as a wakeup call. Alcohol and drug abuse can destroy your health and happiness. I urge you not to let this happen!

Thank you for your donation to The Robert James Frascino AIDS Foundation (www.concertedeffort.org). It's warmly appreciated. In return, I'm sending you my best good-luck karma that your follow-up HIV tests remain negative. Either way Dave, I'm here if you need me, OK?

Good luck. Be well!

Dr. Bob



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