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PEP? #3
Apr 16, 2009

happy easter dr. bob. i am the same guy who wrote "PEP?" and "PEP? follow-up and donation confirmation". i have started taking the PEP (combivir & stoctrin) and its already taking it's toll on me... i am feeeling terrible.. i feel like i have to throw up every hour and i am weak and shaky on my legs, i have muscle pain and a weird appetite to eat anything with a huge amount of fat... that seems to calm my stomach short-term, only to make it feel like it's blowing up after a few hours after the meal... I TRULY HATE IT. no, its not a picnic, it's indeed serious stuff... i wonder if that stuff is similar to chemo-therapy? also, do HIV+ people have to go through this every day because of the medication they take? if that is the case, then we must stress here. PEP and HIV medication is not an option, being safe is. the condom website you cave me. do they ship overseas??!! let me check again... anyways, here the bit of good news. i invited the gal-pal to a weekend in singapore in a 5 star hotel and she said she maybe will go for the test with me.. now of course i am trying to make this a condition for the trip..sort of trying to imply that gently to her.. she said she likes to do it but is extremely scared of doctor and needles!!! so anyways, maybe its her first time she even gets an injection!!! so what kind of test shall i ask the french doctor here in Vietnam to perform? thanks again and hope your good luck karma will provide me ZEN after the test results... if it's negative, i can stop taking the above mentioned medication, right? i hope so, because it's causing seriuos inconveniences to me. also, i know that doctors dont share test results with people other than the patient. how can i get her test result? i dont think bribing a french doctor works.. :p

Response from Dr. Frascino

Hi,

Welcome back to the forum. Sorry you are having such a difficult time.

Combination antiretroviral therapy is indeed potent stuff. It is quite similar to some forms of chemotherapy. Yes, those of us who are "virally enhanced" do have to take these medications every day essentially forever (or at least until we find a cure). I've been popping fistfuls of antivirals for well over a decade. No picnic indeed! The old adage "an ounce of prevention (the weight of a latex condom) is worth a pound of cure (I've swallowed pounds and pounds of antivirals!)" definitely applies to HIV disease. Regarding condomania.com's overseas shipping policy, I'm not sure. However, I would assume they do ship worldwide. After all, condoms are not contraband, unless of course you want to ship them to Vatican City!

I would be very upfront with your gal-pal. Getting an HIV test is part of the deal. Remind her you are getting tested as well and this is information she should want to have. The basic HIV screening test is an ELISA test (sometimes called an EIA test). It's also possible that OraQuick oral fluid rapid tests may be available in your area. These do not require a needle or any blood. You just swab the gums and the results are available within 20 minutes. A negative OraQuick rapid test is considered to be a true negative. A positive test, however, is only considered to be "preliminarily positive" and a blood test is required for confirmation because OraQuick tests do pick up some false-positive results.

As for finding out the test results, both you and she should ask for a written copy of your test result from the doctor or clinic. You can then show the results to each other.

I'm resending my best good-luck/good-health karma and I'm anticipating considerable "ZEN".

If indeed you are both negative, yes, I would recommend you discontinue PEP, as I previously mentioned. See below.

Good luck.

Dr. Bob

PEP? follow-up and donation confirmation Apr 10, 2009

dear dr. bob, i have just donated us$599.99. the reason why i chose this odd figure is because its going to be easier for you to confirm that the cash has been wired... well, you know, the thing with pep is.. is it worth taking the risk of the serious side-effects (although last time i took it i didnt have severe side-effects, but unpleasant ones; but that may be different this time?!)? plus, let us say i start taking the course and ask the girl to do a test (which i havent managed yet, she feels i think she is dirty when i ask her to go for a test with me and me mentioning to her that i will do a test too to make her feel safe dont really work at this point..) and then she finally would consent, could i stop using the course then? yes, the window period i know.. but thats all a bit too far stretched then, isnt it.. remote chances, i would agree. now, does PEP function like an antibiotic? i know it isnt, because it doesnt treat a bacterial infection, but does the body build up resistances against the meds if the full course is not taken? what do i need to tell the doctor here in vietnam to regularly check me for if i chose to do the PEP (PEP is not available here as far as I know and I would buy it in Bangkok which probably shows you that doctors here are not really experienced in PEP, etc. but if i get a set of clinical tests (for liver function for example i would assume), then what shall i ask them to check: blood count/liver function?! what about the potential of getting diabetes from PEP? I know it doesnt really belong in this forum, but the initial reason for talking about PEP is my unprotected penile-vaginal exposure... i hope you let it slip.. ;p again, thanks for your help. i am one of the worried-wells... but only after i get the test result i know if am well or not, so i am worried sick, not well now... how would you convince a girl to go for a test with you after such an exposure? consider vietnamese traditions etc. etc... if you can..;p i am young, and i dont really feel proud of what i am doing and that i am not proud to say that i went through 2 PEP courses in my life ... but i am the way i am, i have mistakes and i tried to fix them.. i am on the right track, sometimes.. but i feel ashamed just throwing money at medicine after such an exposure. it should not have happened in the first place, i know.. i read an article by a guy from europe who basically said that HIV transmission between man and women.. or more specifically from female-to-male is very very difficult to occur. there have to be obvious cuts or wounds on the penis... but then i ask myself?!! who is fiddling around with a knife on his woody that there are such cuts? i mean there must be a natural way of transmission, where does it actually enter?? another thought and maybe a bit far stretched. if you use a condom, you will notice that there is a layer of lubricant that remains on your penis.. and if you then take a shower, you will see that the water will drop off that layer without penetrating your skin.. wouldnt it be great to invent a liquid that can be applied on your penis and does prevent liquid, including vaginal fluid from penetrating your skin? or does that not work at all?! you know bob, its hard to convince a vietnamese girl to use a female condom... they think: dude, you are shaging me, you need to be responsible and take all possible meassures that you wish to make it work, i am not doing anything...you know what i mean? now, enough said.. i hope my posts help some other folks out there too... i think in most cases its an accident or a one-time case that someone doesnt protect themseleves and then they learn from it. not me.. i am not there yet, but i am trying... i have been seeing psychologists for ages and it didnt help. now i need to work on myself to improve.. but please guys, please out there.. stop being scared about a lap-dance with underwear, etc... this is ridicululous for a disease like HIV. Its not easy to catch, but you dont want to take the chances. If you are going for a lap-dance or if you are rubbing your penis around her wet underwear... dont worry too much - i would feel bored by a lap-dance and grinding my thing on someones underwear, but if you are up for it, do it every day and you dont need to worry about getting HIV... it doesnt "fly" like a bee from blossom to blossom... and also toothbrushing and if she uses her slightly moist juicy juice hand to rub your woody.... NO RISK!!! i am sick of these questions... sorry bob, had to mention it... take care 27 years old worried guy on the other side of the planet

Response from Dr. Frascino

Hi,

Wow, you certainly have posed many questions! I'll try to hit the high points, OK?

1. Is PEP worth the risk? This is a difficult question to respond to because each exposure situation is somewhat unique and a discussion of "to PEP or not to PEP" can be complex, as there are many variables to consider. In general a recommendation to take PEP is made if a person has had a significant exposure to HIV. IN cases such as these it is definitely worth the risk. In cases where an exposure is not definite, the best we can do is discuss how likely an exposure could have been. As with any medication, the potential benefits of a therapy need to be carefully weighed against the potential risks of side effects and toxicities.

I should also mention "PEP" (post-exposure prophylaxis) is a general term and does not refer to specific medications. There are many different combinations of antiretroviral medications that can be used for PEP. Each medication, of course, has different potential side effects and toxicities. Selection of which medications to include in a PEP regimen depends on several different variables (such as taking into account HIV medications the source patient may be taking, drug allergies, potential side effects associated with certain drugs, drug-drug interactions with other medications you may be taking for other conditions, etc.) As you can see the PEP decision is not always straightforward. If you'd like to read the US Guidelines for when and how to use PEP, you can download the document at www.cdc.gov/mmwr/PDF/rr/rr5402.pdf.

2. Should you stop PEP if your gal-pal tests HIV negative? Yes, I would advise stopping. The only risk remaining, if she tests negative, would involve her still being in her three-month window period. The chances of this actually being the case are very remote at best.

3. Does PEP function like an antibiotic? No, not exactly. Antibiotics treat established infections. PEP is designed to abort a potential infection.

4. Not taking a full 28-day course of PEP would not cause resistance to the drugs. Resistance could develop however, if the medications are not taken as directed on a daily basis, i.e. if you skip or miss doses. The problem with not taking a full 28-day course of PEP is that it would be less likely to be effective in aborting a potential HIV infection.

5. Diabetes is not a risk, because PEP only lasts 28 days. Diabetes is more of a risk for those of us who need to take these medications for years and years.

6. How do you convince a girl to go for a test? Ask nicely. Offer to be tested with her as this is information that could help her as well. Consider going out to lunch or dinner with her after the test. Thank her for her cooperation and let her know you're a worry wart kind of guy and you're not accusing her of anything.

7. Articles that claim female-to-male transmission is rare or difficult are just plain wrong. Remember there are 34,000,000 folks infected worldwide today. The vast, vast majority of these folks contracted HIV through heterosexual unsafe sex, both male-to-female and female-to-male! It is more efficient for an infected male to transmit the virus to an HIV-negative female, because he shoots a load of infected jizz directly into her vagina, which is lined with a mucous membrane that can directly absorb the virus. For female-to-male transmission, the infected vaginal/cervical fluids need to come into contact with the mucous membrane lining the male urethra (pee hole). Cuts and wounds are not a prerequisite for infection!

8. Microbicidal gels have been the subject of clinical research for years. Unfortunately so far we've been unable to devise one that is both safe and effective.

9. I'm glad you are getting psychological help. Don't be too hard on yourself. We are all only human and that means we all make mistakes, even yours truly! The important thing is to recognize our mistakes, accept responsibility for our actions and learn from our indiscretions! I hope you'll consider some of the safer sex ideas I posted in reply to your initial question. (See below.)

10. Thank you for your generous donation to the Robert James Frascino AIDS Foundation. It's urgently needed and warmly appreciated. Your one gift will touch many lives. In return I'm sending my best good-luck/good-health karma that your definitive HIV tests remain negative.

Good luck.

Dr. Bob

PEP? Apr 9, 2009

I had unprotected sex last night with a Vietnamese lady... who I believe is not a prositute but opportunist and would go with a guy who treats her well and has some $ to spend... Now, I am worried sick, because I am sick not using a condom. I tried humangus amounts of condoms with different shapes and sizes and whatever, but my 3rd leg just doesnt stay hard when using it... Plus, here in Vietnam there isnt a selection of condoms, and more importandly, none of them would really fit. Anyways. I still have a half course of PEP that I did not finish last time I had an exposure (and the girl that I had sex with went to test and was negative). Now, shall I start taking that other half course? And then go buy another round when I am in Thailand next? I must say I'd prefer not to take it, because it just made my whole body turn upside down last time and I felt really really bad! And: Can I take it and go to a test after 14-days and it will provide an accurate first result? I know, the 3 months mark is key, but nowadays, p24/antigen/combo/antibody/nuclear tests, etc. should have over 96% chance to provide an accurate result after let us say 14 days? Will the PEP influence that result and provide a false-negative result? Because I feel confident of stop using the PEP if after let us say 10 days the combo tests come back negative. Or am I wrapping myself into unwarranted security? Please help! Freaking out. Since the girl didnt cost me a cent and the cause here is so much more valuable than having a shag and feeling bad for the next couple of month, I will make a donation. Please let me know how as I am not living in the US. Thanks so much and I will donate US$600. Will that help?

Response from Dr. Frascino

Hello,

Your HIV risk is unprotected penile-vaginal sex with a woman of unknown status. Certainly unprotected sex does place you at some degree of risk for STDs, including HIV. PEP would be considered if it was felt your partner was most likely HIV infected and if the treatment could be started soon after the exposure (no later than 72 hours after the exposure). If you are still in contact with your gal-pal, you could accompany her (if she agrees) to get a rapid HIV test. If negative, your chance of being infected decreases significantly. (She would have to still be within her "window period" and the chances of your being that unlucky are remote at best.)

If you do decide to take PEP, it should be started as soon as possible. It's most effective when begun as soon as possible after an exposure. It should be taken for a full 28-day course. (We have no information on the efficacy of taking only a 14-day course.) Yes, PEP can have significant side effects and be difficult to tolerate. As I have mentioned here before, PEP is no picnic!

The guidelines for HIV testing post-PEP recommend testing immediately and at six weeks, three months and six months from the date of exposure. Negative results at 14 days would be encouraging but not definitive or conclusive. I cannot confirm the "96% chance" statistic, as there are far too many variables to consider (generation of HIV test being used, for instance). Even if the 96% figure was correct, missing 4 out of every 100 positive tests is not nearly accurate enough when dealing with an illness such as HIV. HIV viral load tests can be affected by PEP. (The antiretroviral drugs in a PEP regimen could drive an HIV viral load to undetectable levels thereby giving a "false-negative" result if the test was being used for diagnostic purposes.) PEP would not significantly affect HIV-antibody tests using the recommended post-PEP testing schedule mentioned above. Should you feel confident stopping PEP if your HIV combo test comes back negative after 10 days of treatment? No, absolutely not.

Finally, regarding your problem maintaining your erection while using condoms, I have several suggestions:

1. Condomania.com has a wide selection of condoms for a more custom fit.

2. You could try using the female condom with your partner.

3. Try a "cock-ring." It's a constricting band warn at the base of the penis that helps maintain erections.

4. Erectile dysfunction drugs (Viagra, Cialis, etc.) could be tried.

5. Begin a monogamous relationship with an HIV-negative partner.

Thank you for your very generous donation to the Robert James Frascino AIDS Foundation (www.concertedeffort.org). It's urgently needed and warmly appreciated. In return I'm sending you my good-luck/good-health karma that your definitive HIV tests are negative.

Good luck. Be well.

Dr. Bob



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