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PEP torn on continued use
Apr 19, 2009

Hello Dr. Bob

I have read many of your responses and find them all to be enlightning and through. I am a ER nurse and had a exposure to an HIV+ positive patient while pulling out a Saline Lock. The IV cath had visable blood on it. While pulling it out a small flick landed on the medial corner of my eye. Within a couple of minutes I flushed out my eye, I did not want to flush it out too much because I did not want to irritate the tissue for fear of opening a gateway for the HIV to enter, (not sure if this was the right move) In the meantime the patient had left so I was unable to discuss what had happened and her pharmacy regimine in more detail. We did have blood left over in the lab so standards labs were run including a viral load. Anyway PEP was reccomended to me based on the type of exposure; two drug therapy Combivir was given. I did not take the course right away, apprehension, worried of side effects, and the risk associated with transmission of this type put at 0.01 per the CDC. To make a long story short, I researched on thebody and other web sites had innitially decided not take the PEP, until my wife, who is pregnant, asked me that "if you dont take it and you become positive will you regret it? The obivious answer was yes. So at 16 hours post exposure I started PEP. I have since put "Mr Yuck" stickers on my bottle. I have experienced all the common side effects, GI distress, fatigue, insominia, and now severe constipation. In fact I feel like a totally different person, almost like being in a fog. Ive been on for 11 days now. And have since found out that source pt viral load was undetectable in blood. However I'm not sure if her HIV has any resistance to combivir, nor has occupational health made a mention of resistance testing. Based on the additional information of her viral load, method of transmisition, side effects would you reccomend continuing to take Mr. Yuck(PEP) or stop it altogether. Do these symptoms subside, or am I going to have grin and bear it for two more weeks. And wha do the studies say about waiting 16 hours post to start PEP(have been unable to find anything specific) I do have my 14 day labs coming up too. CBC CMP. Thanks so much for your answers to all your questions, they have been very helpful. Sincerely Torn on MR Yuck

PS Through this I have a new found sympathy for persons having to take these meds, and deal with this disease. Best of luck, and health to all who suffer from these meds and disease!

Response from Dr. Frascino

Hello Torn on Mr. Yuck,

Once again your post is an excellent reminder to all our readers that PEP is no picnic! I'm always amazed how many folks still think PEP is like a "morning after pill" and "no big deal." Hopefully those folks will read your post (as well as many other posts in the archives with similar "yucky" reactions to PEP!)

Determining if a course of PEP is warranted over the Internet is difficult, because I cannot have a give-and-take conversation with you regarding the precise details of the exposure. That's one of the reasons I strongly recommend all folks who have an exposure significant enough to warrant a course of PEP be followed by an HIV specialist. An HIV specialist is qualified to evaluate your actual risk and advise whether PEP should be continued or not. (See below.)

From the limited information you provided (source patient undetectable, exposure only to the "corner of the eye," etc.), I most likely would not recommend PEP. My advice is to check with an HIV specialist. Even if he recommends completing your course of PEP, he'll be able to help you cope with your PEP side effects, monitor you for toxicities and arrange for post-PEP HIV testing.

Good luck.

Dr. Bob

EMS Exposure (PEP AND THE NEED FOR HIV SPECIALIST) Mar 2, 2009

A patient of mine had projectile vomiting and some of it landed in my mouth and eyes. There was no way I could have avoided this. I do not think there is a risk of HIV transmission, however, the hospital put me on Viread and Combivir as a precaution. The patient was homeless, intoxicated, and not forthcoming of his medical history.

What do you think of this situation?

Response from Dr. Frascino

Hi,

Vomitus (like saliva, urine, tears, sweat, nasal mucous and feces) is not considered to be a risk for HIV transmission unless there is visible blood present. PEP was most likely not warranted. As with all people who have had a potential exposure significant enough to begin a PEP regimen, I recommend you be evaluated and followed by an HIV specialist physician. (See below.) He will take a detailed history and advise whether or not PEP should be continued or modified. Also, since you know the potential source patient, he could be contacted and asked to undergo HIV screening.

Good luck.

Dr. Bob

pep and the worst year of my life. (PEP AND THE NEED FOR HIV SPECIALIST) Jul 13, 2008

I'm a bit nervous because I just took PEP and I don't know what the side effects are so maybe you can help out with it.

I've been having pains in my right abdomen for about a month now but my liver enzymes are normal. I'm still a bit scared because it is where my liver is.

Yesterday, I has receptive anal sex with a stranger. I put a condom on him and he was doing what he was doing. Then he said, I THINK SOME ONES COMING, So I look around, there was nobody there and looked behind me. Saw that the condom with lube was on the floor and his zipper was zipped up. Didn't think anything of it. Went home and pooped. I saw a glob of his semen in the toilet and was going to kill myself.

My possible exposure before this one was 4 months ago. It was anal receptive without condom with a guy I barely knew who I can't get in touch with. I came down with flu symptoms and was told to test at 3 months and then 6 months and then a year because I got really sick.

So my result was negative today before I started pep. I wanted to know if my testing window period will change for the sexual encounter that took place 4 months ago or should I trust in a 4 month negative??????

PEP treatment is 1 month.

When should I test again.

Should I stop taking the pep?

Does pep have hiv in it that will effect me if I have previously been exposed(4 months ago), ruining my chances of being negative?

I've had the worst luck any guy can have. I didn't have sex for 4 months and the one day I decided to cruise, I got violated.

Will pep have a bad effect on me if I am infected and don't know it from the 4 month issue?

I know that you're the only one that can answer these questions for me.

Response from Dr. Frascino

Hello,

Why would you think I am the only one who could answer your questions! Your questions are not uncommon or particularly challenging. Any HIV specialist should be able to help. I'm a bit concerned by your first statement, ". . . I just took PEP and I don't know what the side effects are . . . ." The prescribing physician (hopefully an HIV specialist) should have explained potential side effects at the time the medications were recommended. I can't specifically answer this question, because side effects are different from person to person and also the range of potential side effects differs depending on which antiretroviral medications are in the PEP regimen. I'm also concerned about several of your other questions, such as "Does PED have HIV in it?" Questions like this demonstrate a profound lack of understanding of post-exposure prophylaxis and antiretroviral therapy. (The brief response is no, of course these medications do not contain HIV!)

Your multiple concerns clearly demonstrate why I strongly recommend that all folks who have had an HIV exposure significant enough to warrant PEP have an HIV specialist involved in their care. The HIV specialist will:

1. Evaluate and document the HIV risk exposure.

2. Recommend PEP if warranted.

3. If PEP has already been started, the HIV specialist will revise, optimize or suggest discontinuation of the PEP regimen as indicated.

4. Evaluate and manage all PEP-related side effects and toxicities.

5. Evaluate all symptoms, including potential acute retroviral syndrome symptoms, occurring during the course of PEP therapy.

6. Arrange for and interpret post-PEP HIV testing.

My advice to you is to contact an HIV specialist. He or she will specifically address all your concerns in detail. I would also suggest that you be a bit more discerning regarding your sexual partners. When that last jerk said "I THINK SOME ONES COMING," apparently he was talking about himself! If he managed to ditch the condom without your realizing it, you really need to pay more attention to "what he is doing while he's doing what he's doing," particularly when he's "doing" you!

Good luck!

Dr. Bob

ARS or PEP side-effect? Jul 3, 2008

Hi Doc,

Thank God for you and this website! Quite concerned over the following:

I'm on PEP (Kaletra and Truvada) after a potential exposure (4 days ago) and noticed yesterday for a time (and again today) that my face is quite warm and I feel flushed. I have had the usual loose stool, stomach-related side-effects of the meds but I'm REALLY hoping that you can tell me if a slight temperature might also be a side effect and not a result of the "ARS" I see so many here concerned about. Obviously self-diagnosis is a BIG mistake, as is worrying and stressing but I'd very much appreciate your honest opinion.

Many thanks

Response from Dr. Frascino

Hi,

Your question graphically demonstrates the reason I suggest anyone who has had an HIV exposure significant enough to warrant a course of PEP be followed by an HIV specialist. The HIV specialist can document your true degree of HIV risk, optimize PEP regimens, evaluate and manage all PEP-related side effects or toxicities, monitor for and evaluate any possible ARS symptoms and arrange for an interpret all post-PEP HIV tests. Having to take a course of PEP is indeed stressful. Having an HIV specialist involved can significantly reduce that stress. I cannot evaluate symptoms or make diagnoses over the Internet. What I can tell you is that "feeling flushed" and actually having a significant fever are two very different things. Also, even if you were to have an elevated temperature, there are many conditions other than HIV that could be the cause. I can also advise you that symptoms four days after exposure would not be related to HIV. It takes weeks, not days, for the symptoms of acute retroviral syndrome (ARS) to appear.

Dr. Bob

condom broke during the act Jan 20, 2007

First, Thank you so much for this forum.

about 4 days ago i had vaginal sex with a woman who i later discovered to be very high risk. the condom broke during our act and it was less than 3 or four minutes later that i finished. i don't know if she was hiv positive and have no way of finding out. the following day I went to the emergency room and was perscribed ATRIPLA. and of course i am not feeling very well at all on it. I go to the bathroom often and have the symptoms of a low fever at times during the day. cottonmouth, sore throat ...

I live in san francisco, and am wondering if I should have a follow up visit with a specialist in the area. And How I would find such a doctor.

Also was my risk and exposure high enough to warrant such a drastic step as ATRIPLA?

And of course I am completely freaking out that one stupid drunk moment has damaged my body to such a degree, has anyone built a time machine yet?

Response from Dr. Frascino

Hi,

Personally, I feel anyone who has had an HIV exposure significant enough to warrant a course of PEP should be followed by an HIV specialist, if possible. The HIV specialist would:

1. Evaluate the risk to see if PEP was really warranted.

2. Optimize the PEP regimen.

3. Evaluate and manage PEP-related side effects and toxicities.

4. Arrange for and evaluate post-PEP HIV testing.

Living in San Francisco, you have many options from which to choose regarding HIV specialist. Certified HIV/AIDS specialist physicians in your area can be located by consulting the American Academy of HIV Medicine Web site, www.aahivm.org.

Finally, if you do find that time machine, let me know. I know millions of folks who want to go back to 2000 and 2004 and recast their presidential vote.

Good luck.

Dr. Bob



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