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When can I sleep again?
Sep 9, 2009

Can you please clear one thing up for me once and for all, I have scoured the Internet and the contradictions are driving me insane. I am currently on a course of PEP after a risky encounter. From the date of the encounter when is the earliest time I can have a HIV test? Is it 3 months after the encounter or 3 months after the last pill has been swallowed or is it Something else altogether? If I have a test 6 weeks after the risky encounter will that give me a pretty good idea (although I realise not conclusive) or will the antivirals mask my results? Can you clear this up for all us PEP People. My clinic said "oh just come when you've finished the course and you'll be 99% sure then" even though they did insist I come back at the 3 month since incident mark too. Please clear this up for me Doc. And can I say what you do on here is remarkable, when people have no-one to turn to in what can be a most difficult and lonely time you are here for them all, you are truly a great person, thanks from us all.

Response from Dr. Frascino

Hi,

The clinic's advice, "oh just come back when you've finished the course and you'll be 99% sure then," is incorrect. Misinformation like this is one of the reasons I recommend that anyone who has had an HIV exposure significant enough to warrant a course of PEP be followed by an HIV physician specialist. (See below.)

As for testing recommendations post-PEP, you didn't need to scour the Internet. All you needed to do was check the archives of this forum. I've already "cleared this up" for all you PEPers!! (See below.)

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

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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