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Trauma Resuscitation Differing opinions

Oct 22, 2009

Dr. Bob,

I recently wrote to you in a message titled "Trauma Resuscitation". Due to some questioning, my colleagues and I called the national healthcare workers PEP hotline (this was before you were able to address my question). One specialist said that since it was a possibility for a small amount of blood to have gotten in our eyes or mouths during the time we were washing the blood out of our hair, she recommended PEP. So now 3 of us are on Truvada. Another stated that she would be fine if we didnt start but to start if it would give us peace of mind. Its interesting and sad to see that even among experts, there is no agreement. I think this adds to the misinformation out there regarding HIV transmission among HCW. Nonetheless, I appreciate your work and the time you take to help people. Even with this possibly life changing event, I still go into to work to help those in need whether they are pos, neg, black, white, green, republican, democrat.

Even a poorly paid resident can muster up a donation, especially one for a good cause.


Trauma resuscitation Oct 20, 2009

While part of a trauma resuscitation, I was splashed by an HIV+ patient. I was gowned, gloved, and masked. Some blood got on my hair, and 30 min after we finished i washed my hair in the sink. When I stood straight up, water from my hair got onto my face and eyes. Could this pose a risk?

Response from Dr. Frascino



Dr. Bob

Response from Dr. Frascino


I agree medical decision making is often not merely black or white, but an infinite number of shades of gray. Perhaps that's why folks often talk about both the art and the science of medicine. That said, I still strongly disagree with the recommendations for PEP and I'd be willing to wager the vast majority of experienced HIV physician specialists would agree with me. You were gowned, gloved and masked. The blood in your hair was at least 30 minutes old when you washed it out. Your HIV-acquisition risk is nonexistent. PEP is not warranted. You can print out a copy of the updated U.S Public Health Services Guidelines for the Management of Occupational Exposures to HIV and Recommendations for Post-exposure Prophylaxis at

If you choose to continue PEP, I would recommend you be followed by an HIV specialist physician (see below). And if he's a good HIV specialist, I wouldn't be surprised at all if he advised you to discontinue PEP. Also, when PEP is warranted, I generally use a three-drug regimen rather than two (Truvada is a combination of tenofovir and emtricitabine). The selection of which PEP drugs to use should take into account the medications the source patient is on and those he has shown resistance to antiretrovirals to in the past (if known).

Thank you for your donation to The Robert James Frascino AIDS Foundation ( It's warmly appreciated. In return I'm sending you my good-luck karma that you are and remain HIV negative!

Dr. Bob

Will PEP help me (PEP AND THE NEED FOR HIV SPECIALIST, 2009) Jun 24, 2009

Dear Doctor Frascino,

I had written to you earlier also. I do understand that sheer volume of mail does not permit you to answer every mail.

I made the mistake of seeing a sex-worker and had vaginal intercourse with her. I used a condom, and I think did not break or tear during the act which lasted for 12-15 minutes, but what really bothers me is

1. She applied baby oil for lubrication; oil is known to make latex very porous and considering the duration was 12-15 minutes.

2. The condom, though latex, did not state "for disease prevention" - per CDC.

I do not know of her HIV status, and upon asking she got nasty. But due to occupation she would certainly qualify as 'high risk'

This was on a Saturday, June 20, and after visiting several ERs I was able to get Truvada prescribed - which I started on the 60th hour.

What are my chances ? and should I request my Physician to consider a 3/4 drug combination ?

I would also like to note that I found the website, answers to queries, and information on PEP very useful. Something that the government should have been doing. I also wanted to share with you that - So you and your foundation can continue to offer support and help, I will make a financial contribution to the foundation.


Response from Dr. Frascino


From the information you provided I would not have recommended a course of post-exposure prophylaxis (PEP).

You are correct that oil-based lubricants applied to latex condoms can cause the latex to denature making them more likely to fail (break). However, your condom remained intact per your report.

Most sex workers are well versed in safer sex practices and know to use latex (or polyurethane) condoms. (Then again they should also know not to use oil-based lubricants on latex!)

My advice now that you've been started on Truvada as PEP for a questionable exposure (at best) is that you consult an HIV specialist. He will review your exposure history in greater detail and advise whether PEP should be continued or modified. If you continue with PEP, he will monitor you for side effects and toxicities. He will also set up and interpret post-PEP HIV testing out to six months. I'll reprint below some information on the desirability of having an HIV specialist involved in supervising those who have had an HIV exposure significant enough to warrant a course of PEP. As mentioned above, I would not have recommended PEP!

Good luck. Thank you for your interest in making a donation to the Robert James Frascino AIDS Foundation (

Be well!

Dr. Bob


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


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


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


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


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,

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

Missed taking my meds
Fear and Shame..affraid to get tested (WHAT YOU DONT KNOW CAN KILL YOU, 2009) ( IS IT BETTER TO GET HIV TESTED OR NOT TO KNOW, 2009)

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