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Extremely Scared MEDICAL STUDENT After Possible Needle Stick! (PEP AND THE NEED FOR HIV SPECIALIST, 2010)
Feb 10, 2010

Dear Dr. Bob...I'm really hoping you can provide some information for me specific to my case. I would love to donate to your cause, but as you could guess, I'm living loan check to loan check with barely any money in between. If I need to donate I will because your expertise is very valuable to me but I hope you can help a student out. Long Story but here goes:

6 weeks ago I was drawing blood on a confirmed HIV+ patient (Viral Load 34000 and CD4 Count 87), using a 23 gauge butterfly needle. After I finished, I pulled the tubing to retract the needle back into the tube which I did, or atleast I thought I did because it didn't retract back all the way. Any ways, as I was cleaning my work area, and I was holding the butterfly in my hand (I know stupid stupid stupid me), I felt a small prick, something like a sharp pencil poking you, and so I reflexively pulled away and then noticed there was blood under my glove. Within 30 seconds I removed the glove wiped the blood off the base of my right palm and began to milk and inspect for a puncture mark but could not find any. I washed my hands but being embarassed like I am right now, I didn't report it to anyone for about 4 hours but then the fear took over and told my attending and he inspected for a puncture mark and said its up to me if I want to go to the ED and so I did. They gave me the stats along with my own research I saw its a 0.3% risk of transmission and prescribed PEP (Combivir and Viread x 30 days) and told me that it would drop the rate down another 79% or basically to 0.1%. Obviously my baseline EIA was negative and was negative at 4 weeks as well. I am due for my 6 week test this week, but I'm so scared. I took the medication for the entire month probably missing about 3 or 4 doses total, due to side effects but I forced myself to.

Now while on medication, at about week 3-4 I came down with what felt like a fever and tiredness, temp check ranged about 99.0 to 99.7 F. I also had a soar throat but was experiencing post nasal drip at the time as well so it could've been attributed to that. No swollen nodes, or visible rash. I did have a few episodes of diarrhea and lots of flatulance but nothing explosive. I felt weak and tired during the entire time on the meds but I was still able to finish my Interal Medicine rotation and start my Cardiology elective. Im now 2 weeks past PEP regimen and I started to have this itch on my left sole which has now progressed to a burning type sensation of both my feet, upto my ankles and side of my calves. I also have these brown pigment spots on both heels that are not raised lesions, but seem to be under the skin. I can't confirm if the spots are a new onset or old onset prior to exposure. I also have burning sensation in both my hands, forearms, and up to my axilla region. I also am starting to feel the same sensation on my neck and face as I type this to you. I read about Peripheral Neurapathies with acute HIV during seroconversion and now I feel so scared that I HAVE IT!!

Please answer the following:

1. What is your take on my risk exposure? 2. Did I have ARS? 3. Am I experiencing HIV associated peripheral neuropathy? 4. How long after stopping PEP can one experience drug related side effects?

Thank You so Much!

Response from Dr. Frascino

Hello Scared Med. Stud.,

Relax Max! Take three big clean yoga breaths. Go ahead, we'll wait. There, now ratchet that anxiety level down and let's review things calmly and rationally, OK?

Addressing your specific questions:

1. You only felt a small prick and you couldn't even find a puncture mark, frevinsakes! That hardly qualifies for a significant puncture wound. Many specialists may not even have recommended a course of PEP! I would suggest you review the published guidelines for occupational HIV exposures and the use of PEP. They can be downloaded at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5409a1.htm.

2. No. I very, very strongly doubt it. You do not have peripheral neuropathy. Rather, you have classic anxiety-related symptoms. I recommend all folks who have an HIV exposure significant enough to warrant a course of PEP be followed by an HIV specialist physician. The specialist not only is best equipped to evaluate and document actual risk, but he can also optimize PEP if it's warranted; evaluate and manage any symptoms or side effects that occur during the 28-day course of therapy; and, finally, he can arrange for and interpret post-PEP HIV tests. (See below.)

3. No. See above.

4. Drug-related side effects generally occur during treatment, not after it's been stopped.

You're welcome. I hope you learn a good deal from this experience, not only about needle/syringe safety, but also about anxiety, HIV-related fears, PEP, etc. These lessons will help you help others once you become a physician.

Good luck.

Dr. Bob

PEP meds timing slip-up ... help! (PEP AND THE NEED FOR HIV SPECIALIST, 2009) Sep 23, 2009

Dear Dr Bob,

I asked this question a few days ago, but didn't get a response, maybe cos I go the day wrong (d'oh) ... I've been wracking my brain since this happened. I'd be tremendously grateful if you could give me some advice!

After a relatively low risk encounter in a sauna in the early hours of Sunday the 13th (5 seconds of insertive anal after someone sat on me without my permission; I'd seen this guy bottoming with someone else previously), I was prescribed PEP and started my regimen of Truvada and Kaletra within 6 hours of the exposure.

So far I've taken my meds religiously at 9am (Truvada + Kaletra) and 9pm (Kaletra), as close to the 12 hour mark as possible, never more than 10 minutes out ... I've been informed that I can vary my dosage time by about one hour on this regimen without worrying.

The morning of day 7 of the regimen, I slept through my alarm. A friend phoned me and woke me up, which struck me as weird, and I immediately realised and took my meds at 10:40am.

Is my delay of between 1hr 40m and (as far as the treatment leaflets are concerned) 40m cause for significant concern?

Most of the questions regarding missed or lapsed doses on these forums refer to people who've been on meds for ages, and my documentation from the healthcare provider simply says "don't miss meds and take them on time", with lots of scary language. Am I at significant risk for PEP failure, as far as the science is concerned, due to this lapse?

Response from Dr. Frascino

Hello,

Setting aside the issue of whether PEP should have even been recommended for such a "relatively low risk encounter," your concerns about a one-hour-forty-minute delay in dosing is not a problem. This will not affect the efficacy of your PEP regimen. As I have mentioned frequently in this forum, I do recommend that anyone who has had an HIV exposure significant enough to warrant a course of PEP be followed by an HIV specialist physician for a number of reasons. (See below.) Such a specialist could have easily calmed your fears over issues, such as a delayed or missed dose. He would also more completely evaluate your HIV-acquisition risk and advise whether PEP is really warranted.

Now that we have that cleared up, I was wondering exactly how sauna-boy managed to impale himself on your throbbing tallywhacker without your permission???

Good luck!

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.

Regards

Response from Dr. Frascino

Hi,

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 (www.concertedeffort.org).

Be well!

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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