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Re: What happens in Vegas...PEP HELP

Dec 31, 2010

Thank you for your reply, I understand your position on the PEP being offered, however in your opinion would you have recommended it? And from what Ive read the 2 drug PEP would more than likely been the regimen recommended for an unknown status exposure. Also, regarding the vaginal secretion exposure to non-intact skin... what is the risk calculation of this type? If I was on my back and the female on top, and she was rather wet with vaginal fluid and of course it was wet below where the condom had been rolled to, and definitely on and around the base of the penis? , now I would agree that this happens everyday in heterosexual sex with a condom, however, she was grinding with such force that I received small abrasions on this area, not bleeding per se, but more like a bad shaving rash on the neck sometimes looks like. The infectious disease contact at the hospital did say this qualifies as non-intact skin. Also the psoriasis on my head and corona looked kind of like chapped lips, again not bleeding, but cracked . In your opinion, should I have worries of transmission via this type of exposure? I am a little confused as when I revisited your original answer You had worded it rather guardedly, as to say it was at least a "theoretical exposure" and again PEP should be " offered" but you didn't say recommended. I say this because after the side effects I was unable to access the prescribing Dr , so I sought some counselling at a local HIV resource centre and they almost laughed me outa there(not really, they were very nice but obviously were regularly seeing people for unprotected receptive anal sex and thought my case a rather humorous break in their day) One of the senior councillors there sat me down and said look you're taking PEP for a condom protected hetero sex encounter...regardless of whatever rash you had, you are fine, we have never had anyone with this type of exposure in this clinic and probably never will so stop putting those dangerous chemicals in your body and go back to your life, get tested at the prescribed interval and be done with it. What do you make of this? Could you weigh in on this please? Im having a real hard time finishing the PEP, I have missed a couple doses of Kaletra but still am taking the Truvada because of the side effects. Thank You

Response from Dr. Frascino


Sorry, but I really can't perform a more specific evaluation over the Internet, as I don't have the benefit of a thorough medical history and physical examination.

Based on the information provided, your overall HIV-acquisition risk is low, but not completely nonexistent. If HIV-infected vaginal fluids came into contact with non-intact skin, there is at least a theoretical risk of HIV transmission. Your parter was a rough-riding seedy hooker. PEP would not be strongly recommended in this scenario, but would be offered in light of the extenuating circumstances. If this were merely a case of "condom protected hetero sex," PEP would not be warranted.

My assessment and advice remain unchanged. (See below.)

Dr. Bob

What Happens in Vegas stays in Vegas I hope!!!! Dec 13, 2010

Hello Dr.Frascino,

Let me say that after discovering this web site I must say you and your colleagues are obviously very passionate and committed and on behalf of everyone here in need of some advice and perspective...Thank You sir. Im contacting you because I had a very bad experience, I was extremely inebriated in the wee hours at a rather seedy casino bar off the strip (yes I know,mistake #1, I actually was staying at a famous 5 star , but I ended up on the wrong side of the tracks for the filming of a television show earlier in the evening and I ended up staying for some drinks after it wrapped). I definitely had a target on my back as I was wearing high end clothing and jewellery and must have seemed wealthy looking compared to the local barflies that were hanging around. I really don't recall what exactly happened however I am convinced I was drugged by a pair of locals that I ended up befriending at the bar. I say that because I recall hallucinating and having blackouts during the next few hours. My fear is that I was exposed to body fluids during some sex with a prostitute. I recall having sex with a latino prostitute in a hotel room and I was lying on my back, It was dark and I recall she was on top and very rough and grinding my pubic bone , I estimate this lasted maybe 10 minutes, but I actually don't know . I didn't want this to continue and I wanted her off of me and I pushed her off and stood up, I recall a condom was somewhat halfway up my penis and I grabbed the end and pulled it off. There were definitely secretions all over the base of my penis. She grabbed at me and very vigorously started giving me a hand job with the secretions likely rubbing into my penis. Again she was very rough and I stopped her again after 5 minutes or so because it was painful the amount of force she was using. I recollect I tried to get rid of her and I blacked out and woke up an hour or so later robbed of my jewellery and cash. I immediately went to the shower and washed all over very well with soap however, the real fear is stemming from the fact that I do get psoriasis from time to time, and I happened to have an outbreak around my head and corona I also had some mild friction abrasions around the base or my penis/pubic area from the grinding. I flew back to the east coast the next evening and after I finished work I went to the free clinic to be checked out. As you know they informed me there are no tests for STDs that are accurate immediately after an incident, however they took my information and informed me I could be at risk for being exposed to virtually all of the STDs and I should also think about getting PEP. They arranged for me to go to the hospital for assessment. There I encountered a nurse to whom I told the story, she told me that it was probably fairly low risk but it was ultimately up to me if I wanted to start PEP. I was informed of the cost and the possible side effects and they gave me the first dose of Truvada and Kalestra at 60 hrs post occurrence. they told me to continue every 12hrs for 28 days and testing is arranged for 6 weeks and 3 and 6 months respectively. It is now day 5 on PEP and I am having body rashes and nausea and loose stools, I assume this is from the pills. Im so afraid of a possible exposure that I don't want to discontinue the PEP. My questions to you are ...

1) What is your opinion on the level of exposure ? and 2) In your opinion would you say that PEP is warranted in my situation?

Thank you so much, you are providing a great service.

Response from Dr. Frascino


Yours is an alarming and far-too-common Vegas story. Unfortunately, because the details of your walk on the wild side with the rough-riding (and tugging) Latina hooker are somewhat clouded by your inebriated (and perhaps drugged) state, it is difficult for me to provide an accurate assessment of your HIV-acquisition risk. On the upside, you did use a condom and even though it slipped a bit, the business end of your tallywhacker remained ensconced in his latex rain slicker. On the downside, you report Bouncing Betty at the Badda Bing was anything but gentle when riding your trouser snake or tugging on him. Plus, you had vaginal secretions on the base of your Mr. Happy, which Bouncing Betty used to aggressively yank your crank. Plus, you had a psoriasis outbreak around your "head and corona" and "friction abrasions around the base of (your) penis."

While I agree with the assessment you received at the hospital, "fairly low risk," your exposure was not a "no risk" situation. If Bouncing Betty was positively charged and if her vaginal fluids came into contact with non-intact skin on your home entertainment center, there would be at least a theoretical risk for HIV transmission.

To address your specific concerns:

1. Low, but not no risk.

2. PEP should be offered for this level of exposure, particularly considering the extenuating circumstances: seedy casino, seedier hooker, local trauma from the rough ride and the psoriasis outbreak.

I recommend anyone who has an HIV exposure significant enough to warrant a course of PEP be followed by an HIV specialist during the 28-day course of treatment. That physician can help with PEP-related side effects and other aspects of the treatment. See below.

Good luck. Hopefully what happened in Vegas will indeed stay in Vegas.

Dr. Bob

Is Altripla only sufficient for PEP (PEP AND THE NEED FOR HIV SPECIALIST, 2010) Mar 30, 2010

Hi Doctor,

I had an sexual encounter with a stranger. He sucked my cock and he ride on my cock just less than 1 min with out condom. i dint feel any pressure in the ass and it was very smooth.I release cum into to his ass.

I was worried, since i dont know the health status of the person, i have consulted emergency medical center after 30 hrs. The doctor gave me Altripla to take one daily before bed time and asked me to take an appointment with an HIV specialist.

I got appointment for date after 14 days from now.

Is Altripla only sufficient for PEP to avoid HIV? Do i need to consult HIV specialist ASAP(urgently)? Is the emergency medical center is giving correct dosage for me ?

Please answer my question ASAP. Thanks in advance.

Response from Dr. Frascino


Unsafe sex is risky business!

Atripla is a combination of three antiretroviral drugs -- efavirenz (Sustiva), emtricitabine (Emtriva) and tenofovir (Viread). It's the ultimate in convenience -- the three-in-one tablet is taken just once per day. It is a recommended fixed-dose combination drug for PEP.

It would be helpful if you could see an HIV specialist sooner than 14 days, particularly if you have any difficulty tolerating the therapy (drug side effects or toxicities) or develop any symptoms. A full course of PEP is only 28 days in duration. Perhaps the HIV specialist could work you in sooner or you could see a different specialist. I'll post some information below from the archives regarding PEP and the need to be followed by an HIV specialist.

Good luck.

Dr. Bob

Condom failure - PEP side effects (PEP AND THE NEED FOR HIV SPECIALIST, 2010) Jan 25, 2010

Dear Doc

I am a bisexual male who has always tried to be safe when it comes to sexual partners.

However during recent insertive anal sex with a casual male partner (of unknown HIV status), the condom split. I withdrew less than a minute later without ejaculation. There did not appear to be any blood or mucus, nor were there any cuts, lesions or anything else on me. I am circumcised (in case this makes a difference) - and my most recent HIV test (on the day of the condom failure) was negative.

I started the PEP course within 30 hours. However, almost at the same time as starting the PEP, my tongue became coated with a yellow mucus and I developed night sweats and a very sore throat which only started to subside on day 5 of the course. I have suffered the usual side effects from the PEP drugs (loss of appetite, nausea, etc).

Could this be a sign of seroconversion? Or is it coincidence/side effects from the PEP drugs?



Response from Dr. Frascino

Hello Concerned,

"Symptoms" that begin 30 hours after a potential HIV exposure would not be caused by HIV seroconversions. The symptoms associated with ARS (acute retroviral syndrome) become manifest two to three weeks after HIV primary infection.

As I have mentioned frequently in this forum, I strongly encourage anyone who has had an HIV exposure significant enough to warrant a course of PEP be followed by an HIV specialist. The specialist would be able to quickly evaluate and address concerns such as those you raise. (See below.)

Dr. Bob

Can PEP meds mimic ARS? (PEP AND THE NEED FOR HIV SPECIALIST, 2009) Aug 22, 2009

Hi Dr. Bob,

Thank you for all you have done and continue to do for people who find themselves scared and bewildered. A twist of humor is also helpful.

I have searched the archives. Simple question, I think, can PEP meds side effects mimic ARS?

Thank you kindly for your answer and please find a donation forthcoming to the foundation.

Regards, Amas

Response from Dr. Frascino

Hi Amas,

Simple question, yes. However, the answer is not quite so simple! HIV acute retroviral syndrome (ARS) symptoms are quite variable from case to case. These symptoms are also "non-specific," which means they can be caused by many different conditions (for instance many underlying conditions can cause fever, rash, malaise, etc.). Post-exposure prophylaxis (PEP) is any combination of antiretroviral drugs used to try to abort an HIV infection following an exposure. Each of these drugs has a wide array of potential side effects. Not everyone uses the same PEP regimen and not every drug has the same side effect profile. So since ARS symptoms are broad, varied and non-specific and since PEP regimens are varied with each component drug having a wide array of potential side effects, it is possible (although not highly likely) that some PEP-related side effects could mimic some HIV ARS symptoms. This is one of the reasons I always recommend (when possible) that folks who have had an HIV exposure significant enough to warrant a course of PEP be followed by an HIV specialist during the 28-day course of treatment. An HIV specialist is best suited to evaluate and manage any symptoms that might arise during a course of PEP. (See below.)

Amas, as you can see, not all simple questions have simple answers.

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

10 weeks conclusive? will donate!
Carpal Tunnel Syndrome Vs Masturbation

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