worried-unwell PEP related q...
Mar 5, 2011
Dear Dr. Bob,
I had the pleasure of using your services (your generousity in replying millions of emails here) previously and also made a donation of US$700 I think around about a year ago when I was on PEP... Yes, you can feel free to hit me, because I am on PEP again... I had unprotected penile-to-vaginal penetration with a prostitute from the streets in Vietnam and my being drunk also meant my being braindead... so condom use .... nope! How stupid can one be? Anyways, I hope my questions, although perhaps controversial because I am implying a reply on them may help other people also in their fears, their worries and their responsibility towards their own health and towards other people's health. The status of the girl is unknown in terms of HIV but clearly she was not the healthiest girls I have seen (discovered that in the day after the night sort of...in daylight) Risk for a man? Relatively low but not non-existent.. PEP warranted? In Vietnam on the streets? Perhaps yes... perhaps no.. we will never know... now a few questions: - What would you recommend someone who has severe side-effects... mainly nausea...and fatigue Is there something that you could say will work to counter that? I feel ill and like shit but that's the punishment for my stupidity I guess.. nevertheless perhaps someone will forgive me and knows a good remedy for severe nausea.. I have been working only half days and I am thinking.. can I work half-days for a WHOLE MONTH while on PEP and havin nausea/fatigue? Uuuhm.. not so good for my job ... then comes the question: Isnt it that in studies actually only 2 weeks PEP has also proven effective? One week as too little and two weeks as relatively effective? You know why I am asking.. because the side-effects make me really ill..
Another question is: Why do pharma companies pretend there is no cure for HIV while they surely must have a treatment? How can it be that they can prevent the virus from entering the body (I guess with the meds we have now relatively successfully)...but they cant make them go away? See I think they have meds that only reduce viral loads because they can keep on selling them... Also I heard that there is a chromosome that prevents HIV from affecting the body and if you get a bone-marrow transplant from a person with that chromosome (or is it another DNA thing, not sure now) then you get cured. Surely a bit of a massive undertaking but there must be people willing to do that. Anyways, this forum is safe sex (which we should all know by now what it means.. yet hit me on the head I ignored, once more) and HIV prevention. So now down to testing .. if I get tested while on PEP for 2 weeks. What kind of test would relatively likely provide me with a 90%+ result? Nuclear tests? Another donation on the way...this time it may be a bit lower... US$500 sounds good?
Response from Dr. Frascino
Welcome back to the forum. Although I'm sorry it has to do with another unsafe sex experience. I certainly won't chastise you excessively, because even without being drunk, it's a well-documented fact that the higher powers gave man both a brain and tallywhacker but only enough blood to run one at a time.
Regarding your lapse of judgment in Vietnam, I agree your overall HIV-acquisition risk is relatively low, but not nonexistent. Considering the circumstances and that your partner looked somewhat unwell, a course of PEP is certainly reasonable.
PEP-related side effects are common and can be very annoying to downright incapacitating in some situations. Do you have to just tolerate the intense nausea and fatigue? No, absolutely not. As I have mentioned many times in this forum, I very strongly recommend that anyone who has had an HIV exposure significant enough to warrant a course of PEP should be followed by an HIV specialist physician. See below. One of the main reasons for this recommendation is that HIV specialists are best equipped to evaluate and manage PEP-related side effects and toxicities. There are, for instance, many anti-nausea medicaments that could ameliorate your symptoms (depending on severity). The fatigue symptom can be a bit more challenging, but various treatments are indeed available. When PEP-related side effects can not be adequately controlled, an HIV specialist may recommend a change in the PEP regimen. There are now a number of very effective PEP regimens from which to choose. Because many of the remedies I would recommend require a prescription, I won't give you specific names of the medications, but rather recommend you sync up with a local HIV specialist for a complete evaluation of your current symptoms and ongoing management.
Regarding recommendations for duration of PEP therapy, a full 28-day course is still recommended and remains universally accepted as the appropriate dosing regimen.
Regarding a cure for HIV/AIDS, your concerns about a Big Pharma conspiracy are quite common, but completely unwarranted. Check out my recent three-part blog discussing potential HIV cures on The Body's blog page. Within the blog you'll find links to questions I've already responded to that discuss the "delta 32 mutation" and the bone marrow transplant "cure" (The "Berlin Patient").
As for HIV diagnostic testing while on PEP, RNA PCR viral load testing would not be recommended for diagnostic purposes. If you were HIV infected your PEP medications could suppress HIV plasma viral load to undetectable levels. If you then use this test to try to determine if you are infected or not, you could get a false-negative (you could be infected, but have undetectable viral load on PEP).
As for a test that will provide "90%+ result" at week two, none exists! I would strongly suggest you follow the post-PEP testing guidelines, which recommend HIV-antibody testing at four-six weeks, three months and six months from the date of exposure. This is the only way for definitively determining if you are infected or not.
Finally, thank you for your ongoing support of The Robert James Frascino AIDS Foundation (www.concertedeffort.org). Your generous gifts have and will continue to touch many lives in desperate need. In return I'm sending you my best good-luck/good-health karma that your definitive HIV-antibody tests remain negative.
Good luck. Be well. I'm here if you need me, OK?
Baseline HIV Testing before giving PEP? (PEP AND THE NEED FOR HIV SPECIALIST, 2011) Feb 6, 2011
Hi there Dr. Frascino,
I understand you must have tons of questions to answer so I'll try to be as short as I can. I went to the ER after a possible exposure, they called the ID doctor that was on call and he decided that my risk were "low-moderate" and warranted PEP. They took some blood and for a complete STD panel including HIV (I had to sign a consent for the HIV test). I was given an initial dose of PEP, a prescription, and told to follow up with the ID doctor in the clinic in a week. They also said that I should be able to get my test results in 3 days from Hospital Records. I picked up my results 3 days after and everything was negative, but the HIV test results was not there; I then contacted Records by phone and asked why my HIV results where not there; the lady said to call back which I did and she explained that she had called the lab and the test where not ready that sometimes those get sent out and take longer. I called a few days later and still no results so I contacted the lab directly and this is the answer that I got "The HIV test was cancelled per request of the ID doctor and that is why there are no results at records, the test was never done." I kind of found that weird but waited for my follow up appointment with the ID doctor. He ordered some liver tests and explained that my risk was low-moderate. I asked him about my baseline HIV test and he said that that was not really needed, that I should do a PCR at 15 days at a location other than the hospital because since I do not have insurance they will not do it there, and if it was negative then I could decide to stop PEP. I told him that I had called the hospital lab and that they had told me that the test was cancelled by him; he looked confused and said "they said that?"
Now here is my question, since this is giving me a lot of stress as it is, I've started to wonder why this happened? did the hospital told him to cancel the test because they don't do hiv testing or because I do not have insurance? I think I am even being delusional and I am wondering if those baseline tests were indeed performed and it was positive and he decided not to tell me since I had already started PEP? I do not know I am freaking out here... What do you think really went on Bob????
Please drop me a much needed lines about this, Thank you so much for your time,
David btw: I am a premed student.
Response from Dr. Frascino
I agree you should have an HIV-antibody baseline test. You can get it done now. If you are HIV infected, the HIV-antibody test will still be positive, even though you are taking PEP.
I'm quite concerned on several levels about the ID doctor's advice. First, there was that confusion about your baseline HIV test. Plus, I'm concerned about his recommendation you get a PCR test done while on PEP to ascertain if you've been infected. That doesn't make much sense! If you are positive or seroconverting to positive, PEP could suppress the HIV plasma viral load to undetectable levels. Consequently, if the ID doc is using the PCR as a diagnostic test at day 15 while you are still on PEP to determine if you are infected, the test could be a "false negative." I would suggest you find a more competent physician preferably an HIV specialist (see below).
PEP Dec 27, 2010
I m currently on PEP on day 5 which is Aspen Lamzid,can i still go see the doctor for better medication or this is enough to reduce the chance of being HIV+.My PEP as started 16 hours after exposure.Please help
Response from Dr. Frascino
Yes. You should be followed by an HIV physician specialist. She will advise whether your current PEP regimen is adequate or should be modified.
Is Altripla only sufficient for PEP (PEP AND THE NEED FOR HIV SPECIALIST, 2010) Mar 30, 2010
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.
Condom failure - PEP side effects (PEP AND THE NEED FOR HIV SPECIALIST, 2010) Jan 25, 2010
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
"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.)
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.
Response from Dr. Frascino
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.
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
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.
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!
ARS or PEP side-effect? Jul 3, 2008
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.
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.
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, 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.
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