(I think I accidentally posted this question in the wrong section 10 seconds ago; disregard that, and my apologies)

Hi Dr. Bob,

First, let me thank you for doing such a great job with this site; it's a real service.

My question has to do with PEP and whether or not the possible side effects are worth the gamble. I had receptive anal intercourse; first time, no problem with the condom. Second time? It's unclear, but there's reason to think the condom was compromised/broke. (Why unclear you ask? Umm, alcohol induced fuzziness, coupled with the language barrier I was encountering with this cute Brazillian). Anyhow. Guy said he had been tested neg 2 months ago, most recent sex 2 weeks ago (didn't say whether he was safe or not), so I don't worry too much. Then...over time...after talking to friends...worrying starts to increase. Go to my doctor, tell her the story, and because my bum was already tender from other STD/irritation issues and had mild bleeding, (and was definitely bleeding after sex) she decides that PEP is warranted. I go on Truvada once a day, and Kaletra 2 x 2 a day. PEP is initiated at apprx. 65 hours post exposure.

Soooo, my question is, a) is it worth it to start PEP at 65 hours? Lots of sites say 72, but some others that seem equally reputable say it's worthless after 36 hours. This question of cost/benefit is then also influenced by my primary question: will taking Truvada and Kaletra for 28 days permanently alter my body? From what I've been able to garner online, taking Truvada and Kaletra poses the risk of bone density loss (not good for a runner like me) and fat hypertrophy/lipoatrophy even in a short time. Is this true? Do people lose bone mass and get the dreaded buffalo hump in 28 days, and if so, do you think my exposure and delayed onset of treatment warrant the risk of the drug side effects? My doc is great, but no HIV expert, so I thought I'd throw a hail mary out to ya, especially as you might be able to use to this to speak to the larger issues of juggling the balance of PEP's efficacy versus the downside of a month of toxic drugs.

best, Selling his Trojan Stock, one thinks

Hey Selling his Trojan Stock,

Much of this information I've already covered many times in this forum. Check the archives for a more detailed discussion. Briefly the story with PEP is that it's most effective when begun as soon as possible after the HIV exposure. So beginning within minutes is more effective than hours, which in turn is still better than days. In general we believe PEP must be started within 72 hours to have a significant effect in aborting a potential infection. Consequently, although not ideal at 65 hours, you are still within the 72-hour limit.

As for side effects, it is indeed true taking antiretrovirals is no picnic and the side effects you mention as well as a host of others can occur with use of these potent medications. However, the specific side effects you refer to, loss of bone density and lipoatrophy/lipohypertrophy, would not be expected to occur within 28 days. They are considered to be more long-term affects when and if they occur. The complaints most folks have with PEP are the more common ones of diarrhea, nausea, generally "not feeling well," etc. However many folks handle a brief course of PEP drugs without any adverse effects whatsoever. How you specifically will do is impossible to predict.

Should you take PEP? Well, I like your doctor would be concerned about the "other STD/irritation issues" and bleeding at your backdoor. What's up with that? My advice would be to continue your PEP. Since you state your doc is not an HIV expert, I would also encourage you to see an HIV specialist if possible. I encourage everyone who has had an HIV exposure significant enough to warrant a course of PEP to be followed by an HIV specialist physician. That specialist will document your degree of risk; optimize your PEP regimen if necessary; monitor for, evaluate and treat all PEP-related side effects and toxicities; and arrange for and interpret all post-PEP HIV tests (out to six months).

Finally I certainly wouldn't sell your Trojan stock. After this entire experience I'm confident you'll be using Trojans for each and every episode of penetrative sex. That alone should increase market share and stock price considerable. I'm thinking of buying some myself.

Good luck!

Dr. Bob

first of all...thanks for answering this. this was very sweet and caring to receive. I have a few follow-ups: 1. If the person I was with tests negative, would I then be ok to stop the PEP? 2. How do they know that 28 days is the right amount of time? why not 12 days or 6 months? 3. I did get an HIV anti-body test and got results today - negative. 4. is there any testing that can be done now or within the month to know if I am ok now? DNA? 5. does the rate of transmission(.1%) change dramatically if the viral load is high? 6. I have heard to really be safe the pep should be 3 drugs, yet I am only taking combivir and viread. is this an ok treatment in your opinion?

thanks again for your response. when you are out here on the front lines, it is nice to hear from someone.

I am sure I will be fine this time, but MAN have I learned a lesson. why anyone would think people would use PEP as a means to not be safe is beyond me. the side effects suck!!

1. Yes, as long as we can be confident they were not in the acute phase of their HIV infection. 2. You are right to say that the 28 days is somewhat arbitrary. A week or so is probably the minimum effective time to be considered, but this will never be formally tested in humans, I fear... 3. This initial negative test is excellent news, and means that you were not previously infected with HIV before this incident occurred. 4. The HIV DNA test is, in many countries, an approved diagnostic test to figure out if someone is infected before the HIV antibody test is reliably positive in the course of infection. The viral load or RNA test is also sometimes done in acute infection. 5. The rate of transmission is affected by the viral load, but not dramatically (i.e. it wouldn't go from 0.1% to 5%, for example). 6. You are on 3 drugs, as Combivir is a combination of zidovudine and lamivudine.

Finally, learning a lesson is what this is all about. It is not how you fall down that I am interested in, but how you get up...

Good luck...

Dr. Bob-

Well, I had a possible exposure to HIV from the guy I've been seeing briefly. In a horrible lapse of judgement mainly due to alcohol-we had unprotected anal sex (I was the receipient) and even more worrisom was that he only used spit and it hurt alot-but I was pretty out of it. Yes, I'm kicking myself. Anyways-he says he gets tested every 6 months but he never actually said he's negative or positive. I went to the E.R. and they started me on Combivir and Viread for 4 weeks. I've taken two doses so far with minimal nausea. I didn't start the meds though until around 41 hrs after possible exposure-will the meds still be effective??? Thanks for your time and advice signed, worried and waiting

Hello Worried and Waiting PEPer,

Post-Exposure Prophylaxis has the best chance of preventing HIV transmission when it's begun as soon as possible after a significant HIV exposure, i.e., minutes are better than hours and both are better than days. Beginning PEP beyond 72 hours is generally not recommended. Even when PEP is started promptly and a full 28-day course is taken exactly as directed, it is not always effective in aborting an HIV infection. There are PEP failures even under the best of circumstances. (Yours truly is an example!) Will your PEP be effective? No one can say for certain; however, it was begun before 72 hours; consequently, we can all certainly hope for the best. I'll repost some PEP questions from the archives that give additional information.

Good luck!

Dr. Bob

Me again Oct 11, 2006

Hey Doc- First off, you really are a wonderful man. It is me of the previous two days posts entitled "Hello again old friend" and "thanks." Day three on PEP after the popped condom with the girl I met at the club. A few questions. First off...side effects. As you recall, I am on Atripla. The side effects have not been too pleasant. After I take it at night I get a kind of stoned feeling. In the morning I am groggy and have been pretty crabby until after lunch time. My mouth has also been very dry. I can't wait for this to be over! I just have a few questions. First off, I know that the normal testing window is three months. Would taking PEP affect the amount of time before I can see a conclusive test? Would PEP be likely to cause false positives or negatives? Secondly, Can I count on the side effects to wear off. Lastly, my mensch of a doctor prescribed PEP for 30 days. Can I stop after 28, or must I go all 30? Is there a difference? As you can tell, I am very eager to be done with this, and hope that after three months, find out all is ok. Very much because of you, I have been able to keep a pretty cool head throughout this, and I am very grateful.

Response from Dr. Frascino

Hello Me Again,

Your questions about nPEP (Nonoccupational Post-Exposure Prophylaxis), nPEP side effects and post-nPEP HIV testing are extremely common to almost everyone undergoing this treatment. That is why I have repeatedly encouraged all folks who have had an exposure significant enough to warrant PEP to hook up with an HIV/AIDS specialist. See my response to your original question below that anticipates your current concerns. The same advice still stands.

To briefly address your questions:

1. The guidelines for testing after nPEP call for HIV-antibody testing at 4-6 weeks, 3 months and 6 months.

2. nPEP side effects vary considerably in severity and duration. Your HIV specialist should be able to help evaluate and manage your symptoms.

3. A full course of nPEP is 28 days.

If you would like to read more about nPEP, I suggest you download the recommendations from the U.S. Department of Health and Human Services report entitled "Antiretroviral Post-Exposure Prophylaxis After Sexual, Injection-Drug Use or Other Nonoccupational Exposure to HIV in the United States." It can be easily accessed on their Web site.

Good luck! I'm continuing to send my good-luck karma that your follow-up HIV tests remain negative.

Dr. Bob

Hello again old friend Oct 2, 2006

Dr. B- Long time reader and many time donater here. I finally thought I got it right and have been exclusively using condoms. On Friday, I met a girl at a club and she came home with me. We had both been drinking. I put a condom on before sex, and it was feeling to good. After roughly three minutes, I noticed that the condom had completely broke. It has been about 48 hours, and because it is the weekend, I have not found an open clinic to get PEP. I am very upset. I know all the stats, but have two questions:

1) Assuming the condom broke immediately, the time of exposure would have been 1.5-3 minutes. Would this be considered a brief exposure (as oppossed to full on sex), and if so, would a brief exposure carry less likelihood of transmission than a long exposure.

2) I am going to look for a clinic tomorrow, but most of the clinics are closed due to Yom Kippur. Assuming the worst, that this woman was positive (she stated that she tested negative in March, but who knows), would you recommend PEP in this situation?

Thanks

Response from Dr. Frascino

Hello,

Welcome back to the forum. Sorry it has to be under such stressful conditions!

To answer your questions:

1. Certainly the briefer the exposure the less the overall risk of HIV transmission. However, even a brief exposure is an exposure and therefore carries some degree of risk.

2. PEP would be offered in this type of situation, but not necessarily strongly encouraged. There are many factors that come into consideration in ultimately deciding whether to PEP or not to PEP the likelihood that the partner is HIV positive, exposure to menstrual blood, the level of concern/worry of the exposed individual, etc.

Regarding PEP availability, any emergency room should be able to evaluate your risk and prescribe PEP, if warranted, to get you started ASAP. If PEP is begun, I would recommend you see an HIV specialist over the next few days to more carefully evaluate your exposure risk, optimize the PEP regimen, handle any PEP-related side effects or toxicities and arrange for post-PEP HIV testing.

One final thought: if you are still in contact with your club-gal, you might ask her to get an HIV rapid test now. If negative, that would very dramatically reduce any chance you contracted the virus.

I'm sending you my best good-luck/good-health karma, OK?

I'm here if you need me.

Dr. Bob

brief encounter with a masseur Jul 25, 2006

Hello Dr. Bob.

I am a recent reader of your forums, and I found some of the articles very informative. However, I have some specific questions of my own after I got stupid and got myself exposed to unprotected sex with someone who offers massage with release.

I went and got his services thinking, how unsafe can a massage get, the worst that can happen is he'll give me a massage, and stroke me and then I pay him, that's it.

Wrong. when I got there, things got out of hand, we both got carried away, but before we did anything I asked him if he plays safe, he said "always", but as I learned the hard way, that doesn't mean anything. So we proceeded, he gave me the massage, started to rub his stubbles on my anal area, used spit to lube me up, he tried to push his penis inside my rectum, but he didn't go all the way through, I gave him oral stimulation, but he didn't cum inside my mouth, and he did the same to me in return. I think I tasted precum on him. I then penetrated him anally, thrusted 3 times then realized i shouldn't be doing it so I pulled back and just jacked off until I came. He came on my chest. I started freaking out when I realized he had had some hiv+ clients before, but he said he only gave them massages and nothing else, and he didn't have sex with all of his clients, like I really believed him at this point.

My questions are:

1: Is it possible that his rubbing of his stubbles on my anal region caused breaks on the skin where the virus can enter? 2: Will this have led to the possibility that he might have infected me (if he was lying about his hiv status) by using spit to stimulate my anal region?

3: Precum in the mouth during oral sex: I only did it for probably a minute or two. Does that make a difference on my risk?

4: He tried penetrating me, but didn't go in entirely. Am I possibly infected by his pushing his penis inside me? He didn't thrust in and out or anything because I asked him to stop.

5: I topped for him, thrusted thrice, with him on top, me lying on my back. It was gentle thrusting. How does this affect my risk? Could I have gotten the virus (granting he's positive and lied about his status) even if I pulled out after thrusting 3 times?

5: I went to my doctor on the 3rd day ( the encounter happened on a Friday night, saw my doctor that following Monday morning) and inquired about NPEP. He said it was too late (I thought it was 72 hours?) to start it; besides he thinks the risks/side effects of taking it far outweigh the benefits in my case. How is this so?

He did test me for HIV and VDRL as baseline, I'm still waiting for those results. In the meantime, what can I do? The anxiety is killing me. Thanks for your answer in advance. I can't tell you enough how grateful I am for people like you. Where can I send my donation? I'll be waiting for your answer. Thanks again and more power.

Response from Dr. Frascino

Hello,

So Rub-a-dub-dub guy tells you he "always" plays safe and then he tries to bareback your backside like Jack and Ennis on Brokeback Mountain and subsequently allows you to go commando on his buns???? Hmmm . . . I'm not sure Mr. Rub-a-Dub understands either the word "always" or "safe." OK, on to your questions:

1. No. this would be highly unlikely, even if he had Jake Gyllenhaal's stubble!

2. No. HIV is not transmitted via spit.

3. Less exposure means less risk.

4. If he got in, there is a potential risk; although, because it was so brief, again the risk would be minimized.

5. Unprotected sex is unprotected sex. Your risk would be "insertive anal sex with a partner of unknown HIV status." Could three thrusts be enough to transmit HIV? Theoretically yes.

6. PEP and nPEP work best when started as soon as possible after exposure, i.e. minutes are better than hours and hours are better than days! Beginning PEP beyond 72 hours is not recommended. PEP is generally advised only after a significant HIV exposure. Taking PEP is not easy and there are indeed risks associated with these potent medications.

7. What can you do while suffering through the window period? I'd suggest volunteering some of your time at an AIDS hospice or other AIDS service organization. Helping others who are much less fortunate than ourselves is an excellent way to keep our own problems and challenges in their proper perspectives. If HIV/AIDS organizations are too stressful, try a pediatric cancer center or read to the blind or hand out meals to the homeless.

Thank you for your willingness to donate to The Robert James Frascino AIDS Foundation. Donation information can be found on the foundation's Web site at www.concertedeffort.org. Our address is:

The Robert James Frascino AIDS Foundation 1000 Fremont Ave., Suite 145 Los Altos, CA 94024

In return, I'm sending you my very best good-luck karma that your HIV tests remain negative.

Good luck.

Dr. Bob