Expert: Terry B - 1/29/2008

Question
QUESTION: Hello,
On January 2nd I was having vaginal insertive sex with a female sex worker. As I pulled out, I realized that the condom had rolled up to the very tip of my penis. It was still holding the semen but I was still very concerned by how unprotected the rest of the shaft was as well as a bit of the head. I was also concerned about the volume of fluid in the general area.
Needless to say I panicked. I asked her if this was common, she said "We're fine, sometimes they come all the way off"
That of course threw me in to deeper panic.
Two minutes later, (my penis was still somewhat moist) I went to the bathroom and rubbed my penis down with Clorox bleach. I'm afraid though, that by rubbing the penis down as well as pushing my finger into the urethra, although coated with bleach I may have reactivated the virus and infected myself.
After she left I applied more bleach and went to bed.
The incident occurred at around 11:30 PM.
I didn't sleep.
The Following morning I went down to the Emergency Room and after hours of waiting, I took my first dose of Combivir at 3:30 pm the following day.

I am now on the Combivir post exposure prophylaxis regimen and although I feel a little loopy I'm going to stick to it. Eitherway, I find that my anxiety levels are high and that I'm becoming quite depressed about my decisions.

I'm really terrified. Do you have any advice for my situation? I  know you probably get frantic questions like these incessantly but I would appreciate any help that you could offer.
Thanks and Keep writing online, you're doing a great job and offering an informative service.
-Sam



ANSWER: Dear Sam:

Peace.  I am glad you saw a health professional, and hope that the symptoms from PEP subside.  I wish I could offer you some advice that would help, but I can't push the clock back nor forward.  The chances of contracting HIV (if you were without other STI/STD) from this single exposure is at best moderate; the addition of PEP may reduce your chances further.  That's about all I can offer.  What does your doctor say, and will you be tested for antigen at some point in the coming weeks?  While there is some risk of 'false-positive' antigen results further increasing your anxiety (about 10% false positives from some studies), a negative result in a week or two might provide you some relief.

That's about all I have to offer, will add you to my intentions and wish the best for your and yours.

Terry



---------- FOLLOW-UP ----------

QUESTION: The health provider was an emergency room physician however not a HIV specialist. He just said to take the combivir and come back for a test.
Does the PEP actually work? I realized that you said it "may" reduce my chances further. That does not sound very promising.
One other question, I was hoping you could put moderate in to more perspective. Is a moderate chance 5 in 10, 1 in 10?
I ordered the Home Access Kit. I have no idea what kind of HIV test method it uses and if it will be able to detect anything at this point. What are your thoughts?
Thank you for your prompt response.
-Sam

Answer
Dear Sam:

Thanks for caring so much for my thoughts, but the physician providing your care is the right person to ask.  

The research on PEP is a little hard to assess - mostly comes from a small group of health care workers with significant exposures, some become infected, some do not, but that would happen anyway.  There seems enough statistical evidence to suggest that PEP is better than non-PEP.

In theory, weakening HIV by attacking it with antiretrovial agents should reduce the chances of an infection occurring.  A real problem has been that in early PEP studies, many of the workers stopped taking the meds because of side effects.  Thus, I said "may" because I cannot speak definitively on the matter.  Would 'probably' have been better?

Regading "moderate" - you don't know the HIV status of the other person; you were exposed to vaginal secretions for a shorter time than you might have been if you'd not worn a condom; if this is your only exposure, your frequency of possible exposures is low, precisely "once"; if you have no othee sexually transmitted diseases/infections your risk is lower still; your exercise with the bleach probably reduced the duration of your possible exposure, though it may also have increased irritation and potential breaks in skin or mucosa; we have no other information on your partner's status so we can't figure that into the equation.

I say "moderate" because it seems a significant exposure; the other factors place it on the "low-moderate risk" in my estimation.

I don't know the specifics on the Home Access Test kit, but I can tell you that FDA approved testing requires you to send sample (on blotter) to a lab and call in for results.  These then require confirmatory testing.

My thoughts?  Your risk is low to moderate and taking PEP may reduce your chances of becoming infected.  Protect yourself and others from fluid exchanges and stay in touch with the doctor who treated you.  If s/he cannot follow you as your primary physician, ask for a referral.

That's about the extent of what I know and advixe.

Best to you and yours,

Terry