In desperate need of expert guidance

[fredfredfrdfrd]

Late at night on 6/11, I had brief unprotected insertive vaginal intercourse with a 22 year old CSW (stripper in Vegas) of unknown risk.  I've read on this site that very few CSWs in North America are HIV positive, but she was Asian (she said Japanese, but I don't really know) with a pretty thick accent, so I don't know how long she has been in this country.  

The potential exposure lasted no longer than 30 seconds and there was no ejaculation.

Within 36 hours, I got tested for STDs and HIV (to establish baseline).  HIV was negative, syphilis was also negative.  I should get the results of the chlamydia and gonorrhea tests today.  

I had an HIV counselor tell me that my HIV risk was low enough that he might not even recommend HIV testing at all.  Further he said that for this situation, PEP would not make sense.  However, I don't think this counselor has any real medical training... so I'm hesitant to heed his advice.

I went to the emergency room and convinced the MD to prescribe Atripla.  I've been taking it since 6/13 (started within 48 hours of the potential exposure).  Needless to say, the side effects are awful.  The HIV counselor thinks I should stop it.

I'm planning to do the PCR DNA at 14 days and antibody testing at 35 days (at a previously scheduled physical).  From what I have read on here, I think that if both of these planned tests were to come back negative, I should feel very confident that I do not have HIV.  However, I'm worried the Atripla could cause false negatives.

So here are my questions:

1.  What is your assessment of my HIV risk?
2.  What would you advise regarding the Atripla?  Would you guide me to continue or discontinue it?
3.  What impact could the Atripla have on the different HIV tests - PCR vs. antibody?
4.  Also what about my risk for having contracted HSV2 and what should I do in terms of testing for that?  Could the Atripla confound that testing?

Thank you very much.

[fredfredfrdfrd]

Doctor,

Is there any data (or do you have any clinical experience) with Atripla or similar PEP therapy affecting the normal symptoms/patterns of a HSV2 contraction?  

I'm probably just obsessing about every wrinkle and pigment on my penis since I'm scouring it multiple times per day for any signs of lesions... but I've read about people who have such mild symptoms that they may even go unnoticed.  Thus, I'm concerned about the PEP masking symptoms altogether or making them so mild that I mistake any normal pigment/wrinkle in my penis for a "mild" sign of HSV2.

Thank you

[Edward W Hook, MD]

I said it was a toss up because it is your decision.  That you ahve not had side effects yet does not mean that you will;

The side effects are numerous and well describe in the pacjkage inseret which you have read, I will not repeat them

You've taken therapy which can, as I explained, delay positive test results, IF YOU ARE INFECTED (somehting that I find most unlikely).  the most you take, the more a test result could be impacted.  EWH

[fredfredfrdfrd]

Thank you doctor.  I can't tell you how much I value your guidance.  

First, I wanted to add that my chlamydia and gonorrhea tests came back negative today.  

I just had a couple of quick clarifying questions for you:

1.  Would you please clarify why you called the decision regarding whether or not to continue the Atripla a "toss up?"  I totally appreciate the fact that you would not have given it (and I of course noted that you did say you would discontinue it if it were you)... I'm just curious why you phrased it this way.
2.  What are the potential serious side effects of Atripla?  I read the package insert, but it's a bit hard to discern which of the myriad of listed potential side effects are the ones of greatest concern.  I can deal with the dreams/headaches/etc... but I'm concerned about kidney damage, etc.  Any thoughts on that?
3.  If I were to stop the Atripla now (day 6-7), do you think that my planned tests (PCR at day 14 or 15 and antibody at 35 or so) would be unlikely to produce false negatives?  

Thank you very much again.

[Edward W Hook, MD]

It sounds to me as though the counselor you spoke to was knowledgeable and gave you just about the same sort of advice that I am about to give.  Overall, when considering the chances that your partner was HIV infected and the odds of transmission from a brief exposure, I would place your odds of getting HIV from the exposure you describe as being somewhere between 1 in 50,000 to 1 in 100,000.  These are far lower than the odds of you have unpleasant and potential harmful side effects from the anti-retroviral therapy (ART) you are receiving.  

As for your questions:

1.  See above.  Very, very low risk.  So low that the only reason for getting tested is for your own peace of mind, not for a medical reason.
2.  I'm sorry you were successful in convincing the ER doctor to give you Atripla.  I would not have.  That said, at this time, whether or not to continue  is a toss-up.  I would not continue.
3.  The HIV antibody development could be delayed, if you gave it.  The PCR is less likely to be delayed but this too is a possibility,
4.. There is nothing you've said that suggests that you got HSV from the exposure you describe.  Typically the lesions of a herpes outbreak appear 4-10 days following exposure.  Should a genital lesion appear, I would suggest you get it cultured ofr a HSV PCR test performed on a specimen from the lesion as soon as possible after it appears.  A blood test a this time will not be helpful.  If it is positive it would not tell yo if the antibodies detected reflected recently acquired herpes or an test which was acquired in the past (80-90% of people with herpes do not know they have it.

Good luck.  EWH