And the third case is here

[Sarif98]

On 3/1/2017 at 4:51 AM, MuscledHorse said:

Sorry, but I work in health care and I don't care what he claims: The fact he used a pile of recreational drugs, including one that involve the word "injected" takes this off my list of credible PrEP failure.

I work in healthcare as well and completely agree with you there. 

[Bluepanther89]

Yikes! I did not even consider the localized gut infection factor; makes one wonder if slight bleeding while bottoming even on Prep reduces protection.

[6811283]

27 minutes ago, Bluepanther89 said:

Yikes! I did not even consider the localized gut infection factor; makes one wonder if slight bleeding while bottoming even on Prep reduces protection.

I don't think that's what this is about. You can bet that of the 199,997 people on PrEP who did NOT seroconvert, some of them had slight (or not-so-slight) bleeding -- and they were still fine.

You can drive yourself nuts reading these extreme outlier cases and spinning all kinds of scary fantasies. You might as well obsessively read about every freak car accident and worry yourself sick every time you get in a car. Could you, theoretically, get HIV while taking PrEP correctly? Yes -- but the odds are so extremely low that it simply doesn't make sense to worry about it.

[6811283]

2 hours ago, Sarif98 said:

I work in healthcare as well and completely agree with you there. 

Approximately 1 in 8 Americans "work in healthcare" -- a term that can mean anything from receptionist to brain surgeon. Unless you are an HIV scientist qualified to pronounce on the validity of this research, the fact that you "work in healthcare" really isn't relevant.

[MuscledHorse]

I work in the direct patient care, non-administrative side of health care. I have a doctorate in pharmacy as well as other degrees, so you can bet i know my medicinal and organic chemistry as well as my pharmacology, microbiology and immunology. 

[DBCB]

14 hours ago, 6811283 said:

It's pretty fascinating -- this thing about a localized infection in his gut, never heard of such a thing. This case could potentially reveal a good bit about how HIV works. There are mysteries and outliers in every area of medicine... for example, spontaneous remission of Stage 4 cancer.

We'll never understand everything, but we know enough about PrEP at this point to be confident that it is at least as effective as most vaccines or other preventive interventions. It's still a resounding success, even though the naysayers are going to grab every negative story to try to discredit it (something they never do with the tens of thousands of infections due to condom failure).

Theoretically, this has always been possible- both drugs in Truvada, Emitricitibine and Tenofovir, are NRTIs, rather than Fusion/Entry Inhibitors.  I could go into the specifics of the HIV lifecycle, but the short of it is that technically, it doesn't stop the HIV from getting in and attempting to infect CD4/CD8 cells- rather, once the HIV is in, it prevents it from successfully translating its genetic material from RNA to DNA, at which point it would attempt to insert the DNA into the cell's genome.  So, in theory, some hardy HIV virions could stick out for a while in a set of CD4/CD8 cells, until there is turnover and the cells die and are replaced with new ones.  For the majority of these cells, that happens within weeks- but there is a subpopulation of these cells that has a turnover of about 8-9 months or so (give or take).  So, if these fairly hardy HIV virions stuck it out long enough, and there was a dip in the amount of Truvada in the blood, some of them could end up getting their RNA translated and integrated (since the PrEP formulation doesn't include and integrase inhibitor)- at which point it would begin to reproduce, and since there would be no other drugs effective at other stages of the HIV life cycle, a localized infection could be sustained until there was enough of a dip for it to enter the blood stream.  Typically, without PrEP, this takes 1-3 days (hence the "crucial window" for PEP), but with PrEP under the right conditions it could hold out.

Again, this has always been a theoretical possibility- the chances of this happening are incredibly slim, because so, so many factors have to line up for it to work out this way (one of which is, of course, the amount of virus someone is exposed to and how many different strains are present).  It's absolutely fascinating that it has occurred, if they're correct about it- but I don't know that the majority of people will have to worry about it. This is the 1% they're talking about when they say up to 99%.  Also, forgive any mistakes, while I do work in science, it's been some time since I've had anything to do with virology/HIV specifically.

[6811283]

6 hours ago, nbcb21 said:

Theoretically, this has always been possible [snip] This is the 1% they're talking about when they say up to 99%.  Also, forgive any mistakes, while I do work in science, it's been some time since I've had anything to do with virology/HIV specifically.

Thanks for the fascinating, succinct explainer. Of course it sucks that this guy got infected, but what an interesting case.

[6811283]

9 hours ago, MuscledHorse said:

I work in the direct patient care, non-administrative side of health care. I have a doctorate in pharmacy as well as other degrees, so you can bet i know my medicinal and organic chemistry as well as my pharmacology, microbiology and immunology. 

OK, thanks for clarifying.

[Guest Upstateguy518]

Just after a quick glance I read this:
During the first 7 months, He averaged having 16 days per month having condom-less sex on top of having a minimum of 3 partners a day during those days. Not to mention all the drugs, including cocaine, that he admitted to using.

No wonder he ended up poz. I don't think this was a PreP failure. It was because this guy was treating his body like a fucking outhouse and filling it with whatever cock and drug he could get his hands on.

[6811283]

18 hours ago, Upstateguy518 said:

It was because this guy was treating his body like a fucking outhouse and filling it with whatever cock and drug he could get his hands on.

It may be the case that this guy pushed the boundaries of what PrEP can protect against, and that most other people are not at risk of the same. But I would be careful about characterizing anyone else's sexual behavior in terms like "treating his body like a fucking outhouse." Most of us have what the straight world would consider pretty out-there sex lives. Judge not, lest ye be judged.

[Guest JizzDumpWI]

My thoughts on the case where they stopped PrEP on the compliant guy due to a poz result was probably a bad idea.  He had HIV in his system, but there was evidence it was not taking hold.  I wonder what would have happened had he stayed on PrEP for another month? 

[Guest Upstateguy518]

8 hours ago, 6811283 said:

It may be the case that this guy pushed the boundaries of what PrEP can protect against, and that most other people are not at risk of the same. But I would be careful about characterizing anyone else's sexual behavior in terms like "treating his body like a fucking outhouse." Most of us have what the straight world would consider pretty out-there sex lives. Judge not, lest ye be judged.

Could also be because he skipped doses while maintaining his high risk behavior. Maybe I shouldn't have been so harsh but I just found it so hypocritical that he cares about not getting HIV and yet he's abusing all these hardcore drugs. I'm mean if you are gonna fucking do all the shit he is doing, You might as well say fuck prep.

[Theo8]

A clue may lie in the fact that the man had a lot of high-risk sex, even for someone enrolling in a PrEP trial. During his first seven months in the study he averaged 56 anal sex partners per month and about 30 episodes of condomless sex a month. He averaged 16 days per month when he did have condomless sex and on those days averaged 3.7 partners.

“This PrEP user came to the study saying he had no doubt he would acquire HIV unless he went on PrEP,” said Dr Hoornenborg. “He was highly educated and knew exactly what the risks were but did not feel he was able to change his sexual risk pattern, so took action by applying for the study.”

He did have ‘chemsex’ and took mephedrone, GHB/GBL, ketamine, cocaine and amphetamine, and admitted to injecting ketamine twice but insisted he used sterile needles. He had two episodes of rectal gonorrhoea and one of rectal chlamydia in his first seven months on PrEP. He did not contract hepatitis C and was vaccinated against hepatitis B.

 

I'm curious as to the effects of the other STDs on the PrEP regime specifically as well as the drug use.  I'm no medical professional but I'd assume, which I know is dangerous, that they had a negative effect. 

[rehtnap]

one of the problems i have seen here in the uk is that prep was pushed hard including a few websites. in all the hype it was overlooked that these sites have made prep available without prescription and even blood results. now what u have is guys buying prep without knowing if they are already poz. go on prep when poz and ur on the real way to prep resistant hiv.if you read proff bob grants papers(he pionered prep) he makes a big thing that prep must not go to guys who are poz. one other thing that has shown up recently in dutch studies is the dramatic rise in hep c amoung at risk guys.

[rehtnap]

truvada used for prep was chosen as it has a charicteristic that it is not all absorbed in the gut so some of it is passed through the rectum. this allows a stronger concentration of meds in the risk area. an sti  causes more white cells to be around the area of sti infection so these again can help to fight hiv in semen. a down side is the area of infection can make an easier pathway into the body for hiv.so its a sort of no real answer but the odds are aginst hiv. drug use lowers the immune sytem effectivness,even poppers do that.now again if youve followed prep instructions then the theory is that the prep gaurds against lowered immune sytem response. trouble is how much drugs knock the immune system down to where prep is fighting the battle alone. dont know if u know how prep works.it blocks only one of the prosseses that hiv has to go through to reproduce,but uses 2 similar drugs to double block the process.now when ur neg theres no hiv in ur blood, when u get hiv semen in u its first blocked by the body and prep in ur arse. should any get passed that lot into the blood stream its almost in uber small amounts and the immune white cells and prep blocking the process get rid of it. but if u do drugs and sti and other stuff you stand the chance of raising the hiv levels in ur blood(things like if you plug drugs) to a point where drug resistance can happen. just as a note,drug resistance can happen through natural mutation of hiv. currently there are 45/48 mutation types of hiv1 recognized.

oh yeh forgot to say it would also depend on who he had sex with as in if it was a guy on meds then uber low amount of hiv in semen. on the other hand if the guy was high vl say in the millions then u have more hiv in the semen to do battle with.

Edited April 1, 2017 by rehtnap