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National Protocol -Examination Process -HIV Concerns
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STI Evaluation and Care (cont)

Address concerns about HIV infection.

 

Although the risk of human immunodeficiency virus (HIV) infection1 from a sexual assault appears to be low,2 it is typically of grave concern for sexual assault patients.

Provide information and referrals.3 Examiners should talk with patients about their concerns regarding the possibility of contracting HIV.4 Although a definitive statement of benefit cannot be made regarding Post Exposure Prophylaxis (PEP) after sexual assault, the possibility of HIV exposure from the assault should be assessed at the time of the examination. The possible benefit of PEP in preventing HIV infection should also be discussed with the patient if the details of the assault pose an elevated risk for HIV exposure. These particular factors may include: the likelihood that the assailant has HIV, the time elapsed since the event, the exposure characteristics, and local epidemiology of HIV/AIDS. A specialist consultation on PEP regimens is recommended if HIV exposure during the assault was possible and PEP is being considered. The sooner PEP is initiated after exposure, the higher the likelihood it will prevent HIV transmission if exposure occurred. The CDC recommends offering the patient a 3-5 day supply of PEP if the medication is judged to be necessary and the patient decides to utilize the treatment.5

As with other STIs, offer patients information about HIV risks, symptoms and the need for immediate examination if symptoms occur, testing and treatment options, and the need for abstinence or barrier use (condoms) during sexual intercourse until any treatment received is completed. Include local referrals for testing/counseling and comprehensive HIV services in the community and region. This information can help patients make decisions about testing and treatment based on facts rather than fear.6

Discuss testing options. Baseline HIV testing is not typically an exam component. However, if the assault is considered a high risk for HIV exposure, patients should establish their baseline HIV status within 72 hours after the assault and then be tested periodically as directed by health care personnel. However, even if the assault is not considered a high risk for HIV exposure, some patients may still wish to be tested.

HIV testing should be done in settings where counseling can be offered to explain results and implications. When providing testing referrals, let patients know whether testing services are free, anonymous, and/or confidential.280 Confidential and anonymous testing is recommended.

Assess the need to offer HIV postexposure prophylaxis.7 In certain circumstances, the likelihood of HIV transmission may be reduced by postexposure therapy for HIV with antiretroviral agents. Postexposure

therapy with zidovudine has been associated with a reduced risk for HIV infection and has become the standard of care for health workers who have percutaneous (e.g., needle stick) exposure to HIV, but whether these findings can be extrapolated to other exposure situations, including sexual assault, is unknown.

The use of antiretroviral agents after possible exposure through sexual assault must balance potential benefits of treatment with its possible adverse side effects.8 Health care personnel must evaluate patients’ risk of exposure to HIV and consider whether to offer treatment based on their perceived risk. Examiners unfamiliar with known risks associated with exposure or side effects of postexposure therapeutic agents should consult with a specialist in HIV treatment. Numerous factors may influence the decision to offer treatment, such as the time since the exposure occurred; the probability that the assailant is infected with HIV; the likelihood that transmission could occur from the assault; and the prevalence of HIV in the geographic area or institutional setting (e.g., a prison) where the assault occurred.9

Offer postexposure prophylaxis for HIV to patients at high risk for exposure, particularly when it is known that suspects have HIV/AIDS. If offered, the following information should be discussed with patients:10

  • The unknown efficacy of postexposure prophylaxis for HIV in cases of sexual assault.

  • The known side effects and toxicity of antiretroviral medications.

  • The need for frequent dosing of medication and the follow-up care necessary.

  • The importance of compliance with the recommended therapy.

  • The necessity for immediate initiation of treatment for maximum effectiveness.

  • The estimated costs of the medication and monitoring.11


When given following a sexual assault, postexposure prophylaxis is the same as for occupational exposure to HIV. Refer to CDC recommendations for postexposure antiretroviral therapy12 and consult with an HIV specialist where possible. Careful monitoring and follow-up by a health care provider or agency experienced in HIV issues is required. Patients should be alerted to symptoms of primary HIV infection (e.g., fever, fatigue, sore throat, lymphadenopathy, and rash) and seek care if these symptoms arise.

Seek informed consent of patients to administer treatment. The decision to begin or withhold treatment should be made by patients and health care personnel after patients have been adequately informed of the risks and benefits of treatment options. (For information on this topic, see A.3. Informed Consent.)

 

 Table of Contents Pregnancy Risk Evaluation and Care

 

 


 

1 Although HIV-antibody seroconversion has been reported among individuals whose only known risk factor was sexual assault or sexual abuse, the risk for acquiring HIV infection through a single episode of sexual assault is likely low. The overall probability of HIV transmission during a single act of intercourse from a suspect known to be HIV-infected depends on many factors. In specific circumstances, the probability of transmission could be high. These factors may include the type of sexual intercourse (oral, vaginal, or anal), presence of oral, vaginal, or anal trauma (including bleeding), site of exposure to ejaculate, viral load in ejaculate, and presence of a STI or genital lesions in assailants or patients. (Sexually Transmitted Diseases Treatment Guidelines, 2010, p. 92.)

2 A useful referral is the CDC’s National HIV/AIDS Information Hotline at 800–342–AIDS. For Spanish speakers, call 800–344–SIDA. For Deaf and hearing-impaired persons, call the TTY/TDD Hotline at 800–AIDS–TTY. Also see the Revised Guidelines for HIV Counseling, Testing, and Referral, Morbidity and Mortality Weekly Report, CDC, September 22, 2006, 55(RR-14). This document is available through aidsinfo.nih.gov/guidelines/ or by calling the CDC’s HIV/AIDS Information Hotline (see below footnote).

3 Some states statutes provide for mandatory HIV testing of suspected sex offenders upon arrest and/or conviction. Patients should be advised of the availability of such testing.

4 This paragraph is drawn from Sexually Transmitted Diseases Treatment Guidelines, 2010, p. 92.

5 L. Ledray, SANE Development and Operations Guide, 2000, p. 74.

6 Drawn from the American College of Emergency Physicians’ Evaluation and Management of the Sexually Assaulted or Abused Patient, 1999, p. 126.

7 The following two paragraphs were drawn from Sexually Transmitted Diseases Treatment Guidelines, p. 70, L. Ledray, SANE Development and Operations Guide, 2000, p. 74, and the California Medical Protocol for Examination of Sexual Assault and Child Sexual Abuse Victims, 2001, pp. 93-4. See also Antiretroviral Postexposure Prophylaxis After Sexual, Injection Drug Use, or Other Non Occupational Exposure to HIV in the United States, Morbidity and Mortality Weekly Report 2005, 54 (RR-2).

8 A table listing primary side effects associated with specific antiretroviral agents is provided in the CDC’s Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis, Morbidity and Mortality Weekly Report 2001, 50 (RR-11), p. 13. Some examples of known shorter term adverse symptoms of antiretroviral medications include nausea, vomiting, diarrhea, and other gastrointestinal effects. Protease inhibitors may cause lipid abnormalities, diabetes mellitus, and hyperglycemia and lead to diabetic ketoacidosis in previously diagnosed diabetics. Combination therapy has lead to some serious side effects, including hepatitis, nephrolithiasis, and pancytopenia. (The American College of Emergency Physicians’ Evaluation and Management of the Sexually Assaulted or Sexually Abused Patient, 1999, p. 125.)

9 Paragraph drawn from the American College of Emergency Physicians’ Evaluation and Management of the Sexually Assaulted or Abused Patient, 1999, p. 125.

10 Bullets drawn from the California Medical Protocol for Examination of Sexual Assault and Child Sexual Abuse Victims, 2001, p. 93.

11 Patients may be able to obtain reimbursement for some or all related costs through state crime victims’ compensation programs. (L. Ledray, SANE Development and Operation Guide, 2000, p. 74.)

12 See aidsinfo.nih.gov/guidelines/ for the CDC’s Guidelines for the following documents: Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents (July 14, 2003); the Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HBV, HCV, and HIV and Recommendations for Postexposure Prophylaxis, Morbidity and Mortality Weekly Report 2001, 50(RR-11), and Management of Possible Sexual, Injecting-Drug-Use, or Other Nonoccupational Exposure to HIV, Including Considerations Related to Antiretroviral Therapy, Public Health Statement, Morbidity and Mortality Weekly Report 1998; 47(RR-17).

 

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