Examination Process- STI Evaluation and Care

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Recommendations at a glance to facilitate evaluation and treatment of STIs:

  • Offer patients information in a language they understand.
  • Consider the need for STI testing on an individual basis.<
  • Encourage patients to accept prophylaxis against STIs if indicated.
  • Encourage follow-up STI exams, testing, immunizations, counseling, and treatment as directed.
  • Address concerns about HIV infection.

Contracting a sexually transmitted infection (STI), also commonly known as a sexually transmitted disease or STD, from assailants is typically a significant concern of sexual assault patients. Because of this concern, it should be addressed as part of the medical forensic exam. Mechanisms should be in place in any setting where these patients are examined for STIs to ensure continuity of care (including timely review of test results) and monitor compliance with and adverse reactions to any therapeutic or prophylactic regimens.1

Offer patients information in a language they understand.

Include information about the risks of STIs, symptoms and the need for immediate examination if symptoms occur, testing and treatment options (and the need for abstinence from sexual intercourse until treatment is completed), follow-up care, and referrals as needed.2 Referrals should include free and low-cost testing, counseling, and treatment offered in various sections of the community. Patients should be aware of the scope of confidentiality related to information in their medical records related to STIs. 3 The level of detail needed when providing this information verbally varies (e.g., some patients may be aware of risks and want treatment, while others may not be as knowledgeable of risks or their options).

Consider the need for STI testing on an individual basis.

Testing at the time of the initial exam does not typically have forensic value if patients are sexually active and an STI could have been acquired prior to the assault. Also, despite rape shield laws, there may be a concern that positive test results could be used against patients (e.g., to suggest sexual promiscuity). There may, however, be situations in which testing has legal purposes, as in cases where the threat of transmission or actual transmission of an STI was an element of the crime. Or, for nonsexually active patients, a baseline negative test followed by an STI could be used as evidence, if the suspect also had an STI.

Trichomoniasis, bacterial vaginosis (BV), gonorrhea, and chlamydial infection are the most frequently diagnosed infections among sexually assaulted women.4 Their presence does not necessarily indicate acquisition during the assault, since these infections exist among some sexually active women.5 The medical forensic exam presents an opportunity to identify preexisting STIs, regardless of when they were acquired, and for examiners to make recommendations for specific treatment. Testing for STIs at the time of the exam also gives examiners and patients the option of deferring treatment until it is needed.

Seek the informed consent of patients for testing, if indicated, following CDC guidelines. (For more information on this topic, see A.3. Informed Consent.)

Encourage patients to accept prophylaxis against STIs if indicated.

If prophylaxis is accepted at the time of the exam, testing is usually not indicated medically. Routine preventive therapy after a sexual assault is often recommended because follow-up with these patients can be difficult.6 It also may reduce the need for more expensive/extensive treatment if an STI is discovered at a later time. Meet or exceed current CDC guidelines for STI preventive therapy for your geographic area. 7 (The CDC suggests a regimen to protect against chlamydia, gonorrhea, trichomonas, and BV, as well as the hepatitis B virus.) If prophylaxis is declined at the time of the initial exam, it is medically prudent to obtain cultures and arrange for a follow-up examination and testing (it is recommended that all patients are reexamined—see the section on follow-up activities). Document patients’ decisions and rationales for declining prophylaxis in their medical records.8

If patients’ clinical presentation suggests a preexisting ascending STI, such as fever, abdominal or pelvic pain, and/or vaginal discharge, they should be evaluated and treated for the ascending infection. This treatment should be based on specific treatment options for sexually transmitted infections in the local community.

Hepatitis B virus (HBV) and postexposure prophylaxis (PEP). See CDC recommendations related to HBV diagnosis, treatment, prevention, postexposure immunizations, prevaccination antibody screening, postexposure prophylaxis, and special considerations.9 Patients who have completed a full hepatitis B vaccination regimen prior to the assault are protected from HBV infection and do not need further doses. (See the CDC recommended regimen for adolescents and adults.) For those who were not fully vaccinated prior to the assault, the vaccine should be completed as scheduled. Patients unvaccinated prior to the assault or unsure of whether they have been vaccinated should receive active postexposure prophylaxis (e.g., hepatitis B vaccine alone) upon the initial clinical evaluation. Follow-up doses should be given 1 to 2 and 4 to 6 months after the first dose. Unless suspects are known to have acute hepatitis B, HBIG (hepatitis B immune globulin) is not required. (When HBIG is needed, use CDC recommended doses.)

Examiners must stress to patients receiving the HBV vaccine the importance of following up for administration of doses as scheduled for full protection. Advocates should also be educated about the possibility of patients receiving prophylaxis against HBV and encourage those who start the vaccine regimen to follow up for required additional doses.

Obtain informed consent from patients for treatment. (For information on this topic, see A.3. Informed Consent.) Patients should be aware of the benefits and toxicity associated with recommended regimens.

Encourage follow-up STI exams, testing, immunizations, counseling, and treatment as directed.10

Although patients may be reluctant to go for follow-up exams for STIs, such exams are essential because they provide an opportunity to detect new infections acquired during or after the assault, complete hepatitis B immunization, if indicated, and complete counseling and treatment for other STIs. Examinations for STIs for all patients should be repeated according to exam facility policy—the CDC recommends a follow-up appointment within 1 to 2 weeks of the assault. If patients tested negative at the time of the medical forensic exam and chose not to receive prophylaxis, follow-up testing should be conducted.11 The CDC recommends that in this case the follow-up exam be done within a week to ensure that positive test results are discussed promptly with patients and treatment is offered. The CDC recommends follow-up testing for patients who received treatment only if they report having symptoms consistent with an STI. (However, patients who were treated should be informed of the option of follow-up testing to confirm the presence or lack of infection.) The CDC recommends that testing for syphilis and HIV infection should be repeated 6 weeks, 3 months, and 6 months after the assault if initial test results were negative and if these infections are likely to be present in assailants (see the upcoming section on evaluating risk for exposure to HIV).

It is important that follow-up communication with patients (particularly by examiners and advocates) include a reminder to go to follow-up exams and receive STI-related testing, immunizations, and treatment as directed. Advocates and health care personnel may be able to assist patients in making follow-up appointments, obtaining transportation to and from appointments, and determining how to pay for expenses involved with follow-up testing and care. Some jurisdictions may cover follow-up treatment as part of initial care through funds such as crime victims’ compensation. In such instances, patients may be more apt to seek follow-up treatment. Advocates may also be able to accompany patients to these follow-up appointments.

 Table of Contents STI Treatment- HIV Concerns

1 Sexually Transmitted Diseases Treatment Guidelines, Morbidity and Mortality Weekly Report, Centers for Disease Control and Prevention, December 17, 2010, 9(RR-12), p. 91. Available at http://www.cdc.gov/STD/treatment/ (CDC general phone: 800–311– 3435). Much of the information in this chapter was drawn from these guidelines. Note that the guidelines are updated periodically. In addition to the guidelines, the CDC Web site at http://www.cdc.gov offers information on related research, news, and Internet links.

2 Drawn partially from Sexually Transmitted Diseases Treatment Guidelines, 2010, p. 92.

3 Laws in all states limit the evidentiary use of a patient’s prior sexual history, including evidence of previously acquired STIs, as part of an effort to undermine the credibility of a patient’s testimony. Evidentiary privilege against revealing any aspect of the exam or treatment is enforced in most states. In unanticipated, exceptional situations, however, STI diagnoses may later be accessed. (Sexually Transmitted Diseases Treatment Guidelines, 2010, p. 90.)

4 Chlamydial and gonococcal infections in women are of particular concern due to the possibility of ascending infection. In addition, post-assault testing can detect hepatitis B virus (HBV) and human immunodeficiency virus (HIV) infection (Sexually Transmitted Diseases Treatment Guidelines, 2010, p. 91).

5 The prevalence and incidence of STIs vary across societies and subpopulations defined by age, gender, race and ethnicity, and socioeconomic status (Fenton, Johnson, and Nicoll 1997)
6 Sexually Transmitted Diseases Treatment Guidelines, 2010, p. 91.

7 Antibiotic prophylaxes are updated periodically and are usually tailored to specific regions (because, for example, one part of the country may be resistant to a certain antibiotic).

8 Nonphysician examiners providing STI prophylaxis typically must operate within the boundaries of a protocol and have access to medical supervision, consultation, and review.

9 Sexually Transmitted Diseases Treatment Guidelines, 2010, p. 91. This section was drawn from this document.

10 This paragraph is drawn from Sexually Transmitted Diseases Treatment Guidelines, 2010, p. 91.

11 Infectious agents acquired through the assault may not have produced sufficient concentrations of organisms to result in positive test results at the medical forensic exam. (Sexually Transmitted Diseases Treatment Guidelines, 2010, p. 91.)