COMMENTARY

HIV Prophylaxis for Victims of Sexual Assault: Guideline and Commentary

Cynthia H. Miller, MD

Disclosures

March 28, 2014

In This Article

HIV Prophylaxis for Victims of Sexual Assault: Expert Commentary

The US Centers for Disease Control and Prevention (CDC) estimates that 18% of women and 1.5% of men will be sexually assaulted in their lifetimes, and the rates are higher in certain high-risk populations.1 Victims of sexual assault must be evaluated for immediate injuries; examined to collect forensic evidence; and treated for prevention of sexually transmitted diseases (STDs), pregnancy, and other physical complications of the assault. Also, it must be remembered that for many individuals, long-term psychological effects such as depression, self- loathing, loss of family support, and other psychological problems, may outweigh the physical consequences of the assault.

Finally, although many victims prefer not to discuss it, the events that led to the assault must be considered and approached by the clinician. For example, use of alcohol and drugs or living in an abusive relationship are all problems that deserve the attention of the clinician. Protection from future assault may be as important as treatment for the previous event.

Guidelines adopted by the New York State Department of Health (NYSDOH) AIDS Institute on postexposure prophylaxis (PEP) to prevent HIV infection after sexual assault, which follow this commentary, are short and easy to follow, and they should be your go-to guide on this topic. Other useful guidelines include CDC guidelines on STDs and sexual assault.

One rationale for HIV prevention efforts after assault is the well-established data regarding prevention of perinatal mother-to-child HIV transmission. Published data show that HIV transmission to the infant can be prevented if HIV treatment is begun within a relatively short period (ie, within 36 hours).2 However, prevention efforts begun more than 1 week after exposure are rarely successful. For this reason, once exposure has occurred, time is of the essence.

The NYSDOH guidelines approach every assault as a potential exposure and do not recommend attempts at guessing whether the assailant is actually positive for HIV. The most clear-cut reason for this system is also the most obvious: Persons who appear to have no risk factors for HIV infection can in fact be HIV-positive. The idea that it takes only one person and only one exposure to become HIV positive is not a subject addressed enough in our society. But the fact remains that if we do not know whether the assailant is positive, we must assume that he or she is.

The choice of antiretroviral treatment for HIV PEP is simple in most cases. Tenofovir and emtricitabine plus raltegravir is the preferred regimen; all of these drugs are well tolerated and rarely cause side effects when used for short periods. In addition, drug interactions are few, and they require minimal monitoring.

For victims of sexual assault with complicated medical problems, who are on multiple medications, or who cannot take oral medications, immediate consultation is recommended with an infectious disease specialist and/or a PEP hotline, such as the Clinician Consultation Center's national PEPline.

If the alleged assailant is known to be infected, it is wise to attempt to obtain information regarding his or her HIV status, including viral load, medication list, and known resistance mutations. These data could be crucial to the selection of an appropriate PEP regimen and to the future health of the victim.

Recommendations from NYSDOH and CDC on follow-up testing for HIV and other STDs after sexual assault are detailed in the Table. This schedule is reasonable, and is certainly within the purview of a practicing provider in medicine, family practice, or gynecology.

Most encouraging, as detailed in the NYSDOH guidelines on HIV prophylaxis after nonoccupational exposure, a negative HIV test at 3 months reasonably excludes HIV infection related to the exposure, and routine testing at 6 months is no longer recommended by NYSDOH (CDC recommends another test at 6 months).

Table. Recommended Laboratory Evaluation for PEP After Sexual Assault

Test Baseline During PEP 4 Weeks 3 Months 6 Months
HIV   a
Comprehensive metabolic panel      
STDs a a    
Hepatitis B    
Hepatitis C    
Pregnancy a    

Based on New York State Department of Health and CDC guidelines.
aRecommended by CDC only.

As an HIV doctor, I have seen many patients after sexual assault. One of the more discouraging things is to have patients' own physicians decline to follow them because they feel uncertain of what to do. The NYSDOH guidelines are readily available and simple to follow. It is my hope that this practice will move to primary care providers so that more complete, well-rounded care will be available to all victims of sexual assault.

References

  1. Centers for Disease Control and Prevention. Sexual violence facts at a glance, 2012. http://www.cdc.gov/ViolencePrevention/pdf/sv-DataSheet-a.pdf Accessed March 12, 2014.

  2. Wade NA, Birkhead GS, Warren BL, et al. Abbreviated regimens of zidovudine prophylaxis and perinatal transmission of the human immunodeficiency virus. N Engl J Med. 1998;339:1409-1414.

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