Post-Exposure Prophylaxis for HIV Infection in Sexual Assault Victims

A Inciarte; L Leal; L Masfarre; E Gonzalez; V Diaz-Brito; C Lucero; J Garcia-Pindado; A León; F García

Disclosures

HIV Medicine. 2020;21(1):43-52. 

In This Article

Abstract and Introduction

Abstract

Objectives: Sexual assault (SA) is recognized as a public health problem of epidemic proportions. Guidelines recommend the administration of post-exposure prophylaxis (PEP) after an SA. However, few data are available about the feasibility of this strategy, and this study was conducted to assess this.

Methods: We conducted a retrospective, longitudinal, observational study in SA victims attending the Hospital Clinic in Barcelona from 2006 to 2015. A total of 1695 SA victims attended the emergency room (ER), of whom 883 met the PEP criteria. Five follow-up visits were scheduled at days 1, 10, 28, 90 and 180 in the out-patient clinic. The primary endpoint was PEP completion rate at day 28. Secondary endpoints were loss to follow-up, treatment discontinuation, occurrence of adverse events (AEs) and rate of seroconversion.

Results: The median age of participants was 25 years [interquartile range (IQR) 21–33 years] and 93% were female. The median interval between exposure and presentation at the ER was 13 h (IQR 6–24 h). The level of risk was appreciable in 47% (n = 466) of individuals. Of 883 patients receiving PEP, 631 lived in Catalonia. In this group, the PEP completion rate at day 28 was 29% (n = 183). The follow-up rate was 63% (n = 400) and 38% (n = 241) at days 1 and 28, respectively. Treatment discontinuation was present in 58 (15%) of 400 patients who attended at least the day 1 visit, the main reason being AEs (n = 35; 60%). AEs were reported in 226 (56%) patients, and were mainly gastrointestinal (n = 196; 49%). Only 211 (33%) patients returned for HIV testing at day 90. A single seroconversion was observed in a men who have sex with men (MSM) patient at day 120.

Conclusions: Follow-up and compliance rates in SA victims were poor. In addition, > 50% of the patients experienced AEs, which were the main reason for PEP interruption. Strategies to increase follow-up testing and new better tolerated drug regimens must be investigated to address these issues.

Introduction

Sexual assault (SA) is a broad term that encompasses nonconsented sexual acts, the definition of which includes touching, rubbing and physical coactions as well as rape (penetration with any object without the consent of the victim). There are no accurate data on the prevalence of SA, partly as a consequence of variation in the operational definition applied. Many victims do not identify their experience as rape.[1,2] In spite of this, the World Health Organization (WHO) reports that one in six women are victims of rape during their lifetime and 35% of women experience some degree of physical or sexual violence.[3,4] This has huge physical, psychological and social repercussions.[5–7] Although SA occurs throughout the world, little information is available in most countries. In Spain, at least 1000 rapes are reported annually, 91% by female victims.[8] There is an important association between SA and the use of alcohol and submission drugs, as has been shown in prospective studies.[9] The most common drug in Barcelona is alcohol (48.8%).[10]

SA victims are vulnerable to a large number of sexually transmitted diseases; the prevalence in cohort studies varies from 8% to 32%.[11–15] In places where there is a high HIV prevalence, 4% of new HIV cases are related to a rape episode. Nevertheless, there are few documented cases of HIV transmission.[16–20] The transmission rate varies depending on the modality of sexual contact; receptive anal exposure carries the highest risk (0.8–3%), followed by receptive vaginal exposure (0.1–0.5%) and oral sex (0.0001–0.01%).[21–23] Furthermore, any sexual exposure is considered to carry a risk when a condom is not used or is broken. The risk of HIV acquisition increases exponentially in the presence of factors such as genital trauma, genital ulcers, sexually transmitted infections (STIs), high viral load, blood exposure, ejaculation and rape by multiple assailants.[24,25] In cases where the victim of an SA had known the assailant for > 24 h, it was found that the perception of risk was lower and the victim tended to consider the use of PEP unnecessary.[26]

The evidence of the efficacy of PEP to prevent HIV infection is based on case–control studies in health care workers, studies of the prevention of perinatal infection in pregnant woman, and animal studies in macaques.[27–29] In populations with a high prevalence of STIs, the use of PEP is recommended as soon as possible in the first 72 h.[30–32] There is a higher rate of completion in nonoccupational consented exposures than in situations of SA, in which completion, follow-up and diagnostic testing rates are low.[33,34] In a meta-analysis of 24 cohort studies, the median adherence to PEP in SA was approximately 40.3%.[35] Factors associated with PEP noncompletion are stigmatization of HIV infection, psychological trauma after rape, adverse events related to medication, limited knowledge about PEP indications, absence of proper multidisciplinary health care support in most Hospitals, and lack of psychological support.[36–38]

Currently, there are few studies in Europe that have investigated the rate of treatment discontinuation, the rate of and factors associated with PEP noncompletion, adverse events and the number of seroconversions in SA victims. The purpose of this study was to describe follow-up in a cohort of sexually assaulted victims in the out-patient clinic at the Hospital Clinic in Barcelona, a reference centre in Catalonia.

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