HIV Nonoccupational Postexposure Prophylaxis for Sexual Assault Cases

A 3-Year Investigation

Lolade Shipeolu; Kari Sampsel; Allegra Reeves; Farriss Blaskovits; Melissa Heimerle; Katherine Muldoon


AIDS. 2020;34(6):869-876. 

In This Article

Abstract and Introduction


Objective: Nonoccupational postexposure prophylaxis (nPEP) programs offer antiretroviral therapy to prevent HIV following at-risk exposures like sexual assault. We investigated the levels of elective nPEP uptake among sexual assault cases presenting for emergency medical care.

Design: Retrospective analysis.

Methods: The analysis included over 3 years (1 January 2015 to 30 September 2018) of clinic information from the Sexual Assault and Partner Abuse Care Program (SAPACP) at The Ottawa Hospital, the regional emergency department care point following sexual assault. Descriptive analyses assessed the number of cases eligible for nPEP and those who started nPEP. Bivariable/multivariable logistic regression modelling assessed factors most strongly associated with starting nPEP using odds ratios (OR), adjusted OR (AOR), and 95% confidence intervals (CI).

Results: The SAPACP saw 1712 patients; 1032 were sexual assault cases, 494 were eligible for nPEP, and 307/494 (62%) eligible patients started nPEP. The median age was 23 years (IQR: 20–31), with 446 (90%) cases being female. There were 86 (17%) cases who arrived by ambulance, and 279 (56%) assaults involving a known assailant. Reduced odds of starting nPEP were observed among female cases (AOR: 0.44, 95% CI: 0.21–0.93), those who arrived by ambulance (AOR: 0.56, 95% CI: 0.35–0.91), and those with a known assailant (AOR: 0.56, 95% CI: 0.36–0.78).

Conclusion: We found that 62% of eligible sexual assault cases started nPEP. Key groups most likely to decline nPEP included female cases, those who arrived by ambulance, and those with known assailants. Providers can use these findings to provide recommendations to sexual assault survivors most likely to decline nPEP, yet still in need of care.


Sexual assault is a pervasive global health concern that negatively impacts individual and population-level health. Globally, 30% of women have experienced physical and/or sexual assault from an intimate partner, and 7.2% have experienced sexual assault from nonintimate partners, including friends, family members, teachers or strangers.[1] HIV transmission can be a life-altering consequence of sexual assault. Up to 72% of sexual assault survivors report being afraid of contracting HIV following a sexual assault.[2] Although the risk of HIV transmission after a singular sexual exposure is low,[3] and the exact risk of HIV transmission from a sexual assault remains unclear,[4] there are several circumstances associated with a sexual assault that put survivors at a greater risk. Penetration with ejaculation, genital injuries and existing sexually transmitted infections (STIs) in the perpetrator or survivor are common pathways for HIV transmission, and areas of concern and investigation among sexual assault cases.[5]

HIV postexposure prophylaxis (PEP) is routinely used in occupational settings when clinical staff are exposed to HIV (e.g. needle stick injuries).[6] PEP is increasingly being used among MSM after high-risk sexual encounters, as this population is disproportionally affected by HIV.[7–9] According to guidelines by the WHO[10] and the Centers for Disease Control and Prevention (CDC),[11] nonoccupational PEP (or nPEP) is recommended following a sexual assault and treatment should be initiated within 72 h of the assault. NPEP consists of a 28-day course of antiretroviral medications that prevents HIV infection following high-risk exposures.[4,11,12] Following sexual assault, healthcare providers offer nPEP to survivors with high or unknown risk of HIV transmission.[12]

The survivor's decision to accept nPEP can be constrained by time (i.e. presentation within 72 h of assault) and impacted by the trauma of sexual violence, which may affect decision-making.[12] There is a growing body of literature exploring factors associated with nPEP acceptance and refusal within the sexual assault population. In Draughon's 2012 systematic review of 27 nPEP studies focusing on sexual assault cases in low-HIV-prevalence countries, majority of the studies concluded that the prevalence of nPEP acceptance among survivors ranged from 40 to 50%.[13] A recent meta-analysis by Scannell et al.[14] reported similar findings, where half of the sexual assault survivors eligible for nPEP accepted treatment. Although, a study by Krause et al.[15] reported nPEP uptake rates as high as 86.7%. Across the studies in Draughon's review, nPEP acceptance was highest among high-risk exposures, which is defined by the CDC as mucous membrane (i.e. vagina, rectum, eye, mouth) contact with blood, semen and vaginal or rectal secretions from a HIV-positive individual.[13] In many cases, a perpetrator's HIV status is unknown, and survivors must decide whether to begin nPEP based on expert recommendation from their healthcare provider. The review[13] concluded that there is a gap examining individual and assault-based characteristics and how these factors influence nPEP uptake.

Studies have found a variety of factors associated with reduced nPEP acceptance rates, including older age,[16] concern for drug side effects, inability to return for follow-up[17] and emotional distress affecting comprehension of HIV risk.[18] Cost of treatment was a predominant barrier in settings without universal healthcare.[13,16,19,20] In most provinces across Canada, however, the cost of nPEP administered through the emergency department is covered by a universal healthcare system.[21] Despite coverage of nPEP costs and established clinical guidelines, not all survivors who are eligible for nPEP choose to begin the course of treatment. Reducing HIV transmission is a critical component of postassault care; therefore, understanding the factors that shape decisions regarding uptake and decline are an important area for future investigation.

The primary objective of this study was to investigate the levels of nPEP uptake among sexual assault cases presenting for emergency medical care. The secondary objectives were to assess the demographic, clinical, and assault-related characteristics associated with nPEP uptake.