Rationale:

• There are no published studies on the effectiveness of HIV postexposure prophylaxis after sexual assault.
• Many patients fear contracting HIV during an assault, and physicians are faced with the dilemma of the possible risk of HIV transmission and providing appropriate care for patients who are vicims of sexual assault.
• Although risk of HIV transmission from one episode of unprotected consensual receptive vaginal intercourse with an infected individual is approximately 1 in 1000, the violent nature of some sexual assaults and resultant skin breakdown may increase the transmission rate.

Evidence:

• An expert consensus review notes that 40% of sexual assault patients fear contracting HIV from the assault (65).
• An expert review of the world literature on sexual assault estimates that the risk of transmission of HIV from one episode of unprotected consensual receptive vaginal intercourse with an infected individual is approximately 1/1000, and with unprotected receptive anal intercourse is 8 to 32/1000 (66).
• Treatment of parenteral occupational exposure to infected body fluids using AZT was effective in preventing the transmission of the HIV in a case-control study involving 33 patients and 665 controls (67).
• In one large-scale retrospective observational trial of AZT/3TC for 28 days after sexual assault, 32% of 367 patients offered prophylaxis accepted the regimen, and one third came back in a week to obtain the remainder of the oral prophylactic course (68).
• Another retrospective observational study of 258 patients found that 28% of sexual assault patients accepted HIV prophylaxis, with 40% of those returning after 5 days for the remaining medication; only 3% of the initial 258 completed the full 4-week regimen. Of the 71 patients who started medications, 63 failed to complete the course after deciding that it was not worth the side effects, including fatigue, flu-like symptoms, and rash (69).
• An expert recommendation summarizes that more definitive clinical studies are needed and that HIV postexposure prophylaxis after rape should be considered on a case-by-case basis (70).
• A retrospective chart review of 181 adult female sexual assault victims noted that HIV nonoccupational postexposure prophylaxis was offered to less than half of the patients. Of the 85 patients who started treatment, only 18 completed it (71).
• Of the 110 U.S. sexual assault response team programs surveyed by telephone in a study published in 2006, only 19% offered HIV prophylaxis all or most of the time, and 59% never or rarely offered it (42).

Comments:

• In 2005, the CDC released formal recommendations supporting administration of a 28-day course of HAART to victims seeking care 72 hours after exposure to blood, genital secretions, or other potentially infectious body fluids of a person known to be HIV infected when the exposure represents a substantial risk for transmission. They noted that evidence is insufficient to make recommendations for other assault situations (72).
• Assistance with postexposure prophylaxis decisions can be obtained by calling the National HIV Telephone Consultation Service (800-933-3413).
• Several states have written policies to guide examiners with this complex issue (73; 74; 75; 76).