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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 for HIV
transmission and providing appropriate care for patients who are victims of sexual assault.
- Although risk for 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.
- Provider encouragement increases the likelihood that patients will accept HIV postexposure prophylaxis after sexual assault,
but completion of the 28-day course is uncommon even with extended provider support.
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Evidence:
- An expert consensus review notes that 40% of sexual assault patients fear contracting HIV from the assault (71).
- An expert review of the world literature on sexual assault estimates that the risk for transmission of HIV from one episode
of unprotected consensual receptive vaginal intercourse with an infected individual is approximately 1 in 1000, and with unprotected
receptive anal intercourse is 8 to 32 in 1000 (72).
- Treatment of parenteral occupational exposure to infected body fluids using AZT was effective in preventing the transmission
of HIV in a case-control study involving 33 patients and 665 controls (73).
- 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
(74).
- 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 (75).
- In an observational study of 386 Canadian adolescent female sexual assault victims, 43% began HIV postexposure prophylaxis
and 34% completed the 28-day course. Provider encouragement was associated with a patient's decision to initiate treatment
(76).
- 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 (77).
- 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 (78).
- In a randomized, controlled South African trial, telephonic intervention was used to try to increase compliance with postexposure
prophylaxis in 279 survivors of sexual assault. The intervention was not effective in significantly improving adherence over
a baseline of approximately 31% to 38% (79).
- 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 (47).
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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. The CDC noted that evidence is insufficient
to make recommendations for other assault situations (80).
- Assistance with postexposure prophylaxis decisions can be obtained by calling the National HIV Telephone Consultation Service
(800-933-3413 or 888-448-4911) or accessing the National HIV/AIDS Clinician's Consultation Center.
- Several states have written policies to guide examiners who face this complex issue (81; 82; 83).
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Carolyn J. Sachs, MD, MPH has no financial relationships with pharmaceutical companies, biomedical device manufacturers, or health-care related organizations.
Deborah Korenstein, MD, FACP, Co-Editor, PIER, has no financial relationships with pharmaceutical companies, biomedical device
manufacturers, or health-care related organizations. Richard B. Lynn, MD, FACP, Co-Editor, PIER, has no financial relationships
with pharmaceutical companies, biomedical device manufacturers, or health-care related organizations.
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