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.

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).

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).