The Journal of the Arkansas Medical Society Issue 6 Volume 115 | Page 16

Preferred Prophylaxis after Sexual Victimization: Postpubertal Adolescents and Adults
For Gonorrhea
Ceftriaxone 250 Mg Im X 1 Dose
Plus
For Chlamydia
Azithromycin 1Gm Po X 1 Dose
Plus
For Trichomoniasis and Bacterial Vaginosis Metronidazole 2 Gm Po X 1Dose ¥
For Hepatitis B Administer Hepatitis B Vaccine if not Fully Immunized
or if Patient Found to be Hepatitis B Non-Immune (I.e.
Hepatitis B Surface Antibody Negative)
For HPV HPV Vaccine Series Should be Initiated if > 9 Years of
Age and if not Already Given or if not Fully Immunized
*for those >8 years and not pregnant
¥
May be given at home to minimize side effects especially if Plan B has been given or if patient has
ingested alcohol
± The patient should have a negative pregnancy test
victim, identify any conditions that would affect
the PEP medication regimen such as hepatitis B,
and to monitor for safety or toxicities related to the
regimen. Testing for other sexually transmitted in-
fections such as syphilis, hepatitis B, hepatitis C,
gonorrhea, and chlamydia should also be provided
at presentation to care. 9,10 (Table 2)
Because of the complexity and potential ad-
verse effects of the PEP regimens, follow-up care
of the exposed patient should be provided. Initial
follow-up of the victim should occur within 14 days,
if possible, to evaluate adherence, monitor toxici-
ties, tolerance, and side effects. Side effects such
as nausea, vomiting, and abdominal pain should
be managed aggressively in order to maximize the
likelihood of adherence to PEP.
At the 4-6 week follow-up visit, serum creati-
nine, alanine transaminase, aspartate aminotrans-
ferase, syphilis serology, and pregnancy testing
should be performed. Evaluation should be done for
gonorrhea and chlamydia if presumptive treatment
was not provided at the baseline visit or if patient is
symptomatic at follow-up visit.
A fourth-generation HIV antigen/antibody
combination test is the recommended serologic
screening test for victims of sexual assault. HIV
testing should be obtained at baseline, week 4-6
and week 12 post-assault. If the exposed person
presents with signs or symptoms of acute HIV sero-
conversion, an HIV serologic screening test should
be used in conjunction with a plasma HIV RNA as-
say to diagnose acute HIV infection. A negative HIV
test result at 12 weeks post-exposure reasonably
excludes HIV infection related to the exposure. If
at any time the HIV test result is positive, an FDA-
approved confirmatory assay must be performed.
Immediate consultation with a clinician experi-
enced in managing ART should be sought for op-
timal treatment options.
Testing for HIV at six months post-exposure is
no longer recommended unless hepatitis C was ac-
quired during the original exposure. Follow-up six
months after exposure should also be performed
in patients who were susceptible to hepatitis B or
hepatitis C at baseline. Individuals who were de-
termined to be infected with syphilis and treated
should undergo serological syphilis testing six
months after treatment. 3, 7-9
Clinicians should provide risk-reduction coun-
seling to exposed persons to prevent secondary
transmission during the follow-up period. This
should include advice regarding use of condoms
to prevent potential sexual transmission, avoid-
ance of pregnancy and breastfeeding, avoidance
of needle-sharing, and abstaining from donating
blood, plasma, organs, tissue, or semen.
Antimicrobial prophylaxis is recommended to
include an empiric regimen to prevent chlamydia,
gonorrhea, trichomonas, and bacterial vaginosis.
Vaccination against hepatitis B and HPV is rec-
ommended if not fully immunized. CDC recom-
mendations for sexual assault prophylaxis can
be found at www.cdc.gov/std/tg2015/sexual-
assault.htm. 9, 10
2. Black MC, Basile KC, Breiding MJ, Smith SG,
Walters ML, Merrick MT, Chen J, Stevens MR.
The National Intimate Partner and Sexual Vio-
lence Survey (NISVS): 2010 Summary Report.
Atlanta, GA: National Center for Injury Preven-
tion and Control, Centers for Disease Control
and Prevention; 2011.
3. Centers for Disease Control and Prevention.
U.S. Department of Health and Human Ser-
vices. Updated guidelines for antiretroviral
postexposure prophylaxis after sexual, injection
drug use, or other nonoccupational exposure to
HIV—United States, 2016. www.cdc.gov/hiv/
pdf/programresources/cdc-hiv-npep-guide-
lines.pdf. Accessed October 2, 2017.
4. Kuhar DT, Henderson DK, Struble KA, Heneine
W, Thomas V, Cheever LW, Gomaa A, Panlilio AL;
US Public Health Service Working Group. Up-
dated US Public Health Service guidelines for
the management of occupational exposures
to human immunodeficiency virus and rec-
ommendations for postexposure prophylaxis.
Infect Control Hosp Epidemiol. 2013
5. Patel P, Borkowf CB, Brooks JT. Et al. Estimat-
ing per-act HIV transmission risk: a systematic
review. AIDS. 2014.
6. Draughon JE. Sexual assault injuries and in-
creased risk of HIV transmission. Adv Emerg
Nurs J. 2012;34:82-87
7. New York State Department of Health AIDS
Institute. HIV Prophylaxis following Non-Occu-
pational Exposure. Albany, NY: NYSDOH AIDS
Institute; 2004. Updated July, 2013.Available
at: http://www.hivguidelines.org/wp-content/
uploads/2013/09/hiv-prophylaxisfollowing-
8. Panel on Antiretroviral Guidelines for Adults
and Adolescents. Guidelines for the Use of
Antiretroviral Agents in HIV-1-Infected Adults
and Adolescents. Bethesda, MD: Department
of Health and Human Services, National Insti-
tutes of Health 2015: Available at http://www.
aidsinfo.nih.gov/ContentFiles/AdultandAdoles-
centGL.pdf. Accessed October 1, 2017.
References 9. Centers for Disease Control and Prevention.
Sexually Transmitted Diseases Treatment
Guidelines, 2015: Sexual Assault and STDs.
Accessed at: http://www.cdc.gov/std/treat-
ment/2015/sexual-assault.htm
1. Seña AC, Hsu KK, Kellogg N, Girardet R, Chris-
tian CW, Linden J, Griffith W, Marchant A, Jenny
C, Hammerschlag MR. Sexual Assault and Sex-
ually Transmitted Infections in Adults, Adoles-
cents, and Children. Clin Infect Dis. 2015 Dec
15;61 Suppl 8:S856-64. 10. Meites E, Kempe A, Markowitz LE. Use of a
2-Dose Schedule for Human Papillomavirus
Vaccination - Updated Recommendations of
the Advisory Committee on Immunization Prac-
tices. MMWR Morb Mortal Wkly Rep. 2016 Dec
16;65(49):1405-1408.
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