Hepatitis B vaccination should be offered if the sexual assault survivor has experienced vaginal, oral, or anal penetration. Hepatitis B is 20 times more infectious than HIV during intercourse (114). Vaccination is recommended at the time of the initial evaluation. Subsequent doses are provided 1 month and 6 months after the first dose is administered. It is not necessary to treat the patient with hepatitis B immune globulin (167). Vaccination is not necessary if the patient has documented hepatitis B immunity.
3.
Tetanus prophylaxis (0.5 mL intramuscularly) should be administered for deep tissue wounds or for bite wounds.
4.
Conversion of HIV through sexual assault, although reported, is low and similar to conversion from occupational exposure (0.1% to 0.3% per episode) (168). The probability of transmission depends on the type of assault, presence of trauma and bleeding, site of ejaculation, HIV viral load in the ejaculate, presence of a concomitant STD or ulcerative lesions in the assailant or survivor, and the community prevalence of HIV/acquired immune deficiency syndrome (153,168). The risk of HIV transmission may be greater in children because of the thinness of the vaginal epithelium. Factors to consider when discussing HIV postexposure prophylaxis with patients include the likelihood of exposure to the virus, the risks and benefits of treatment, the toxicity of routine antiretroviral prophylaxis, the interval between the sexual assault and the initiation of therapy, and the patient’s desire to be treated. All survivors of unprotected vaginal or anal sexual assault presenting within 72 hours should be offered HIV prophylaxis unless the assailant is known and tests negative with rapid HIV testing (169). Treatment should be initiated as soon as possible. The usual regimen is Combivir or its equivalent (300 mg zidovudine [AZT] and 150 mg lamivudine [3TC]) administered twice daily for 4 weeks). Administration of a protease inhibitor (nelfinavir, five 250 mg tablets twice a day for 28 days) should be considered for high-risk exposures, such as when the assailant is known to be HIV infected. Providers should also consider consulting an HIV specialist or calling the National Clinicians’ Post-Exposure Prophylaxis Hotline. Side effects of HIV prophylaxis include nausea, malaise, headache, and anorexia. About 33% of survivors who elect to take antiviral medication discontinue therapy prematurely (168). Patients should be aware that the efficacy of prophylactic treatment for HIV after sexual assault is unknown, and they will have to be carefully monitored if they initiate treatment with antiretroviral medication.
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Bite wounds can be treated with amoxicillin/clavulanate (Augmentin) 875 mg twice a day for 3 days.
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If prophylactic treatment for gonorrhea, chlamydia, trichomonas, and bacterial vaginosis is not given, the survivor should return in 2 weeks for repeat testing for STDs and pregnancy. If the initial serologic test results were negative, repeat serologic tests for syphilis, hepatitis B, and HIV should be performed at 6, 12, and 24 weeks after the assault.
7.
Ongoing supportive counseling for the patient should be arranged, and the patient should be referred to a sexual assault center or a therapist who specializes in the treatment of sexual assault survivors. A number of excellent resources are available for providers caring for women who were sexually assaulted (170). These include a policy statement on treatment of sexual assault survivors from the American Academy of Family Physicians and a national protocol for sexual assault medical forensic evaluations from the U.S. Department of Justice.
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