Postexposure prophylaxis for human immunodeficiency virus (HIV) infection following sexual assault

Although the 1998 Centers for Disease Control and Prevention's guidelines for treatment of sexually transmitted diseases recommend offering postexposure prophylaxis for human immunodeficiency virus (HIV) infection following sexual assault, there are no detailed protocols on how to provide this treatment. Postexposure prophylaxis has been shown to lower the risk of seroconversion following occupational exposure to HIV by 81%, but has not yet been evaluated following sexual exposure. Though scientific data are limited, victims of sexual assault should be given the best information available to make an informed decision regarding postexposure prophylaxis. When the choice is made to take medications to prevent HIV infection, treatment should be initiated as soon as possible, but no later than 72 hours following the assault, and should be continued for 28 days. HIV postexposure prophylaxis should be provided in the context of a comprehensive treatment and counseling program that recognizes the physical and psychosocial trauma experienced by victims of sexual assault.     

Epidemiology of sexually transmitted diseases in rape victims

Rape is a violent crime that is increasing rapidly in incidence. Victims can include male and female adults and children. These victims may be at risk for the acquisition of many sexually transmitted conditions. The risk will vary with the sex and socioeconomic status of the assailant as well as with the nature of the sexual contact. Infections with Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis, herpes simplex virus, human papillomavirus, and Treponema pallidum have all been found to occur following sexual assault of female adults or children. Although data are lacking, male victims of homosexual rape are presumably at risk for the acquisition of the above infections as well as hepatitis B, the acquired immunodeficiency syndrome, and other infections prevalent among homosexual men. All victims of sexual assault should undergo a comprehensive physical examination with a complete history. Baseline and follow-up laboratory tests should be performed. In some instances, prophylactic administration of antimicrobial agents may be warranted.     

Treating sexual assault victims. A protocol for health professionals

Sexual assault victims require a multidisciplinary approach encompassing emotional, medical, and forensic care. Evaluation should include general and genital examinations, collection of forensic specimens, and culturing for sexually transmitted diseases. Obtaining a complete history is not only medically and legally crucial, but also can be a valuable therapeutic activity. Antibiotic prophylaxis, postcoital contraception, and testing for human immunodeficiency virus should be offered. An understanding of the rape trauma syndrome is the foundation for providing emotional support. The need for follow-up evaluation and counseling should be stressed.     

Should we offer antibiotic prophylaxis post sexual assault?

Our objective was to assess whether antibiotic prophylaxis should be offered to women post sexual assault by considering acceptability of prophylaxis, follow up attendance rates and the prevalence of sexually transmitted infections (STIs) in these women. Retrospective case notes review of female survivors of rape or sexual assault attending the Rose Clinic, Ambrose King Centre, Royal London Hospital between 1 January 1997 and 31 May 1999 was carried out. The following selection criteria were applied: age greater than 16 years; attending within two weeks of assault; having experienced vaginal and/or anal penetration. All women were screened for STI using standard investigation methods detailed below. Antibiotic prophylaxis was offered within two weeks of the assault, the antibiotic regimens used as recommended. The women were invited to attend for results at two weeks and offered a further screen at three months post assault. Bacterial vaginosis was present in 32% of the women screened, Chlamydia trachomatis was identified in 8%, none tested positive for Neisseria gonorrhoeae. Of the 25 women who were offered antibiotic prophylaxis, 88% accepted. Follow up attendances were 57% at two weeks and 30% at three months. Antibiotic prophylaxis was acceptable to women. Among recent rape victims, follow-up rates are low confirmed by our study. These factors support the use of antibiotic prophylaxis post sexual assault. There was an apparently high prevalence of STIs amongst women in this study. More research is required with respect to this aspect of the work and to consider the cost-benefit analysis of antibiotic prophylaxis.     

Adult male victims of sexual assault: an underdiagnosed condition

The records of 28 male victims of sexual assault were analysed retrospectively. The mean age at time of assault was 21.7 years and the mean number of assailants was 2.8. Sixteen victims (57%) reported skin or mucosal damage and 25 (89%) sustained penetrative anal intercourse. The threat of transmission of HIV was used by the assailant in 16 cases and sexually transmitted diseases, presumed consequent upon the attack, were found in 5 (18%). These observations suggest that male victims of sexual assault may be at particular risk of sexually transmitted infections, including HIV, and that efforts should be made to encourage them to come forward for help.     

An audit on the management of female victims of sexual assault attending a genitourinary medicine clinic

The victims of sexual assault may attend GUM clinic without any referral from any other agency. The management of these cases need special care. We audited the management of females who were known to us as victims of sexual assault. In 15 months, 68 females attended our clinic. All were screened for sexually transmitted infections (STI). Emergency contraception was offered to only 38.4% at risk cases, and formal counselling support was offered to only 25% cases. Further care is necessary to improve counselling support and offering emergency contraception to the victims of sexual assault.     

Audit of the management of victims of sexual assault in a city centre genitourinary medicine clinic

A total of 113 individuals (101 women, 12 men) who had experienced sexual assault (SA) attended the genitourinary medicine clinic. Of the 60 patients who were seen at a dedicated clinic for victims of SA, the median age was lower, a greater number had reported to the police and the interval between assault and attendance was shorter, compared with the 53 who attended the routine walk-in service. However, the majority of the men attended routine clinics. Drug-facilitated rape was reported in 20%, excess alcohol in 10% and the use of violence in 20% cases. Overall, the prevalence of sexually transmitted infections was the same as the total clinic population.     

The laboratory diagnosis of sexually transmitted infections in cases of sexual assault and abuse.

Laboratory staff dealing with samples from victims must be aware that such patients have been psychologically traumatized and deserve special care. The help of a sexual assault care team should be sought if available, and appropriate specimens should be collected two to 10 days after an incident, preferably in a single visit. Specimens should be clearly labelled, and the laboratory should be informed. In the laboratory, all procedures need to be clearly documented. There are special requirements for the collection of forensic specimens and associated records, which may later be required for legal proceedings. The laboratory must know what the current legal status is for any test being used in that community. The present article serves as a guideline to more detailed practice standards for the investigation of individual sexually transmitted infections in assault and abuse situations.     

Rape among incarcerated men: sex,coercion and STDs

Male inmates fear being raped most of all. Criminologists have yet to reach consensus on the prevalence of male inmate-on-inmate rape. The leading prevalence studies found that 7-12% of the responding male inmates had been raped an average of nine times. With a national jail and prison population of 2 million at mid-year 2002, the United States likely exposes tens of thousands of male inmates to rape, and consequently, to HIV/AIDS and other sexually transmitted diseases (STDs). The release of inmates from jails and prisons-estimated at 11.5 million persons in 1998-transforms the consequences of male rape from a correctional matter into a public health crisis. The quest for dominance and control over other inmates-not sexual release-best explains male custodial rape. Prison sexual predators are typically heterosexual. Their victims, however, involuntarily assume female roles in the prison sexual system. Moreover, they experience stigmatization by inmates and staff as well as physical and mental trauma. Civil rights litigation on behalf of victims rarely succeeds and damage awards are usually small. In 2003, Congress provided $13 million for the study and prevention of rape in jails and prisons. Preventing custodial rape and treating its victims will require a sustained commitment by government.     

Management of survivors of sexual assault within genitourinary medicine

Survivors of sexual assault can access treatment and care within genitourinary (GU) medicine services by attending walk-in, booked or a dedicated clinic. Haven Whitechapel the local Sexual Assault Referral Centre (SARC) provides a forensic and aftercare service. A team was set up to ensure efficient communication and clear referral pathways between the centres. This service was audited after eight months of joint working. A retrospective case note review of women attending between August and March 2007 was undertaken. Sixty-nine women were referred to the dedicated clinic. Vaginal rape was reported by 80% of the women. Offer of forensic medical examination documented in 71% presenting within the forensic timeframe. Emergency contraception was offered to 75% of the women. HIV-acquisition risk was documented in 70%. Seventy-eight percent had a sexually transmitted infection screen at their first visit. An HIV test was done to 41% of the women; all were found to be negative. Sixty-two percent women attended follow-up. GU medicine staff should receive specific training in sexual assault. We recommend that GU medicine services and SARC work in partnership to improve the care of victims of sexual assault who access general GU medicine services.     

Sexually transmitted diseases and rape: the experience of a sexual assault centre

Epidemiological data and rates of sexually transmitted diseases (STDs) are presented from a group of 90 women screened following rape. Forty-eight (53%) women knew their assailant. In 6 cases multiple assailants were involved. In 21 (23%) rapes weapons were used. Of 47 women examined within 48 hours of rape, 17 (36%) had evidence of genital trauma. Anal injury was common (8 of 11, 73%) in those reporting anal intercourse. Anal assault (17 of 90, 19%) and oral assault (16 of 90, 18%) commonly accompanied rape. STDs were diagnosed in 13 (14.4%) women, 3 having mixed infections. Neisseria gonorrhoeae was isolated in 2 women, Chlamydia trachomatis in 7, Trichomonas vaginalis in 6, genital warts in 2 and Pediculosis pubis in 2 women. Five of 16 cervical cytology results showed abnormalities, 2 were suggestive of CIN. Eleven of 13 women with an STD (84.6%) had been sexually active within the 3 months prior to the rape. Previous sexual activity may be the most relevant factor determining those most at risk of harbouring an STD.     

Sexual assault history and risks for sexually transmitted infections among women in an African township in Cape Town, South Africa

Sexual violence is associated with women's risks for HIV infection. The current study investigated factors related to risks for sexually transmitted infections (STIs), including HIV, among South African women with a history of sexual assault. An anonymous street intercept survey of women (N = 272) living in an African township in the Western Cape, South Africa assessed demographic characteristics, history of sexual assault, HIV risk behaviours, substance use and non-sexual relationship abuse. Surveys were completed by 90% of women approached. Forty-four per cent (N = 119) of women reported a history of sexual assault. Multiple logistic regressions, controlling for participant age, education, marital status and survey venue, showed that women who had been sexually assaulted were significantly more likely to have shared injection drug equipment, exchanged sex to meet survival needs, and used alcohol compared to women who had not been sexually assaulted. Women with a history of sexual assault were also significantly more likely to have multiple male sex partners, greater rates of unprotected vaginal intercourse, lower rates of condom protected anal intercourse, more sexual contacts involving blood, more STIs and genital ulcers. Finally, women who had been sexually assaulted were more likely to have been non-sexually abused by relationship partners and were more likely to fear asking partners to use condoms. There is a close connection between sexual assault and women's risks for STIs and HIV. Structural and behavioural interventions are needed to simultaneously reduce the prevalence of sexual assault against women and prevent the transmission of HIV.     

Female sexual assault: medical and legal implications.

STUDY OBJECTIVE: To assess the medical and legal effectiveness of this institution's existing adult female sexual assault protocol. DESIGN: Retrospective review. SETTING: Urban public hospital. TYPE OF PARTICIPANTS: One hundred eighty-two adult female sexual assault victims undergoing evaluation within 36 hours of assault. MEASUREMENTS AND MAIN RESULTS: Each case was reviewed with specific attention to associated injuries, sexually transmitted disease, compliance with medical follow-up, pregnancy, and legal outcome. Half of all cases had associated injuries. Nine percent of the women were found to have genital trauma on pelvic examination, although only 29% of these women had complaints of genital pain or bleeding. Ten percent of all women had positive gonorrhea cultures at initial examination. Thirty percent of the women completed the follow-up protocol. None of the women given postcoital estrogen therapy is known to have become pregnant. Only 53 of the 182 cases had the potential for successful prosecution with both a victim willing to cooperate in prosecution and an identified assailant. Thirty-four percent of these cases resulted in a successful prosecution. Evidence of genital or nongenital trauma was significantly associated with a successful legal outcome. CONCLUSION: A physical and evidentiary examination, including pelvic examination and assays for sperm and acid phosphatase, is warranted in all cases of female sexual assault presenting within 36 hours of the assault. Institutions dealing with victims from a transient, lower socioeconomic population should offer prophylactic treatment for sexually transmitted disease and pregnancy rather than rely on compliance with follow-up schedules.     

Infecciones por Chlamydia trachomatis (incluye linfogranuloma venéreo) y Mycoplasma genitalium

Sexually transmitted infections caused by Chlamydia trachomatis, including lymphogranuloma venereum and Mycoplasma genitalium have increased in last decade. This epidemiological scenario presents new challenges in order to improve and strengthen our control and prevention strategies. The routine clinical diagnosis of urethritis and cervicitis must be combined with the active search for the causal agent in men with symptoms of dysuria or proctitis, and in women with pelvic inflammatory disease. We should also include sexually transmitted infections screening in asymptomatic patients with sexual risk behaviours or sexual contact with patients diagnosed with an sexually transmitted infection. The microbiological diagnosis must be based on molecular techniques capable of detecting Chlamydia trachomatis (discriminating between L genotypes associated with lymphogranuloma venereum and other genotypes) and Mycoplasma genitalium (ideally including the identification of macrolide-resistant strains). A faster and specific diagnosis will allow for a targeted treatment with a suitable antibiotic regimen. We also recommend including contact tracing of sexual partners and, occasionally, a cure test. Finally, sexually transmitted infection screening must be widely implemented in those population groups with a high prevalence of sexually transmitted infections.     

The HIV-positive traveler

Antiretroviral therapy has led to a substantial increase in the life expectancy and quality of life for human immunodeficiency virus (HIV)-positive patients. Increasingly, physicians are asked to counsel them before international travel to regions in which infectious diseases are more prevalent. The pretravel evaluation requires an accurate assessment of the patient’s level of immune compromise as well as an understanding of the risks involved in travel to tropical countries. We review the safety and efficacy of travel medicine-related vaccines, important considerations when selecting antimalarial prophylaxis, and strategies for management of traveler’s diarrhea. The prevention of sexually transmitted infections while abroad also is an important public health intervention for both the traveler and the potential sexual partners abroad. Beyond the health-related issues in international travel, HIV-positive patients may confront some significant legal hurdles in crossing international borders. We provide guidance in navigating the diverse and complex issues that arise for the HIV-positive traveler.     

CDC takes a large tiger by the tail: how to handle post-exposure treatment. Centers for Disease Control and Prevention

Guidelines for post-exposure prophylaxis (PEP) for occupational exposures and sexual and injection drug use exposures continue to be controversial. Occupational exposures are usually single exposures, whereas sexual and drug use exposures may be the result of repeated exposures. Occupational exposure risk is unavoidable for health care workers and PEP can reduce the risk. Patients for whom PEP may be appropriate include rape victims, high-risk couples who have had risky sexual relations, and injection drug users who have shared dirty needles. AIDS activists and health officials have raised concerns that PEP may undermine prevention efforts. There is little efficacy data and many ethical issues are related to aggressively treating potential AIDS infections. The Centers for Disease Control and Prevention (CDC) met with behavioral and medical researchers to create guidelines of the best current practices to insure that patients are receiving useful interventions.     

Emerging Sexual Health Issues Among Women Who Have Sex with Women

Women who have sex with women (WSW) comprise a diverse group of people who evidence a spectrum of sexual identity, sexual behaviors, sexual practices, and risk behaviors. WSW are at risk of acquiring a diversity of sexually transmitted infections (STIs) from current and prior partners, both male and female. Notably, human papillomavirus (HPV) is sexually transmitted between female partners, and Pap smear guidelines should be followed in this group. Bacterial vaginosis is common among WSW. WSW should not be presumed to be at low or no risk for STIs based on sexual orientation, and reporting of same sex behavior by women should not deter providers from considering and performing screening for STIs, including Chlamydia trachomatis, according to current guidelines. Effective delivery of sexual health services to WSW requires a comprehensive and open discussion of sexual and behavioral risks, beyond sexual identity, between care providers and their female clients.     

Infecciones de transmisión sexual en el contexto de una agresión sexual

Sexual violence is a worldwide problem with an impact on health that encompasses medical, legal and psychological aspects. Therefore the management of these patients must be multidisciplinary, and action protocols are compulsory. People who are victims of a sexual assault (SA) are at high risk of acquiring a sexually transmitted infection (STI), which must be prevented, diagnosed, treated and followed up post treatment, according to the established action protocol to prevent potential complications.     

Women's Sexual Health and Aging

Older women are often sexually active, but physicians caring for older women rarely address sexual concerns. Although women's desire for sex declines with age, a majority of older women rate sex as having importance in their lives. Women identify emotional intimacy as an important reason for engaging in sexual relationships. Women are less likely than men to have an available spousal or intimate partner and more likely to have a partner with sexual difficulties of their own. Up to half of sexually active older women report a distressing sexual problem, with low desire and problems related to genitourinary syndrome (vulvovaginal atrophy) being most common. Difficulty with orgasm in older women is often associated with a partner's erectile dysfunction. Sexually transmitted infections (STIs) are increasingly prevalent in older women. A minority of older women report discussing sexual issues with a physician. Most commonly, the patient initiates discussions. Physicians should ask regularly and proactively about sexual activity and function. Important interventions include offering practical advice to common chronic medical conditions and sexual problems that confront older women; treating vulvovaginal atrophy; and providing STI screening, prevention strategies, and treatment when appropriate.