Thanks to those who participated in a great discussion in AMR last week. I wanted to share some of what we talked about here…
Sexual assault is an unusal complaint inside of a primary care clinic. Many victims head straight for the ER or a Rape Crisis Center, others never report their attack. But for many, their primary care doctor may seem like a trusted source for health care in a very scary and chaotic situation. Since it is also a scary and chaotic situation for the provider, I thought that an organized process may help you know what to do in such a scenario.
The patient may need or want an exam in order to collect evidence for future charges against an attacker. There is a very specialized process that is used to collect evidence, and maintain the chain of custody. I would recommend that you contact your Emergency Dept or Rape Crisis Center for help. In Birmingham, the Crisis Center offers Sexual Assault Nurse Examiner (SANE) Exams in a safe and secure facility, and may be a more comfortable alternative to an ED. They have a SANE nurse on call 24/7. Many times, this exam must be done within 72 hours of the attack.
Most women should be offered post-coital contraception after a sexual assault. The most effective oral option is Le
vonorgestrel, (Plan B is one brand name). Ulipristal (Ella) is a newer form of emergency contraception that is effective up to 120 hours after unprotected sex.
The CDC recommends antibiotic prophylaxis for GC, Chlamydia, and Trichomonas. If your patient declines, you should see her back in a week for testing. You need to give (all single dose therapies):
- Ceftriaxone 250mg IM for Gonorrhea
- Azithromycin 1g PO for Chlamydia
- Metronidazole 2g PO for Trichomonas
Hepatitis B Prevention
If the Hepatitis B status of the attacker is not known, and the victim is not already immune, the victim should receive the Hepatitis B vaccine on first visit, and then at 1 and 6 months. If the attacker has Hepatitis B, then you should offer HBIG.
There is some data that post-exposure prophylaxis with antiretroviral drugs prevents HIV transmission. Most of this data is in the healthcare setting, when folks like us are exposed with needles. The studies done in sexual exposure and IV drug users are all small and observational. Side effects with these medicines are fairly common, and usually of the GI variety.
Given limited data, and relatively low risk of transmission for a single sexual exposure (0.1% for consensual vaginal intercourse and 2% for consensual anal intercourse- transmission rates with nonconsensual sex are likely to be higher), the CDC only recommends post exposure prophylaxis (PEP) if:
- The assailant is known to be HIV positive
- The victim presents within 72 hours
- There was exposure OF: eye, mouth, vaginal, rectum, other mucus membrane or nonintact skin
- WITH: semen, vaginal fluid, blood, rectal secretions, milk, or other bodily fluids that are known to transmit HIV.
However, they do give you an option to treat other patients on a case-by-case basis. Many experts recommend that PEP is offered to all victims of sexual assault that present in the first 72 hours and have a chance at HIV exposure. If you were going to prescribe, it should start within 72 hours (the earlier the better), and continue for 4 weeks. Three drug combinations are usually used, the same as in occupational HIV PEP.
- Tenofovir/emtricitabine 300/200 plus Dolutegravir 50mg once daily
- Tenofovir/emtricitabine 300/200 plus Raltegravir 400mg twice daily
Probably the most important thing that you can do. Your patient came to use because you were trusted, available, and supportive. You need to continue to be those things. After an assault, many victims will struggle with nightmares, anorexia, guilt, anxiety, and PTSD. As a primary care doctor, you can gently ask about these issues, and guide your patients to helpful therapies and supportive environments. Again, rely on your local resources for crisis counseling and psychiatry, in addition to using all of your own talents.
Here is a NEJM article (subscription needed) if you are interested in reading more: NEngl J Med 2011; 365:834-841.