The health assessment after sexual assault

Ambreen Butt

Consultant NHS Grampian

Immediate Needs (within 7 days)

• Immediate safety

• Treatment of injuries

Should take precedence over clinical management

Vaginal tears

Palatal Petechaie

Clinical Management

• Emergency Contraception• STI screening follow up• BBV testing/Serum save • STI Prophylaxis• Hep B prophylaxis• HIV PEPSE

The need for any/all of these should start with a detailed sensitively taken sexual history

EMERGENCY CONTRACEPTION

Offered to all women and adolescents

who have had

• Unprotected vaginal sexual intercourse

• Potential failure of contraceptive method

e.g. recent missed pills

EMERGENCY CONTRACEPTION

• Levonelle 2

• ellaOne

• Copper IUCD

Fast track client

Infections

STI identification is unlikely to assumeevidential importance except in certaincircumstances• Young people – children and adolescents not

previously sexually active • Elderly – if no recent consensual sexual activity• Sexually inexperienced orificeChain of evidenceFinding an STI may influence the level of criminal injuries

compensation

Screening for STIS

• What, if any examination required?

• What tests to take and from what sites?

Infections

Most commonly identified STIs after

sexual assault

• Chlamydia- Dual NAAT

• Gonorrhoea – Dual NAAT+/- culture

• Trichomoniasis - direct microscopy

Offer all clients an examination

• if declines then self swab is sufficient to test for chlamydia and gonorrhoea where dual NAAT testing is available – should be done at time of presentation and repeated if necessary after 2 weeks

• Remember to sample all sites affected

In a Primary Care setting where dual NAAT testing available

• If examined –Dual NAAT from all sites affected and in female complaining of vaginal discharge do HVS.

• if declines examination then can self swab from all sites affected

Consider referral to specialist services if symptomatic

STI ANTIBIOTIC PROPHYLAXIS

Consider

• In situations where patient may default

• Unable to tolerate the distress of repeat examination

• Requires IUCD for EC

STI ANTIBIOTIC PROPHYLAXIS

Advantages

• Reduce the need for tests

• Lesson chance of missed infection

• Decrease the chances of detecting a bacterial STI

STI ANTIBIOTIC PROPHYLAXIS

Disadvantages

• Unnecessary treatment

• Reinforcing belief that high risk of infection

• Missing out on partner notification

STI ANTIBIOTIC PROPHYLAXIS

First line antibiotics

• Cefixime 400mgs

• Azithromycin 1g

• Metronidazole 2g

BBV Screen/Serum save

• Offered to all at presentation

HEP B VACCINATIONShould be offered to victims of sexualassault – risk assessment- if risk unknown then should be given

May be of value up to 6 weeks after event

Super-accelerated course recommended as more rapid protection and adherence better

Vaccination interval 0, 1, 3 weeks and 1 year

High risk of hep B- Immunoglobulin ASAP and no later than 7 days

PEPSE

POST EXPOSURE PROPHYLAXIS

FOR HIV FOLLOWING

UNPROTECTED SEXUAL EXPOSURE

PEPSE

RISK OF HIV TRANSMISSION =

RISK THAT THE SOURCE IS HIVPOSITIVE x RISK OF EXPOSURE*

(*including cofactors such as co-existing sexually transmitted infections, high viral

load and bleeding/trauma)

PEPSETable 1 Risk that source is HIV positiveCommunity group HIV seroprevalence (%)Homosexual men*London 20.30Scotland 3.20Elsewhere 3.60

Heterosexuals Male (%) Female (%)(region of birth)UK 0.5 0.2Rest of Europe 2 0.2North America 2.9 0.1Central and South America 2.4 0.9Caribbean 1.2 1.0North Africa and Middle East 0.5 0.4Sub-Saharan Africa 6.9 11.3South Asia 0.5 0.6East and South East Asia 0.5 0.7Australasia 0.8 0.1

Injecting drug users*London 2.90Elsewhere in the UK 0.50

HPA data, 2004. Contemporaneous prevalence estimates can be obtained at:[www.hpa.org.uk/infections/topics_az/hiv and sti]HPA data 2004, HIV prevalence among GUM attendees by world region of birth in 2003. Prevalence rates for exposures outside of the UK orfor individuals recently moved to the UK can be obtained at: [www.unaids.org]

BASHH RECOMMENDATION FOR PRESCRIBING PEP

BASHH RECOMMENDATION FOR PRESCRIBING PEP

Factors influencing the effectiveness of PEP as identified in the BASHH guidelines are:

• Delay in starting treatment, with PEP seen as possibly less effective or ineffective after 72 hours but possibly still considered if exposure is ‘high risk’

• Drug-resistant strains of HIV may reduce PEP’s effectiveness with resistance testing of the ‘source’ of infection considered and/or factoring in resistance when prescribing PEP drug combinations

• HIV remaining in parts of the body where antiretroviral drugs’ ability to penetrate is variable

• Poor adherence to the PEP drug regime

PEPSE

SIDE EFFECTS

Mild• Nausea and diarrhoea- supportive treatment

with Domperidone and Loperamide

Serious• Lipid abnormalities• Liver problems• Diabetes and insulin resistance

PEPSE

PRESCRIBING RECOMMENDATIONS

• Nucleoside reverse transcriptase inhibitors (NRTIs)

• Non-nucleoside reverse transcriptase inhibitors (NNRTIs)

• Protease inhibitors (PIs)

PEPSE

Current pack consists of the following drugs: TRUVADA• Tenofovir 245 mg once daily• Emtricitabine 200mg once dailyKALETRA• Ritonavir boosted Lopinavir 2 tablets twice dailyInitial pack contains 5 days supplyTreatment given for 4 weeks28 day course cost around £650

Follow up

• Repeat STI screen 2 weeks after sexual assault

• Pregnancy testing

• HIV testing- can be done at 1 and 3 months (4 months if taken PEPSE)

• Syphilis testing- 3 months

• Hep B and C testing - at 3 and 6 months

• Review psychosocial needs and coping

BASHH GuidelinesManagement of adult and adolescent complainants of sexual assault (2011)

http://www.bashh.org/documents/3275