Sexually Transmitted Infections

Adult female complainants of sexual assault are at risk of acquiring a sexually transmitted infection (STI) as result of the assault (199,200). Some male complainants have also described STI acquisition after the sexual assault (170,171). In children who may have been sexually abused, there is a low prevalence of infections that are definitely sexually transmitted, although other organisms possibly associated with sexual activity may be identified (201). Therefore, STI testing should be offered when the history and/or physical findings suggest the possibility of oral, genital, or rectal contact.

Some guidelines advocate STI screening for all adults at the time of presentation in recognition of the significant incidence of pre-existing STI amongst women who allege rape and a high default rate for follow-up consultations (202,203). However, disclosure in court of pre-existing STI can be detrimental to the complainant (40,204). Consequently, it may be more appropriate for the first tests to be deferred until 14 d after the assault. When interpreting the results of STI tests in young children, consideration must be given to the possibility that the sexually transmitted organisms could have been acquired perinatally (201,205,206).

Some centers prescribe antibiotic prophylaxis for all complainants of penile penetrative sexual assaults at the time they present (6,207,208). The use of antibiotic prophylaxis reduces the need for repeated examinations, avoids the anxiety incurred in waiting for the results, and is acceptable to the majority of women to whom it is offered (209). Antibiotic prophylaxis should cover the prevalent, treatable organisms in the local population, and advice should be sought from the local center for disease control regarding an appropriate regimen.

Hepatitis B virus (HBV) can be acquired through consensual and nonconsensual sexual activity (210). Therefore, HBV vaccine should be offered to all adult victims of sexual assault (202). In children and young people, a risk/ benefit analysis will inform the decision regarding whether the vaccine should be offered.

It is not known how soon after the sexual assault the HBV vaccine needs to be given to have an effect. However, because of the long incubation period an accelerated course of the vaccine (0, 1, and 2 months or 0, 1, and 6 months) may be efficacious if is initiated within 3 weeks of the exposure (202).

Human immunodeficiency virus (HIV) can be acquired through sexual activity (210). Although preventive antiretroviral treatment (postexposure prophylaxis [PEP]) is increasingly being offered to patients who may have had a sexual exposure to HIV infection, there are no studies that prove the efficacy of PEP in these circumstances (211).

There are two approaches to the management of HIV PEP after a sexual assault. The first approach is to offer HIV PEP to all patients whose mucosa has been or is believed to have been exposed to the blood or semen of the assailant, regardless of the geographic location or likelihood of HIV infection in the assailant (212). The second is for a forensic/genitourinary medicine physician to undertake a risk assessment taking account of the prevalence of HIV in the area where the assault occurred, the timing and nature of the assault, and any HIV risk behaviors exhibited by the assailant (202,212). Animal studies suggest that the sooner HIV PEP is given, the greater the chance of preventing seroconversion. Therefore, it is currently recommended that HIV PEP is com menced no more than 72 hours after the assault, although it still may be effective up to 14 days after exposure (202,213). Patients considering HIV PEP should be advised of the unproven efficacy, side effects, and potential toxicity of the treatment (202,211).

Regardless of whether prophylaxis is given, complainants should be counseled and offered baseline serological tests for syphilis, HBV, hepatitis C, and HIV, which will be repeated at the relevant periods after assault.

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