GMHC Treatment Issues 1997 Jul/Aug 1; 11(7/8): 11
The probability of HIV infection from a single needlestick
exposure is considered to be 0.32%. A single sexual exposure to
HIV through a mucosal surface (vagina or rectum) may pose a
similar probability for HIV infection. In The New England
Journal of Medicine (April 10, 1997), a "Sounding Board"
editorial examined the question of offering postexposure
treatment to people exposed to HIV via sexual contact or
injection drug use. A concomitant issue is the question of
offering postexposure prophylaxis to victims of rape and sexual
assault. Several probable cases of HIV transmission resulting
from rape have been reported, and the NEJM editorial
recommended prophylaxis for rape victims.
The CDC currently recommends postexposure treatment of health
care providers who are exposed to HIV infected blood or other
fluids by needlestick injury, but recommendations regarding
victims of sexual assault are under investigation. The New York
State Department of Health is discussing recommending
antiretroviral prophylaxis following sexual assault after a
risk-benefit discussion between the rape crisis counselor or
health care worker and the rape survivor. Important questions
for clarification regarding such recommendations include:
timing of initiation of treatment; which drugs to recommend for
treatment; cost and drug reimbursement; criteria to define
"significant risk" and recommendations for follow-up HIV
testing and medical care.
A recently published case-control study found that treatment
with AZT for post-occupational exposure decreased the risk of
acquiring HIV by 79%. Current standard of care treatment for
occupational exposure is AZT (200 mg three times a day), 3TC
(150 mg twice a day), and indinavir (800 mg three times a day)
for four weeks.
Interventions for survivors of sexual assault presently include
some or all of the following: crisis intervention; referral for
follow-up counseling; physical exam for evidence; testing
and/or prophylaxis for syphilis, gonorrhea, chlamydia and
hepatitis; pregnancy testing and emergency contraception; and
treatment for any physical injuries. HIV testing as a part of
these interventions is uncommon, yet rape survivors are
increasingly concerned about the possibility of HIV
transmission as a result of the assault, and some are
requesting HIV prophylaxis. The rape survivor should be
counseled regarding risk of HIV transmission via the assault.
Pre-test counseling and HIV testing should take place within
two weeks of the assault and again three months later. If
prophylaxis is requested, it should begin as soon as possible,
certainly within 24 hours of the attack.
The standard three-drug postexposure prophylaxis regimen is
onerous to follow. It involves 17 pills taken in the course of
the day and has a long list of potential side effects. This
regimen also costs about $900 to complete. Clearly there is a
need for emergency departments to receive guidance and training
in order to implement post-rape HIV counseling and prophylaxis.
Further, issues related to access and payment mechanisms will
need to be addressed in order that all women have the same
ability to exercise the postexposure prophylaxis option after a
rape, should they choose to do so.