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Gay Men's Health Crisis
Commentary Postexposure Antiretroviral Treatment for Rape Survivors?
Risa Denenberg RN, FNP, MSN
July 1, 1997
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.