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Lesson 25. Sexual Assault and Abuse and STIs

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References

  • A National Protocol for Sexual Assault Medical Forensic Examinations Adults/Adolescents. Second Edition. U.S. Department of Justice. Office on Violence Against Women. April 2013
  • Adair CD, Gunter M, Stovall TG, McElroy G, Veille JC, Ernest JM. Chlamydia in pregnancy: a randomized trial of azithromycin and erythromycin. Obstet Gynecol. 1998;91:165-8.
  • Centers for Disease Control and Prevention (CDC). HIV testing and risk behaviors among gay, bisexual, and other men who have sex with men - United States. MMWR Morb Mortal Wkly Rep. 2013;62:958-62.
  • Centers for Disease Control and Prevention, U.S. Department of Health and Human Service. Update: Interim Statement Regarding Potential Fetal Harm from Exposure to Dolutegravir—Implications for HIV Post-exposure Prophylaxis (PEP).
    [CDC] -
  • Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. Updated Guidelines for Antiretroviral Postexposure Prophylaxis After Sexual, Injection Drug Use, and Other Nonoccupational Exposure to HIV – United States, 2016.
    [CDC] -
  • Crawford-Jakubiak JE, Alderman EM, Leventhal JM, AAP Committee on child abuse and neglect,, AAP Committee on adolescence. Care of the Adolescent After an Acute Sexual Assault. Pediatrics. 2017;139:e20164243.
  • de Voux A, Kidd S, Grey JA, et al. State-Specific Rates of Primary and Secondary Syphilis Among Men Who Have Sex with Men - United States, 2015. MMWR Morb Mortal Wkly Rep. 2017;66:349-354.
  • Deutsch SA, Benyo S, Xie S, et al. Addressing Human Papillomavirus Prevention During Pediatric Acute Sexual Assault Care. J Forensic Nurs. 2018;14:154-161.
  • Du Mont J, Myhr TL, Husson H, Macdonald S, Rachlis A, Loutfy MR. HIV postexposure prophylaxis use among Ontario female adolescent sexual assault victims: a prospective analysis. Sex Transm Dis. 2008;35:973-8.
  • Fanfair RN, Wallingford M, Long LL, et al. Acquired macrolide-resistant Treponema pallidum after a human bite. Sex Transm Dis. 2014;41:493-5.
  • Houmes BV, Fagan MM, Quintana NM. Establishing a sexual assault nurse examiner (SANE) program in the emergency department. J Emerg Med. 2003;25:111-21.
  • Iversen OE, Miranda MJ, Ulied A, et al. Immunogenicity of the 9-Valent HPV Vaccine Using 2-Dose Regimens in Girls and Boys vs a 3-Dose Regimen in Women. JAMA. 2016;316:2411-2421.
  • Kellogg N. The evaluation of sexual abuse in children. Pediatrics. 2005;116:506-12.
  • Krause KH, Lewis-O'Connor A, Berger A, et al. Current practice of HIV postexposure prophylaxis treatment for sexual assault patients in an emergency department. Womens Health Issues. 2014;24:e407-12.
  • Linden JA. Clinical practice. Care of the adult patient after sexual assault. N Engl J Med. 2011;365:834-41.
  • Meites E, Kempe A, Markowitz LE. Use of a 2-Dose Schedule for Human Papillomavirus Vaccination - Updated Recommendations of the Advisory Committee on Immunization Practices. MMWR Morb Mortal Wkly Rep. 2016;65:1405-8.
  • Ohnishi M, Saika T, Hoshina S, et al. Ceftriaxone-resistant Neisseria gonorrhoeae, Japan. Emerg Infect Dis. 2011;17:148-9.
  • Panel on Treatment of Pregnant Women with HIV Infection and Prevention of Perinatal Transmission. Recommendations for the Use of Antiretroviral Drugs in Pregnant Women with HIV Infection and Interventions to Reduce Perinatal HIV Transmission in the United States. January 17, 2020.
    [HIV.gov] -
  • Patel P, Borkowf CB, Brooks JT, Lasry A, Lansky A, Mermin J. Estimating per-act HIV transmission risk: a systematic review. AIDS. 2014;28:1509-19.
  • Schillie S, Murphy TV, Sawyer M, et al. CDC guidance for evaluating health-care personnel for hepatitis B virus protection and for administering postexposure management. MMWR Recomm Rep. 2013;62:1-19.
  • Seña AC, Hsu KK, Kellogg N, et al. Sexual Assault and Sexually Transmitted Infections in Adults, Adolescents, and Children. Clin Infect Dis. 2015;61 Suppl 8:S856-64.
  • Sonawane K, Suk R, Chiao EY, et al. Oral Human Papillomavirus Infection: Differences in Prevalence Between Sexes and Concordance With Genital Human Papillomavirus Infection, NHANES 2011 to 2014. Ann Intern Med. 2017;167:714-724.
  • Stoltey JE, Cohen SE. Syphilis transmission: a review of the current evidence. Sex Health. 2015;12:103-9.
  • U.S. Department of Justice Office on Violence Against Women. A National Protocol for Sexual Abuse Medical Forensic Examinations, Pediatric. April 2016.
  • U.S. Department of Justice, Office of Justice Programs, National Institute of Justice. National Best Practices for Sexual Assault Kits: A Multidisciplinary Approach. August 8, 2017.
  • Ucciferri C, Tamburro M, Falasca K, Sammarco ML, Ripabelli G, Vecchiet J. Prevalence of anal, oral, penile and urethral Human Papillomavirus in HIV infected and HIV uninfected men who have sex with men. J Med Virol. 2018;90:358-366.
  • Workowski KA, Bachmann LH, Chan PA, et al. Sexually transmitted infections treatment guidelines, 2021. Sexual assault and abuse and STIs: adolescents and adults. MMWR Recomm Rep. 2021;70(No. RR-4):1-187.
  • Wu T, Kwok RM, Tran TT. Isolated anti-HBc: The Relevance of Hepatitis B Core Antibody-A Review of New Issues. Am J Gastroenterol. 2017;112:1780-8.
  • Yakely AE, Avni-Singer L, Oliveira CR, Niccolai LM. Human Papillomavirus Vaccination and Anogenital Warts: A Systematic Review of Impact and Effectiveness in the United States. Sex Transm Dis. 2019;46:213-20.
  • Yasuda M, Ito S, Hatazaki K, Deguchi T. Remarkable increase of Neisseria gonorrhoeae with decreased susceptibility of azithromycin and increase in the failure of azithromycin therapy in male gonococcal urethritis in Sendai in 2015. J Infect Chemother. 2016;22:841-843.

Tables

Table 1.

Postexposure Prophylaxis for HBV Following Sexual Assault
HBV Status of Sexual Assault Survivor HBsAg Status of Assailant
HBsAg Positive HBsAg Status Unknown HBsAg Negative
Unvaccinated HBIG x 1, and
HBV vaccine series (first dose now)		 HBV vaccine series (first dose now) HBV vaccine series (first dose now)
Partially vaccinated HBIG x 1, and
complete HBV vaccine series		 Complete HBV vaccine series (give next dose in series now) Complete HBV vaccine series (give next dose in series now)
Fully vaccinated but response to vaccine unknown HBV vaccine booster dose x 1 (give dose now) HBV vaccine booster dose x 1 (give dose now) No treatment
Fully vaccinated with documented response to vaccine* No treatment No treatment No treatment
Vaccine nonresponder^ HBIG x 2 (separated by 1 month) HBIG x 2 (separated by 1 month) No treatment

*A responder is defined as a person with anti-HBs ≥10 mIU/mL after ≥3 doses of HBV vaccine.
^A nonresponder is defined as a person with anti-HBs <10 mIU/mL after ≥6 doses of HBV vaccine.
Abbreviations: HBV = hepatitis B virus; HBsAg = hepatitis B surface antigen; HBIG = hepatitis B immune globulin
NOTE: this table is based on recommendations from several different publications from the Centers for Disease Control and Prevention (CDC)
Source:
  • Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. Updated Guidelines for Antiretroviral Postexposure Prophylaxis After Sexual, Injection Drug Use, and Other Nonoccupational Exposure to HIV – United States, 2016. [CDC]
  • Workowski KA, Bachmann LH, Chan PA, et al. Sexually transmitted infections treatment guidelines, 2021. Sexual assault and abuse and STIs: adolescents and adults. MMWR Recomm Rep. 2021;70(No. RR-4):1-187. [2021 STI Treatment Guidelines]
  • Workowski KA, Bolan GA; Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines, 2015. Sexual assault and abuse and STDs. MMWR Recomm Rep. 2015;64(No. RR-3):1-137. [2015 STD Treatment Guidelines]

Table 1. 2021 STI Treatment Guidelines: Sexual Assault
Empiric Antimicrobial Treatment after Sexual Assault

Source: Workowski KA, Bachmann LH, Chan PA, et al. Sexually transmitted infections treatment guidelines, 2021. Sexual assault and abuse and STIs. MMWR Recomm Rep. 2021;70(No. RR-4):1-187. [2021 STI Treatment Guidelines]
Table 2.

Estimated Per-Act Probability of Acquiring HIV from an Infected Source, by Exposure Act*
Exposure Type Rate for HIV Acquisition per 10,000 Exposures
Parenteral
  Blood transfusion 9,250
  Needle sharing during injection drug use 63
  Percutaneous (needlestick) 23
Sexual
  Receptive anal intercourse 138
  Insertive anal intercourse 11
  Receptive penile-vaginal intercourse 8
  Insertive penile-vaginal intercourse 4
  Receptive oral intercourse Low
  Insertive oral intercourse Low
Other^  
  Biting Negligible
  Spitting Negligible
  Throwing body fluids (including semen or saliva) Negligible
  Sharing sex toys Negligible

*Factors that may increase the risk of HIV transmission include sexually transmitted diseases, acute and late-stage HIV infection, and high viral load. Factors that may decrease the risk include condom use, male circumcision, antiretroviral treatment, and preexposure prophylaxis. None of these factors are accounted for in the estimates presented in the table.

^HIV transmission through these exposure routes is technically possible but unlikely and not well documented
Source:
  • Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. Updated Guidelines for Antiretroviral Postexposure Prophylaxis After Sexual, Injection Drug Use, and Other Nonoccupational Exposure to HIV – United States, 2016. [CDC]
  • Patel P, Borkowf CB, Brooks JT, Lasry A, Lansky A, Mermin J. Estimating per-act HIV transmission risk: a systematic review. AIDS. 2014;28:1509-19. [PubMed Abstract]
Table 3. 2016 CDC and HHS Guidelines for Nonoccupational Exposure to HIV

Preferred and Alternative 28-Day Regimens for Nonoccupational PEPa,b

Adults and adolescents aged ≥13 years, including pregnant women, with normal renal function (creatinine clearance ≥60 mL/min)

Preferred Regimens:

  • Raltegravir (400 mg twice daily) plus tenofovir DF-emtricitabine (300-200 mg once daily)
  • Dolutegravir (50 mg once daily) plus tenofovir DF-emtricitabine (300-200 mg once daily)

Alternative Regimen:

  • Darunavir (800 mg once daily) plus ritonavir (100 mg once daily) plus tenofovir DF-emtricitabine (300-200 mg once daily)

Adults and adolescents aged ≥13 years with renal dysfunction (creatinine clearance ≤59 mL/min)+

Preferred Regimens:

  • Raltegravir (400 mg twice daily) plus zidovudine (dose adjusted) plus lamivudine (dose adjusted)
  • Dolutegravir (50 mg once daily) plus zidovudine (dose adjusted) plus lamivudine (dose adjusted)

Alternative Regimen:

  • Darunavir (800 mg once daily) plus ritonavir (100 mg once daily) plus zidovudine (dose adjusted) plus lamivudine (dose adjusted)

aThese recommendations do not reflect current Food and Drug Administration-approved labeling for antiretroviral medications listed in this table.

bRitonavir is used in clinical practice as a pharmacokinetic enhancer to increase the trough concentration and prolong the half-life of darunavir, lopinavir, and other protease inhibitors. Ritonavir is not counted as a drug directly active against HIV in the above “3-drug” regimens.

+The dose adjustments for zidovudine and lamivudine are made based on degree of renal function
Source:
  • Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. Updated Guidelines for Antiretroviral Postexposure Prophylaxis After Sexual, Injection Drug Use, and Other Nonoccupational Exposure to HIV – United States, 2016. [CDC]
Table 4.

nPEP: Recommended Laboratory Monitoring of Source and Exposed Persons
Test Source Exposed
Baseline Baseline 4-6 Weeks after exposure 3 Months after exposure 6 months after exposure
  For all persons considered for or prescribed nPEP for any exposure
HIV Ag/Ab testinga
(or antibody testing if Ag/Ab test unavailable)		 √ √ √ √ √b

Hepatitis B serology, including:
 hepatitis B surface antigen
 hepatitis B surface antibody
 hepatitis B core antibody

 √ √ __ __ √c
Hepatitis C antibody test √ √ __ __ √d
  For all persons considered for or prescribed nPEP for sexual exposure
Syphilis serologye √ √ √ __ √
Gonorrheaf √ √ √g __ __
Chlamydiaf √ √ √g __ __
Pregnancyh __ √ √ __ __
 

For women prescribed:

  • Tenofovir DF-emtricitabine + raltegravir
  • Tenofovir DF-emtricitabine + dolutegravir
Serum creatinine (for calculating estimated creatinine clearance) √ √ __ __
Alanine transaminase, aspartate aminotransferase √ √ __ __
  For all persons with HIV confirmed at any visit
HIV viral load √ √i
HIV genotypic resistance √ √i

Abbreviations: Ag/Ab = antigen/antibody combination test; HIV = human immunodeficiency virus; nPEP = nonoccupational postexposure prophylaxis; tenofovir DF = tenofovir disoproxil fumarate.
a Any positive or indeterminate HIV antibody test should undergo confirmatory testing of HIV infection status.
b Only if hepatitis C infection was acquired during the original exposure; delayed HIV seroconversion has been seen in persons who simultaneously acquire HIV and hepatitis C infection.
c If exposed person susceptible to hepatitis B at baseline.
d If exposed person susceptible to hepatitis C at baseline.
e If determined to be infected with syphilis and treated, should undergo serologic syphilis testing 6 months after treatment
f Testing for chlamydia and gonorrhea should be performed using nucleic acid amplification tests. For patients diagnosed with a chlamydia or gonorrhea infection, retesting 3 months after treatment is recommended.
- For men reporting insertive vaginal, anal, or oral sex, a urine specimen should be tested for chlamydia and gonorrhea.
- For women reporting receptive vaginal sex, a vaginal (preferred) or endocervical swab or urine specimen should be tested for chlamydia and gonorrhea.
- For men and women reporting receptive anal sex, a rectal swab specimen should be tested for chlamydia and gonorrhea.
- For men and women reporting receptive oral sex, an oropharyngeal swab should be tested for gonorrhea.
g If not provided presumptive treatment at baseline, or if symptomatic at follow-up visit.
h If woman of reproductive age, not using effective contraception, and with vaginal exposure to semen.
i eCrCl = estimated creatinine clearance calculated by the Cockcroft-Gault formula; eCrClCG = [(140 − age) x ideal body weight] ÷ (serum creatinine x 72) (x 0.85 for females).
j At first visit where determined to have HIV infection.
Source:
  • Centers for Disease Control and Prevention, U.S. Department of Health and Human Services. Updated Guidelines for Antiretroviral Postexposure Prophylaxis After Sexual, Injection Drug Use, and Other Nonoccupational Exposure to HIV – United States, 2016. [CDC]
Table 5.

Baseline Laboratory Testing
Laboratory Test Sexual Assault Survivor Alleged Assailant
Hepatitis B surface antibody (anti-HBs) Negative Negative
Hepatitis B surface antigen (HBsAg) Negative Positive
Hepatitis B core antibody (anti-HBc) Negative Positive
Hepatitis C antibody Negative Negative
HIV-1/2 antigen-antibody Negative Negative
Table 6.

Baseline HBV Serologic Results
HBsAg anti-HBs anti-HBc Interpretation Recommended Action
(+) (-) (+) Chronic HBV infection Link to care for HBV treatment
(+) (-) IgM (+) Acute HBV infection Link to care for management and follow-up
(-) (+) (+) Resolved HBV infection Reassurance
(-) (+) (-) Immune to HBV Reassurance
(-) (-) (-) Susceptible to HBV (non immune) Vaccinate
(-) (-) (+)

"Isolated anti-HBc" may represent (1) prior HBV infection, (2) a false-positive test, (3) occult HBV infection, or (4) window phase of acute HBV infection

 Expert consultation advised to determing optional further evaluation and management. 
Abbreviations: HBV= hepatitis B Virus; HbsAg = hepatitis B surface antigen; anti-HBs = hepatitis B surface antibody; anti-HBc = hepatitis B core antibody
Table 7.

Implications of Diagnosis of Sexually Transmitted Infections and Reporting in Prepubertal Children and Infants
Sexually Transmitted Infection Sexual Abuse Suggested Action
Chlamydia trachomatis Diagnostic* Report
Neisseria gonorrhoeae Diagnostic* Report
HIV Diagnostic** Report
Syphilis Diagnostic* Report
Trichomonas vaginalis Highly suspicious Report
Anogenital warts Suspicious* Report
Herpes simplex virus (genital location) Suspicious^ Report
Bacterial vaginosis Inconclusive Medical follow-up
*If not acquired perinatally and rare, nonsexual vertical transmission can be excluded.
**If not acquired perinatally, through breastfeeding, or transfusion.
^Autoinoculation should be excluded.
Adapted from: Kellogg N. The evaluation of sexual abuse in children. Pediatrics. 2005;116:506-12.
Source:
  • Kellogg N. The evaluation of sexual abuse in children. Pediatrics. 2005;116:506-12. [PubMed Abstract]

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