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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.
  • Schillie S, Vellozzi C, Reingold A, et al. Prevention of Hepatitis B Virus Infection in the United States: Recommendations of the Advisory Committee on Immunization Practices. MMWR Recomm Rep. 2018;67:1-31.
  • 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.
  • Tanner MR, O'Shea JG, Byrd KM, et al. Antiretroviral Postexposure Prophylaxis After Sexual, Injection Drug Use, or Other Nonoccupational Exposure to HIV - CDC Recommendations, United States, 2025. MMWR Recomm Rep. 2025;74:1-56.
  • 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.

HBV Nonoccupational Postexposure Prophylaxis 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

Abbreviations: HBV = hepatitis B virus; HBsAg = hepatitis B surface antigen; HBIG = hepatitis B immune globulin
*HBV vaccine responder is defined as a person with anti-HBs ≥10 mIU/mL after completing the HBV vaccine series.
^HBV vaccine nonresponder is defined as a person with anti-HBs <10 mIU/mL after ≥6 doses of HBV vaccine.
Source:
  • Tanner MR, O'Shea JG, Byrd KM, et al. Antiretroviral Postexposure Prophylaxis After Sexual, Injection Drug Use, or Other Nonoccupational Exposure to HIV - CDC Recommendations, United States, 2025. MMWR Recomm Rep. 2025;74:1-56. [PubMed Abstract]
  • 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 a Source with HIV, 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. 2025 CDC Recommendations for Nonoccupational Postexposure Prophylaxis after Exposure to HIV

Preferred and Alternative Regimens for HIV Nonoccupational PEP in Adults and Adolescents*
 Adults and Adolescents Aged ≥12 years (with creatinine clearance ≥50 mL/min)
 Preferred

 Integrase Strand Transfer Inhibitor PLUS Two Nucleoside Reverse Transcriptase Inhibitors

  • Bictegravir-tenofovir alafenamide-emtricitabine
  • Dolutegravir PLUS (tenofovir alafenamide OR tenofovir DF) PLUS (emtricitabine OR lamivudine)
 Alternative

Boosted Protease Inhibitor PLUS Two Nucleoside Reverse Transcriptase Inhibitors

  • (Darunavir-cobicistat OR Darunavir and ritonavir) PLUS (tenofovir alafenamide OR tenofovir DF) PLUS (emtricitabine OR lamivudine)
 Pregnant Women (with creatinine clearance ≥50 mL/min)
 Preferred

Integrase Strand Transfer Inhibitor PLUS Two Nucleoside Reverse Transcriptase Inhibitors

  • Bictegravir-tenofovir alafenamide-emtricitabine
  • Dolutegravir PLUS (tenofovir alafenamide OR tenofovir DF) PLUS (emtricitabine OR lamivudine)
 Alternative

Boosted Protease Inhibitor PLUS Two Nucleoside Reverse Transcriptase Inhibitors

  • Darunavir and ritonavir (twice daily) PLUS (tenofovir alafenamide OR tenofovir DF) PLUS (emtricitabine OR lamivudine)
*The regimens within categories are listed in alphabetical order and not to preference.
Source:
  • Tanner MR, O'Shea JG, Byrd KM, et al. Antiretroviral Postexposure Prophylaxis After Sexual, Injection Drug Use, or Other Nonoccupational Exposure to HIV - CDC Recommendations, United States, 2025. MMWR Recomm Rep. 2025;74:1-56. [PubMed Abstract]
Table 4.

HIV Nonoccupational PEP: Recommended Laboratory Monitoring of Source and Exposed Persons
Test Source Exposed
Baseline Baseline 4-6 Weeks after exposure 12 weeks after exposure 6 Months after exposure
  All persons evaluated for nPEP
Rapid (point-of-care) or laboratory-based HIV Ag/Ab test)† √ √  √§ √ —
HIV diagnostic NAT   √**    √**  √§ √ —
HBV serology, including: HBsAg, HBsAb, and HBcAb √    √†† — — If HBV nonimmune at baseline
HCV antibody testing —    √§§ — — If follow-up testing recommended¶¶
HCV RNA NAT    √*** — If follow-up testing recommended††† — —
Syphilis serology§§§ √ √     √§§§    √§§§ —
Gonorrhea NAAT**** √ √ — — —
Chlamydia NAAT**** √ √ — — —
Pregnancy test†††† — √ √ — —
  All persons considered for or prescribed nPEP
Serum creatinine √ Only if abnormalities at baseline — —
Alanine aminotransferase and aspartate aminotransferase √ Only if abnormalities at baseline or symptomatic — —

Abbreviations: Ag/Ab = antigen/antibody combination test; ARV = antiretroviral; HBcAb = hepatitis B core antibody; HBsAb = hepatitis B surface antibody; HBsAg = hepatitis B surface antigen; HBV= hepatitis B virus; HCV = hepatitis C virus; NAT = nucleic acid test; NAAT = nucleic acid amplification test; nPEP = nonoccupational postexposure prophylaxis; PEP = postexposure prophylaxis; STI = sexually transmitted infection.

*Any person diagnosed with an infection or condition through testing should be informed and treated or referred for treatment as needed.
†If a rapid (point-of-care) HIV Ag/Ab test is used, a laboratory-based HIV Ag/Ab test obtained at the same time will increase diagnostic sensitivity. PEP should not be delayed awaiting laboratory results. If the preferred HIV diagnostic test is not accessible, the most sensitive available test should be used.
§HIV testing 4–6 weeks post-nPEP initiation can be deferred for persons who started nPEP within 24 hours of exposure, completed the full PEP course, and are not starting PrEP at this time.
NATs that detect HIV RNA include qualitative tests for diagnosis (e.g., HIV-1 RNA assay) and quantitative tests for disease monitoring (e.g., viral load). Diagnostic HIV NATs are recommended because they are more likely than viral load tests to detect very low levels of HIV. If the preferred HIV diagnostic test is not accessible, the most sensitive available test should be used; inability to access HIV NAT should not prevent provision of HIV nPEP to persons with indications.
**HIV NAT recommended at baseline assessment for persons with injectable ARV exposure during the past 6 months.
††HBV PEP recommendations vary by the exposed person’s HBV immune status, and by the source’s HBV status (when information available).
§§Reflex to HCV RNA NAT if HCV antibody test is positive. Add HCV RNA NAT to original order if signs and symptoms of acute HCV infection are present (e.g., hepatic enzyme elevation).
¶¶If follow-up testing is recommended based on the source’s status (e.g., HCV RNA positive or HCV antibody test is positive with unavailable HCV RNA, or if the HCV infection status is unknown), and HCV RNA NAT is negative 3–6 weeks postexposure, a final test for HCV antibodies 4–6 months postexposure is recommended.
***HCV RNA NAT is preferred for testing of the source, but if not accessible, HCV antibody testing with reflex HCV RNA NAT if positive is an alternative strategy.
††If follow-up testing is recommended based on the source’s status (e.g., HCV RNA positive or positive HCV antibody with unavailable HCV RNA, or if the HCV infection status is unknown), HCV RNA NAT is recommended for the exposed persons 3–6 weeks postexposure.
¶¶¶If initial syphilis testing negative and infection in the source cannot be ruled out, follow-up testing may be performed 4–6 weeks and 3 months postexposure.
****NAATs are recommended for Chlamydia trachomatis and Neisseria gonorrhoeae at exposure sites (e.g., pharynx, rectum, or vagina) at initial visit and can be repeated 1–2 weeks postexposure if no presumptive treatment was provided and initial test results were negative. Repeat testing can also be done if the person reports symptoms concerning for STIs. Certain experts would also perform a NAAT for Trichomonas vaginalis from a urine or vaginal specimen for persons with vaginas.
††††For all women of child-bearing potential who are not known to be pregnant.
Source:
  • Tanner MR, O'Shea JG, Byrd KM, et al. Antiretroviral Postexposure Prophylaxis After Sexual, Injection Drug Use, or Other Nonoccupational Exposure to HIV - CDC Recommendations, United States, 2025. MMWR Recomm Rep. 2025;74:1-56. [PubMed Abstract]
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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