Many survivors of sexual assault are very frightened by the possibility that they may have been exposed to the HIV virus. Remember that your risk of becoming infected as a result of a sexual assault is probably very low (but, of course, depends upon the specifics of your situation).   It is very important that you talk to your doctor about this issue; gaining knowledge will almost always help to lessen your fears, and talking with your doctor as soon as possible following a sexual assault will help you to make the best possible decisions about protecting your health.  The bottom line is, no matter how much time has passed since your sexual assault, if you are concerned about HIV, you need to get medical advice specific to your situation.

Many people are aware that medications can be taken after a rape which can help to prevent HIV infection.  It is important that you understand that these drugs are not appropriate for many sexual assault survivors.  Preventative medications (known as "PEP" or "Post Exposure Prophylaxis") are not risk-free; in fact, they can have very serious negative side effects.  For this reason, health care providers only recommend or offer PEP when it appears that the potential benefits may outweigh the very real risks of taking these drugs.  Your doctor can talk with you to assess whether or not PEP makes sense in your unique situation. 

The following information provides an overview of physician guidelines recently developed in the State of Ohio.  Again, if you are concerned about your own risk of exposure to HIV, please reach out for help.  Never rely on a website for important medical information-- you need to talk to a doctor about the specifics of your situation.  If you were recently sexually assaulted, go to your local hospital emergency department for help.  If the assault happened some time ago, call your doctor or clinic.  Let medical professionals and rape crisis program staff help you through this stressful time. 

OFFERING HIV PROPHYLAXIS FOLLOWING SEXUAL ASSAULT -- Physician Guidelines for the State of Ohio

(Based upon  recommendations for the State of California, the full text of which is available online at http://www.pepstudy.com/PEPSA.pdf  

These guidelines are the standard developed by the Ohio Department of Health in conjunction with the Ohio Chapter of the American College of Emergency Physicians, the Ohio Chapter of the International Association of Forensic Nurses, the Ohio Bureau of Criminal Identification and Investigation, the Ohio Committee on Child Abuse and Neglect/American Academy of Pediatrics, and the Ohio Coalition on Sexual Assault.  Revised July 2002.) 
 

1. Recommendation Regarding Timing

In cases where PEP (Post Exposure Prophylaxis/preventative medication) is appropriate, PEP should be offered as soon as possible to the survivor.  In no case should PEP be offered after 72 hours following the assault.

It is biologically possible that PEP medications taken soon after exposure to HIV can prevent HIV infection. There is limited evidence available to suggest that antiretroviral medications are efficacious when taken prophylactically (to help prevent infection). In particular, one study of PEP following occupational exposure to HIV showed an 81 percent reduction in risk of seroconversion when medications were started, on average, 4 hours after exposure.

Animal studies suggest that PEP is most beneficial when taken within 1-2 hours of  exposure to HIV.  While the animal studies show that PEP is not likely to be effective when initiated later than 24-36 hours following the exposure, and not effective after 72 hours there is no definitive answer as to the interval during which PEP may be beneficial in humans.  

The advisory panel recommends offering PEP to survivors presenting within 72 hours after the assault. The Center for Disease Control's (CDC's) Hospital Infections Director has recommended that PEP be initiated within 72 hours for individuals with recent sexual exposure to HIV and San Francisco's non-occupational PEP service uses 72 hours as its cut-off. In the sexual assault context, given the delay that commonly occurs between assault and medical treatment, the advisory panel recommends setting the cut-off for treatment initiation at the outermost acceptable limit.

For individuals that seek out medical care more than 72 hours following the potential exposure to HIV, the advisory group recommends that providers offer HIV antibody testing as well as pre- and post-test counseling. Follow-up testing and counseling is recommended at 8 and 14 weeks. If a survivor tests HIV antibody positive on follow-up testing, appropriate referral to an HIV specialist should be expedited to potentially initiate early intervention treatment. Follow-up testing could be offered as part of primary care follow-up or at a local confidential or anonymous testing site.  

2. Recommendation Regarding Age of Survivor

An individual must be 12 years of age or older in order to be eligible to receive PEP using the following recommendations. A pediatric HIV specialist should be consulted when a child younger than 12 presents with possible exposure to HIV from a sexual assault.

Medical providers treat individuals 12 years of age and older for STDs such as gonorrhea, chlamydia, and syphilis. The advisory panel recommends that the same age be used as a cut-off for PEP treatment. For individuals less than 12 years old who have potentially been exposed to HIV, a pediatric HIV specialist should be consulted in determining whether PEP is indicated. For children younger than 12 years old, the child's parent(s) or legal guardian(s) should be contacted and included in the discussion whether to initiate PEP.

3.  Recommendations Regarding Consideration
of Act(s) Involved in the Assault

When deciding whether to offer PEP, categorize the act of assault into 1 of 3 categories:

1) acts with measurable risk of HIV transmission; 2) acts with possible risk of HIV transmission, or 3) acts with no risk of HIV transmission.  

Not all acts of assault warrant PEP. Based upon the best available epidemiological data, the risk of contracting HIV from one act of unprotected consensual anal sex with a known HIV positive partner is approximately 0.3 - 5 percent.  The risk of contracting HIV from one act of unprotected consensual vaginal sex with an HIV positive partner is approximately 0.1 percent. Some acts of assault, however, carry no risk of HIV transmission and, therefore, do not warrant PEP. When deciding whether to offer PEP, categorize the act of assault into 1 of 3 categories:  

1.         Acts with measurable risk of HIV transmission, including anal penetration, vaginal penetration and injection with a contaminated needle; or

2.         Acts with possible risk of HIV transmission, including oral penetration with ejaculation, unknown act, contact with other mucous membrane, victim biting assailant, and assailant with bloody mouth biting victim; or

3.         Acts with no risk of HIV transmission, including kissing; digital or object penetration of vagina, mouth or anus; and ejaculation on intact skin.  

4. Recommendations Regarding Consideration of Assailant's HIV Status

As a part of the determination of whether to offer PEP to a survivor, it is necessary to consider the assailant's history. The assailant's HIV status can be divided into 3 categories: 1) known HIV-positive assailant; 2) assailant with known or suspected risk factors; and 3) unknown assailant or an assailant with unknown risk factors.

Past or present intravenous drug users, commercial sex workers, men who have sex with men, individuals with multiple sex partners, and individuals with either prior convictions for sexual assault or prior prison incarceration all fall into the high risk category.

Because HIV is rarely transmitted by sexual assault in the United States, information concerning potential increased risk of transmission is useful when considered in conjunction with the type of assault and other risk factors. Although the decision whether to initiate PEP cannot be made by solely considering the perpetrator's HIV status, the more information known about the details of the assault, the better known the risk of HIV transmission.

5. Recommendations Regarding Consideration of Other Factors

When deciding whether to offer PEP, consider if any of the following factors were present during the assault: presence of blood; survivor or assailant with a sexually transmitted disease with inflammation such as gonorrhea, chlamydia, herpes, syphilis, bacterial vaginosis, trichomoniasis, etc.; significant trauma to survivor; ejaculation by assailant; multiple assailants or multiple penetrations by assailant(s).

The specific circumstances of each assault influence the likelihood of HIV transmission following the assault. The presence of the above factors creates higher risk of contracting HIV for the survivor. Each additional factor present raises the risk of HIV transmission.

Rationale Behind Recommendations and Language Used

The literature concerning PEP following occupational exposure, as well as the CDC's recommendations for PEP following occupational exposure, take into account the many details of the exposure. Specifically, the CDC recommendations consider the type of bodily fluid involved in the exposure as well as the route and severity of the exposure. The CDC recommendations also consider the source of the possible exposure and make different recommendations depending on whether the source patient is known to be HIV positive, HIV negative or of unknown serostatus. The CDC suggests that PEP decisions be individualized so as to account for various risk scenarios.

The advisory panel bases the recommendations for PEP following sexual assault upon the CDC's recommendations for PEP following occupational exposure, specifically the idea of basing each decision to offer PEP upon the details of each assault. The decision to offer PEP will depend upon the type of assault, the assailant's status and other risks present.

The advisory panel's recommendations distinguish between "recommending" PEP and "offering" PEP to survivors. In cases with no apparent risk of HIV transmission, the advisory panel recommends that medical providers not offer PEP to survivors. In these cases, PEP medications have side effects whose harm can outweigh any potential benefit to the survivor. By offering PEP, rather than recommending PEP, to survivors in situations with low but possible risk of HIV transmission, medical providers allow survivors some autonomy over their medical treatment.

When the medical provider offers or recommends PEP, the provider should clearly explain the possible benefits and side effects of taking the medications. The provider should also explain the lack of definitive answers regarding the medications' efficacy in preventing HIV transmission. It is plausible that the survivor will not be able to process the information or make a truly informed decision in the stressful post-assault period.

Given the short time period following the assault during which the advisory panel recommends starting PEP, when a survivor is unable to decide whether to initiate PEP, the provider should encourage the survivor to begin the medications immediately. The survivor may discontinue the medications at any time.

It is important to consider PEP medications as one important part of the larger post-assault treatment program. Specialized counseling is another critical aspect of the post-assault treatment.

Quick Guide to Offering HIV PEP

1.         Has less than 72 hours passed since the assault occurred?

a.         If no, do not offer PEP but recommend baseline and follow-up H IV antibody testing.
b.         If yes, continue risk analysis.

2.         Is survivor 12 years of age or older?

a.         If yes, continue risk analysis.
b.         If no, consult pediatric HIV specialist (who must be identified in advance).

3.         What is the risk of HIV transmission from the assault?  

a.         Was the assault one with measurable risk of HIV
transmission, such as an assault with anal penetration, vaginal penetration, or injection?  

b.         Was the assault one with possible risk of HIV transmission, such as oral penetration with ejaculation, an assault involving other mucous membranes (e.g. eyes), an unknown assault, an assault in which the survivor bit the assailant or the assailant with a bloody mouth bit the survivor?

c.         Was the assault one with no risk of HIV transmission, such as kissing; digital or object penetration of vagina, mouth or anus; ejaculation on intact skin; or an assault in which a condom was used?  

d.         What other risk factors were present in the assault, including presence of blood, survivor or perpetrator with STD, significant trauma to survivor, ejaculation by assailant, multiple assailants or multiple penetrations by assailant(s)?

4.         Is the assailant's HIV status known?

a.         If known HIV negative, do not offer PEP.

b.         If known HIV positive,

▪            Recommend PEP if assault with measurable risk of HIV transmission has occurred.

▪            Recommend PEP if assault with possible risk of HIV transmission has occurred and at least one additional risk co-factor was present in assault.

▪            Offer PEP if assault with possible risk of HIV transmission has occurred with no additional risk co-factors present.

▪            Do not offer PEP for exposures carrying no risk.

5.         Does the assailant engage in behaviors that put him/her at risk for contracting HIV? High risk groups include men who have sex with men, past or present injection drug users, commercial sex workers, individuals with multiple sex partners, individuals with prior convictions for sexual assault, and individuals with a history of prison and/or jail incarceration.

       a.     If known or suspected risk factors exist,

▪            Recommend PEP if assault with measurable risk of HIV transmission has occurred.

▪            Recommend PEP if assault with possible risk of HIV transmission has occurred and more than one additional risk co-factor was present in assault.

▪            Recommend or offer PEP if assault with possible risk of HIV has occurred and only one additional risk co-factor was present in assault.

▪            Offer PEP if assault with possible risk of HIV transmission has occurred with no additional risk co-factors present.

▪            Do not offer PEP for exposures carrying no risk.
 

c.         If assailant is not known and/or if assailant's risk factors are unknown,

▪            Offer PEP if assault with measurable risk of HIV transmission has occurred.

▪            Offer PEP if assault with possible risk of HIV transmission has occurred and more than one additional risk co-factor was present in assault.

▪            Offer PEP if assault with possible risk of HIV has occurred and only one additional risk co-factor was present in assault.

▪            Offer or do not offer PEP if assault with possible risk of HIV transmission has occurred with no additional risk co-factors present.

▪            Do not offer PEP for exposures carrying no risk.