Patient Education and Consent

If HIV nPEP is offered, the following information should be discussed with the patient:

The low risk of HIV infection following a single sexual encounter
The theoretical but unproven benefit and known toxicities of antiretrovirals
The importance of close follow-up
The importance of adherence to recommended dosing to prevent selection of resistant viruses
The necessity of early initiation of PEP to optimize potential benefits (ie, as soon as possible and up to 72 hours after the assault)
Cost of the medication regimen

Patients should be informed that various payment methods for nPEP are available for survivors of sexual assault, including Medicaid, Medicare, or Crime Victims Compensation. Third-party reimbursement may cover nPEP, depending on the plan’s prescription drug policy, if the individual has prescription drug coverage. In cases where the medication-dispensing facility does not receive reimbursement for these services, such expenses may be included in their annual Institutional Cost Report as part of indigent care costs.

The Crime Victim’s Board (CVB) has developed special procedures to ensure availability of nPEP for sexual assault victims. Victims of sexual assault may also contact a Rape Crisis Center or Victims Services Agency in their county or region for assistance in filing claims with the CVB, particularly when emergency assistance is needed. Many of these agencies have 24-hour hotlines. For more information about accessing Crime Victims Compensation and for a list of Victims Services Agencies and other resources, consult the CVB website.

For more details on sexual assault in general, see Sexual Assault. For child sexual abuse, see the article Child Sexual Abuse.

Additional resources for HIV/sexual assault include the following:

CDC / National Prevention Information Network

Patient informational handouts and discharge instructions available:

Updated U.S. Public Health Service Guidelines for the Management of Occupational Exposures to HIV and Recommendations for Postexposure Prophylaxis

National HIV/AIDS Hotline

American Social Health Association PO Box 13827 Research Triangle Park, NC 27709 (800) 342 - AIDS (800) 344 - SIDA (Spanish) (800) 243 - 7889 (TDD)

They provide HIV/AIDS information 24 hours a day, 7 days a week and will send free written information. They also make referrals to any organization/agency that provides information, including legal services, counseling, and therapies.

National Center for Victims of Crime 2000 M Street NW, Suite 480 Washington, DC 20036 Phone: (202) 467-8700 Fax: (202) 467-8701

National Sexual Violence Resource Center 123 North Enola Drive Enola, Pennsylvania 17025 877-739-3895 (toll-free) 717-909-0710(phone) 717-909-0714 (fax) 717-909-0715 (TTY)

Rape, Abuse, and Incest National Network (RAINN) National Sexual Assault Hotline 2000 L Street, NW, Suite 40 Washington, DC 20036 (202) 544-1034 (800) 656-HOPE (4613) info@rainn.org

National Native American AIDS Prevention Center 2100 Lakeshore, Suite A Oakland, CA 94606 (800) 283 - AIDS

National Association of People with AIDS (NAPWA) 1413 K Street, NW Washington, DC 20005 (202) 898 - 0414 (202) 789 - 2222 (FAX: AIDS information facts on demand)

NAPWA is a nonprofit organization that provides information services, educational resources, national advocacy, and technical assistance for community-based organizations.

Pre-Procedure Planning

Assistance with PEP-related decisions can be obtained by contacting the following:

National Clinician Consultation Center
HIV Antiretroviral Pregnancy Registry; Address: Research Park, 1011 Ashes Drive, Wilmington, NC 28405. Telephone: 800-258-4263; Fax: 800-800-1052; E-mail: registry@nc.crl.com
FDA (for reporting unusual or severe toxicity to antiretroviral agents); Telephone: 800-332-1088; Address: MedWatch, HF-2, Food and Drug Administration, 5600 Fishers Lane, Rockville, MD 20857
CDC (for reporting HIV infections in HCP and failures of PEP) at telephone 800-893-0485
HIV/AIDS Treatment Information Service

In New York State: For referrals to HIV specialists, call the AIDS Institute’s Office of the Medical Director: (212) 417-4536 (M-F, 8am-5pm); all other hours, call the HIV/AIDS Hotline: 1-866-881-2809. For NYSDOH protocol for management of sexual assault victims, call the NYSDOH Rape Crisis Program: (518) 474-3664 and/or visit the NYSDOH HIV Guidelines Website.

Follow Up

Patients evaluated for PEP should be educated about the symptoms of acute HIV seroconversion (notably fever, sore throat, lymphadenopathy, and/or diffuse rash)^[32]and instructed to seek medical care if they develop. Follow-up with a primary care provider or infectious disease physician should occur at 4-6 weeks, 3 months, and 6 months regardless of whether PEP was initiated in order to screen for medication side effects, to evaluate for symptoms of seroconversion, and to test for development of infections. If initiated, PEP adherence should be stressed, as overall adherence rates are around 60% but are commonly reported to be below 30%, often due to medication side effects such as nausea.^[33]

Patients who are pregnant or become pregnant should be advised on the risk of HIV-transmission with breast feeding.

All patients should be advised to abstain from sexual encounters or stricly adhere to condom usage for all encounters (including oral sex) until 3 month follow up, as risk of secondary HIV transmission is highest during the acute phase of illness.

Medication

[Guideline] Updated Guidelines for Antiretroviral Postexposure Prophylaxis After Sexual, Injection Drug Use, or Other Nonoccupational Exposure to HIV—United States, 2016. [Full Text].
[Guideline] Kuhar DT, Henderson DK, Struble KA, et al. Updated US Public Health Service guidelines for the management of occupational exposures to human immunodeficiency virus and recommendations for postexposure prophylaxis. Infect Control Hosp Epidem. Sept 2013. 34(9):874-92. [QxMD MEDLINE Link]. [Full Text].
Ford N, Mayer KH, World Health Organization Postexposure Prophylaxis Guideline Development Group. World Health Organization Guidelines on Postexposure Prophylaxis for HIV: Recommendations for a Public Health Approach. Clin Infect Dis. 2015 Jun 1. 60 Suppl 3:S161-4. [QxMD MEDLINE Link].
Cohen MS, Chen YQ, McCauley M, Gamble T, Hosseinipour MC, et al. Antiretroviral Therapy for the Prevention of HIV-1 Transmission. N Engl J Med. 2016 Sep 1. 375 (9):830-9. [QxMD MEDLINE Link].
Roland ME, Neilands TB, Krone MR, Coates TJ, Franses K, Chesney MA, et al. A randomized noninferiority trial of standard versus enhanced risk reduction and adherence counseling for individuals receiving post-exposure prophylaxis following sexual exposures to HIV. Clin Infect Dis. 2011 Jul 1. 53(1):76-83. [QxMD MEDLINE Link]. [Full Text].
Bamberger JD, Waldo CR, Gerberding JL, Katz MH. Postexposure prophylaxis for human immunodeficiency virus (HIV) infection following sexual assault. Am J Med. 1999 Mar. 106 (3):323-6. [QxMD MEDLINE Link].
Hu J, Gardner MB, Miller CJ. Simian immunodeficiency virus rapidly penetrates the cervicovaginal mucosa after intravaginal inoculation and infects intraepithelial dendritic cells. J Virol. 2000 Jul. 74(13):6087-95. [QxMD MEDLINE Link].
Tsai CC, Emau P, Follis KE, Beck TW, Benveniste RE, Bischofberger N, et al. Effectiveness of postinoculation (R)-9-(2-phosphonylmethoxypropyl) adenine treatment for prevention of persistent simian immunodeficiency virus SIVmne infection depends critically on timing of initiation and duration of treatment. J Virol. 1998 May. 72(5):4265-73. [QxMD MEDLINE Link]. [Full Text].
Otten RA, Smith DK, Adams DR, Pullium JK, Jackson E, Kim CN, et al. Efficacy of postexposure prophylaxis after intravaginal exposure of pig-tailed macaques to a human-derived retrovirus (human immunodeficiency virus type 2). J Virol. 2000 Oct. 74(20):9771-5. [QxMD MEDLINE Link]. [Full Text].
Cardo DM, Culver DH, Ciesielski CA, Srivastava PU, Marcus R, Abiteboul D. Centers for Disease Control and Prevention Needlestick Surveillance Group. A case-control study of HIV seroconversion in health care workers after percutaneous exposure. Centers for Disease Control and Prevention Needlestick Surveillance Group. N Engl J Med. 1997 Nov 20. 337(21):1485-90. [QxMD MEDLINE Link].
Guay LA, Musoke P, Fleming T, Bagenda D, Allen M, Nakabiito C, et al. Intrapartum and neonatal single-dose nevirapine compared with zidovudine for prevention of mother-to-child transmission of HIV-1 in Kampala, Uganda: HIVNET 012 randomised trial. Lancet. 1999 Sep 4. 354(9181):795-802. [QxMD MEDLINE Link].
Connor EM, Sperling RS, Gelber R, Kiselev P, Scott G, O'Sullivan MJ. Reduction of maternal-infant transmission of human immunodeficiency virus type 1 with zidovudine treatment. Pediatric AIDS Clinical Trials Group Protocol 076 Study Group. N Engl J Med. 1994 Nov 3. 331(18):1173-80. [QxMD MEDLINE Link].
Gray GE, Urban M, Chersich MF, Bolton C, van Niekerk R, Violari A, et al. A randomized trial of two postexposure prophylaxis regimens to reduce mother-to-child HIV-1 transmission in infants of untreated mothers. AIDS. 2005 Aug 12. 19(12):1289-97. [QxMD MEDLINE Link].
Taha TE, Kumwenda NI, Gibbons A, Broadhead RL, Fiscus S, Lema V. Short postexposure prophylaxis in newborn babies to reduce mother-to-child transmission of HIV-1: NVAZ randomised clinical trial. Lancet. 2003 Oct 11. 362(9391):1171-7. [QxMD MEDLINE Link].
[Guideline] Centers for Disease Control and Prevention, Workowski KA, Berman SM. Sexually transmitted diseases treatment guidelines, 2010. MMWR Recomm Rep. Dec 17, 2010. 59(RR-12):1-116.
CDC. Updated U.S. Public Health Service guidelines for the management of occupational exposures to HBV, HCV, and HIV and recommendations for postexposure prophylaxis. MMWR. 2001;. 50 (No. RR-11).:
Harrison LH, Do Lago RF, Moreira RI. , Schechter M. Demand for post-sexual-exposure chemoprophylaxis for the prevention of HIV infection in Brazil [abstract 492]. Presented at the 7th Conference on Retroviruses and Opportunistic Infections. San Francisco, California: , January 30–February 2, 2000.
Drezett J. Postexposure prophylaxis in raped women. IV International Conference on HIV infection in women and children. Rio de Janeiro.: Livro de Resumos. Universidade, Federal do Rio De Janeiroe Institute of Virology of Maryland; 2002.
Kahn JO, Martin JN, Roland ME, Bamberger JD, Chesney M, Chambers D, et al. Feasibility of postexposure prophylaxis (PEP) against human immunodeficiency virus infection after sexual or injection drug use exposure: the San Francisco PEP Study. J Infect Dis. 2001 Mar 1. 183(5):707-14. [QxMD MEDLINE Link].
Fournier S, Maillard A, Molina JM. Failure of postexposure prophylaxis after sexual exposure to HIV. AIDS. 2001 Feb 16. 15(3):430. [QxMD MEDLINE Link].
Beltrami EM, Luo C-C, De La Torre N, Cardo DM. Transmission of a drug-resistant HIV after an occupational exposure despite postexposure prophylaxis with a combination drug regimen. Infect Control Hosp Epidemiol. 2002. 23:345–8.
Schechter M, do Lago RF, Mendelsohn AB, et al. Behavioral impact, acceptability, and HIV incidence among homosexual men with access to postexposure chemoprophylaxis for HIV. J Acquir Immun Defic Syndr. 2004. 35:519 – 525.
Grohskopf LA, Smith DK, Kunches LM, et al. Surveillance of postexposure prophylaxis for nonoccupational HIV exposures through the U.S. National Registry. AIDS 2002 XIV International AIDS Conference. Barcelona, Spain: 11 July 2002.
Grulich A, Zheng W, Kippax S, Smith DE. Highly targeted use of nonoccupa-tional postexposure prophylaxis (NPEP) in Australia. 2nd IAS Conference on HIV Pathogenesis and Treatment. Paris, France: 13– 16 July 2003.
Millett GA, Flores SA, Marks G, Reed JB, Herbst JH. Circumcision status and risk of HIV and sexually transmitted infections among men who have sex with men: a meta-analysis. JAMA. 2008 Oct 8. 300(14):1674-84. [QxMD MEDLINE Link].
Rodger AJ, Cambiano V, Bruun T, et al. Sexual Activity Without Condoms and Risk of HIV Transmission in Serodifferent Couples When the HIV-Positive Partner Is Using Suppressive Antiretroviral Therapy. JAMA. Jul 2016. 316(2):171-81. [QxMD MEDLINE Link]. [Full Text].
Wilson DP1, Law MG, Grulich AE et al. Relation between HIV viral load and infectiousness: a model-based analysis. Lancet. July 2008. 372(9635):314-20. [QxMD MEDLINE Link]. [Full Text].
Bavinton BR, Pinto AN, Phanuphak N, Grinsztejn B, Prestage GP, et al. Viral suppression and HIV transmission in serodiscordant male couples: an international, prospective, observational, cohort study. Lancet HIV. 2018 Aug. 5 (8):e438-e447. [QxMD MEDLINE Link].
Sexually Transmitted Diseases Treatment Guidelines, 2015. Center for Disease Control and Prevention Morbidity and Mortality Weekly Report. June 5, 2015. 64:[Full Text].
St Cyr S, Barbee L, Workowski KA, Bachmann LH, Pham C, et al. Update to CDC's Treatment Guidelines for Gonococcal Infection, 2020. MMWR Morb Mortal Wkly Rep. 2020 Dec 18. 69 (50):1911-1916. [QxMD MEDLINE Link].
FDA approves expanded use of Gardasil 9 to include individuals 27 through 45 years old. FDA News Release. October 5, 2018. Available at https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm622715.htm.
Apoola A, Ahmad S, Radcliffe K. Primary HIV infection. Int J STD AIDS. Feb 2002. 13:71-78.
Inciarte A, Leal L, Masfarre L, Gonzalez E, Diaz-Brito V, et al. Post-exposure prophylaxis for HIV infection in sexual assault victims. HIV Med. 2020 Jan. 21 (1):43-52. [QxMD MEDLINE Link].
Zash R, Holmes L, Diseko M, Jacobson DL, Brummel S, et al. Neural-Tube Defects and Antiretroviral Treatment Regimens in Botswana. N Engl J Med. 2019 Aug 29. 381 (9):827-840. [QxMD MEDLINE Link].
Reefhuis J, FitzHarris LF, Gray KM, Nesheim S, Tinker SC, et al. Neural Tube Defects in Pregnancies Among Women With Diagnosed HIV Infection - 15 Jurisdictions, 2013-2017. MMWR Morb Mortal Wkly Rep. 2020 Jan 10. 69 (1):1-5. [QxMD MEDLINE Link].
FDA. US FDA. Juluca, Tivicay, Triumeq (dolutegravir): FDA to Evaluate - Potential Risk of Neural Tube Birth Defects. May 18, 2018. Available at https://www.fda.gov/safety/medwatch/safetyinformation/safetyalertsforhumanmedicalproducts/ucm608168.htm.
[Guideline] Recommendations for the Use of Antiretroviral Drugs in Pregnant Women with HIV Infection and Interventions to Reduce Perinatal HIV Transmission in the United States. HIV.gov. Available at https://clinicalinfo.hiv.gov/en/guidelines/perinatal/whats-new-guidelines. 10 FEB 2021; Accessed: 30 JUN 2021.

Media Gallery

Figure 1 Algorithm

of 1

Author

Derek T Larson, DO Chief of Infectious Disease Service, Co-Chair of Infection Prevention and Control, Fort Belvoir Community Hopsital

Derek T Larson, DO is a member of the following medical societies: Armed Forces Infectious Diseases Society, Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Coauthor(s)

Ryan C Maves, MD, FCCP, FCCM, FIDSA Professor of Medicine and Anesthesiology, Sections of Infectious Diseases and Critical Care Medicine, Wake Forest University School of Medicine

Ryan C Maves, MD, FCCP, FCCM, FIDSA is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Society of Transplantation, Armed Forces Infectious Diseases Society, Infectious Diseases Society of America, Society of Critical Care Medicine

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Shionogi (Scientific Advisory Board member); LumaBridge (Medical Monitor for RCT)<br/>Received research grant from: AiCuris; Sound Pharmaceuticals.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Chief Editor

Michael Stuart Bronze, MD David Ross Boyd Professor and Chairman, Department of Medicine, Stewart G Wolf Endowed Chair in Internal Medicine, Department of Medicine, University of Oklahoma Health Science Center; Master of the American College of Physicians; Fellow, Infectious Diseases Society of America; Fellow of the Royal College of Physicians, London

Michael Stuart Bronze, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American Medical Association, Association of Professors of Medicine, Infectious Diseases Society of America, Oklahoma State Medical Association, Southern Society for Clinical Investigation

Disclosure: Nothing to disclose.

Additional Contributors

Hina Z Ghory, MD Assistant Medical Director, Emergency Department, East Orange General Hospital

Hina Z Ghory, MD is a member of the following medical societies: American College of Emergency Physicians, Phi Beta Kappa

Disclosure: Nothing to disclose.

Joyce S Kuo, MD Resident Physician, Department of Emergency Medicine, New York-Presbyterian Hospital

Disclosure: Nothing to disclose.