The health assessment after sexual assault

1. The health assessment after sexual assault Ambreen Butt Consultant NHS Grampian

2. Immediate Needs (within 7 days) • Immediate safety • Treatment of injuries Should take precedence over clinical management

4. Vaginal tears

5. Palatal Petechaie

6. Clinical Management • Emergency Contraception • STI screening follow up • BBV testing/Serum save • STI Prophylaxis • Hep B prophylaxis • HIV PEPSE The need for any/all of these should start with a detailed sensitively taken sexual history

7. EMERGENCY CONTRACEPTION Offered to all women and adolescents who have had • Unprotected vaginal sexual intercourse • Potential failure of contraceptive method e.g. recent missed pills

8. EMERGENCY CONTRACEPTION • Levonelle 2 • ellaOne • Copper IUCD Fast track client

9. Infections STI identification is unlikely to assume evidential importance except in certain circumstances • Young people – children and adolescents not previously sexually active • Elderly – if no recent consensual sexual activity • Sexually inexperienced orifice Chain of evidence Finding an STI may influence the level of criminal injuries compensation

11. Screening for STIS • What, if any examination required? • What tests to take and from what sites?

12. Infections Most commonly identified STIs after sexual assault • Chlamydia- Dual NAAT • Gonorrhoea – Dual NAAT+/- culture • Trichomoniasis - direct microscopy

13. Offer all clients an examination • if declines then self swab is sufficient to test for chlamydia and gonorrhoea where dual NAAT testing is available – should be done at time of presentation and repeated if necessary after 2 weeks • Remember to sample all sites affected

14. In a Primary Care setting where dual NAAT testing available • If examined –Dual NAAT from all sites affected and in female complaining of vaginal discharge do HVS. • if declines examination then can self swab from all sites affected Consider referral to specialist services if symptomatic

15. STI ANTIBIOTIC PROPHYLAXIS Consider • In situations where patient may default • Unable to tolerate the distress of repeat examination • Requires IUCD for EC

16. STI ANTIBIOTIC PROPHYLAXIS Advantages • Reduce the need for tests • Lesson chance of missed infection • Decrease the chances of detecting a bacterial STI

17. STI ANTIBIOTIC PROPHYLAXIS Disadvantages • Unnecessary treatment • Reinforcing belief that high risk of infection • Missing out on partner notification

18. STI ANTIBIOTIC PROPHYLAXIS First line antibiotics • Cefixime 400mgs • Azithromycin 1g • Metronidazole 2g

19. BBV Screen/Serum save • Offered to all at presentation

20. HEP B VACCINATION Should be offered to victims of sexual assault – risk assessment- if risk unknown then should be given May be of value up to 6 weeks after event Super-accelerated course recommended as more rapid protection and adherence better Vaccination interval 0, 1, 3 weeks and 1 year High risk of hep B- Immunoglobulin ASAP and no later than 7 days

22. PEPSE POST EXPOSURE PROPHYLAXIS FOR HIV FOLLOWING UNPROTECTED SEXUAL EXPOSURE

23. PEPSE RISK OF HIV TRANSMISSION = RISK THAT THE SOURCE IS HIV POSITIVE x RISK OF EXPOSURE* (*including cofactors such as co-existing sexually transmitted infections, high viral load and bleeding/trauma)

26. PEPSE Table 1 Risk that source is HIV positive Community group HIV seroprevalence (%) Homosexual men* London 20.30 Scotland 3.20 Elsewhere 3.60 Heterosexuals Male (%) Female (%) (region of birth) UK 0.5 0.2 Rest of Europe 2 0.2 North America 2.9 0.1 Central and South America 2.4 0.9 Caribbean 1.2 1.0 North Africa and Middle East 0.5 0.4 Sub-Saharan Africa 6.9 11.3 South Asia 0.5 0.6 East and South East Asia 0.5 0.7 Australasia 0.8 0.1 Injecting drug users* London 2.90 Elsewhere in the UK 0.50 HPA data, 2004. Contemporaneous prevalence estimates can be obtained at: [www.hpa.org.uk/infections/topics_az/hiv and sti] HPA data 2004, HIV prevalence among GUM attendees by world region of birth in 2003. Prevalence rates for exposures outside of the UK or for individuals recently moved to the UK can be obtained at: [www.unaids.org]

27. BASHH RECOMMENDATION FOR PRESCRIBING PEP

28. BASHH RECOMMENDATION FOR PRESCRIBING PEP Factors influencing the effectiveness of PEP as identified in the BASHH guidelines are: • Delay in starting treatment, with PEP seen as possibly less effective or ineffective after 72 hours but possibly still considered if exposure is ‘high risk’ • Drug-resistant strains of HIV may reduce PEP’s effectiveness with resistance testing of the ‘source’ of infection considered and/or factoring in resistance when prescribing PEP drug combinations • HIV remaining in parts of the body where antiretroviral drugs’ ability to penetrate is variable • Poor adherence to the PEP drug regime

29. PEPSE SIDE EFFECTS Mild • Nausea and diarrhoea- supportive treatment with Domperidone and Loperamide Serious • Lipid abnormalities • Liver problems • Diabetes and insulin resistance

30. PEPSE PRESCRIBING RECOMMENDATIONS • Nucleoside reverse transcriptase inhibitors (NRTIs) • Non-nucleoside reverse transcriptase inhibitors (NNRTIs) • Protease inhibitors (PIs)

31. PEPSE Current pack consists of the following drugs: TRUVADA • Tenofovir 245 mg once daily • Emtricitabine 200mg once daily KALETRA • Ritonavir boosted Lopinavir 2 tablets twice daily Initial pack contains 5 days supply Treatment given for 4 weeks 28 day course cost around £650

32. Follow up • Repeat STI screen 2 weeks after sexual assault • Pregnancy testing • HIV testing- can be done at 1 and 3 months (4 months if taken PEPSE) • Syphilis testing- 3 months • Hep B and C testing - at 3 and 6 months • Review psychosocial needs and coping

34. BASHH GuidelinesManagement of adult and adolescent complainants of sexual assault (2011) http://www.bashh.org/documents/3275