HIV Postexposure Prophylaxis Algorithm: Sexual Assault
HIV Postexposure Prophylaxis Algorithm: Sexual Assault
Victims of sexual assault should be treated in an emergency department or equivalent healthcare setting. Decision to recommend PEP following sexual assault should be based on the following factors:

• Type of exposure during the assault (whether or not a significant exposure occurred)

• HIV status of the alleged assailant, if known

• Readiness and willingness of victim to initiate and complete PEP regimen


Preferred regimen: tenofovir disoproxil fumarate + emtricitabine plus raltegravir or dolutegravir for 28 days. Dolutegravir-containing regimens should be avoided in the first trimester of pregnancy or in any HIV-exposed individuals who may become pregnant (obtain pregnancy testing prior to PEP initiation).
Alternative regimens may be used in cases of potential HIV resistance, toxicity risks, or drug availability constraints.

                             
                  Significant mucosal exposure?1  
                 
Yes
   
No
   
  Screen assailant for HIV.
Promptly initiate PEP and do not delay while awaiting results.
Unknown Assailant’s HIV status   STOP
 
HIV−
result
 


   
Known HIV+
   
Known HIV−
       
  STOP7

Victim presents within 36hrs of the assault?2   STOP      
       



Yes

   
No
           
    Victim prepared to initiate PEP?   Case by case basis3      
   
Yes
   
No
                 
  Initiate PEP and schedule a follow-up with an HIV-experienced clinician within 24hrs5,6   Offer starter pack of medication and make arrangements for a follow-up with an HIV-experienced clinician within 24hrs4            
                             
NOTES

1 Defined by direct contact of the vagina, penis, anus, or mouth with the semen, vaginal fluids, or blood of the alleged assailant, with or without physical injury, tissue damage, or presence of blood at the site of the assault. PEP should also be offered when broken skin or mucous membranes of the victim get in contact with blood, semen, or vaginal fluids from the alleged assailant, as well as bites that occur resulting in visible blood.

2 Initiate PEP as soon as possible after exposure, ideally within 2hrs. Efficacy of treatment is diminished when timing of initiation is prolonged beyond 36hrs. There is no evidence of PEP efficacy when initiated beyond 72hrs.

3 Decisions to initiate PEP beyond 36hrs (but not beyond 72hrs) post exposure need to be individualized based on the type of exposure, patient’s desire to initiate PEP, and amount of time that has elapsed.

4 Encourage victim to take a single PEP dose and schedule a follow-up within 24hrs to ensure that PEP is initiated within 36hrs of exposure.

5 Discussion regarding PEP initiation should include: a) potential benefit, unproven efficacy, and potential toxicity; b) duration of regimen; c) importance of adherence to prevent PEP failure and development of drug resistance; d) reduction of risk and prevention of exposure to others; e) monitoring parameters and follow-up; f) signs/symptoms of acute HIV infection.

6 Perform baseline rapid HIV testing of the victim. Initiate PEP without waiting for results. Offer prophylactic treatment for gonococcal and chlamydial infections.

7 Decisions to discontinue PEP should be made in consultation with an HIV-experienced clinician.

REFERENCES

PEP for Victims of Sexual Assault. New York State Department of Health AIDS Institute Web site. https://www.hivguidelines.org/pep-for-hiv-prevention/after-sexual-assault/. Published October 2014. Updated March 20, 2019. Accessed March 29, 2019.

(Rev. 5/2019)