26.4 Referral after rape for post-exposure HIV prophylaxis
Rape is a major crime that could happen in your community, and you need to be prepared to support the victims, both in terms of their mental health and their physical health. Cases are treated according to the Ethiopian law for rape management, and anyone who suffers a rape or other penetrating sexual assault should be referred for post-exposure prophylaxis in case the rapist was infected with a blood-borne disease such as HIV or hepatitis. Since police procedures may take time, you have to urge the raped person, and whoever is caring for them, to go immediately to a health centre or hospital that provides PEP. Currently, all ART sites provide this service, as should most of the health centres in your catchment area.
Anyone who has been raped should be counselled by the examining healthcare worker about the potential risks of HIV infection (Figure 26.6). Under these circumstances, the HIV status of the rapist should be considered as ‘unknown’, and therefore HIV transmission is a potential risk. Parents or guardians of traumatised children or adolescents should also be counselled and informed about the risk of HIV infection after a sexual assault.
Points to be covered in counselling after a rape include:
- The precise degree of risk of HIV transmission is not known, but it exists.
- HIV testing is very important, and should be made clear to the person who has been raped and their caregivers, but explain that testing cannot give a confirmed negative result until after the window period is over.
- The raped person can choose to be tested for HIV immediately. However, if they refuse, testing can be delayed until 72 hours after the initial examination visit.
- The management guidelines on sexual assault provide for a three-day starter pack of PEP for those who prefer not to be tested immediately, or those that are not ready to receive the results immediately.
PEP is not recommended if the person presents to a health facility later than 72 hours after the sexual assault. They should be counselled about the possible risk of infection, and the possibility of transmitting infection to another person during the window period. They should be told to return after six weeks and three months for further HIV testing and counselling.
Why is PEP not recommended if a person presents to a health facility more than 72 hours after a sexual assault?
Because by this time the virus has entered the bloodstream, and PEP given more than 72 hours after exposure is not effective. Ideally, PEP has to be started within one to two hours after exposure. If this is not possible, it should be started within the first 72 hours.
A person who undergoes PEP after a sexual assault should be carefully evaluated for psychosocial support and monitored for any adverse side-effects of PEP treatment. They should also be screened for other sexually transmitted infections and referred for treatment as appropriate.