TO DECREASE THE CHANCE OF GETTING

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1 POST ASSAULT MEDICATIONS Terri Stewart RN Naomi Sugar MD TO DECREASE THE CHANCE OF GETTING Pregnant STDs Chlamydia Gonorrhea Trichomonas Hep B HIV EMERGENCY CONTRACEPTION Plan B Levonorgestrel PLAN B Plan B One Step: 1 pill po now Older Formulation: 1 pill po now, 1 pill in 12 hours Optional: 2 pills now Indications When penis to vagina or anus contact within previous 5 days (packaging says 72 hrs) and Not using highly reliable contraceptive Highly effective (at least 75% reduction in pregnancy) Very low incidence of side effects Only contraindication existing pregnancy Time in cycle is NOT a reason to withhold EMERGENCY CONTRACEPTION Legal requirement passed Washington legislature 2003 RCW Every hospital providing emergency care to a victim of sexual assault shall provide information about EC, and orally inform each victim of option for EC at the hospital, and if not medically contraindicated, provide EC immediately at the hospital to each victim of sexual assault who requests it.

2 STD TREATMENT AND PREVENTION Testing or Prophylactic Treatment? Patients really don t want to get a disease If tests are positive, Very difficult to get in touch with patients Many move elsewhere after an assault Contact notification may be inappropriate CDC RECOMMENDED REGIMEN AFTER SEXUAL ASSAULT 1. Azithromycin 1 g orally in a single dose 2. Cefixime 400 mg po single dose OR Ceftriaxone 125 mg IM in a single dose 3. Metronidazole 2 g orally in a single dose 4. Hep B vaccine if not previously immunized. (No HBIG) Follow-up vaccine at 1-2 and 4-6 months after initial vaccine Chlamydia treatment or prophylaxis Chlamydia is a common and silent STD Azithromycin 1 gm Take all 4 pills at once Take with food Gonorrhea Treatment or Prophylaxis Cefixime 400 mg po x1 Take all pills at once OR Ceftriaxone 125 mg IM Gonorrhea prophylaxis for patients with Penicillin allergy Defined as hives or anaphylaxis Penicillin allergic patients may cross react with cephalosporins (Cefixime) Either No GC prophylaxis OR Azithromycin 2 gm total po at once This is active against chlamydia AND gonorrhea But may cause abdominal pain (take with food)

3 Trichomonas Treatment or Prophylaxis Metronidazole 2 gm po x 1 Antabuse-like effect Caution no alcohol for 3 days after medication (Trich is more common than GC, and seems to be transmitted in sexual assaults) HEPATITIS B Prophylaxis Vaccine is effective up to 2 weeks AFTER exposure to the virus May be given in follow-up visit, or patients can be directed to health department It s important Most young people in Washington state are immunized for school titers not needed TESTING FOR SYPHILIS Uncommon No prophylaxis Testing, if done, should be 8 weeks after possible exposure Important in gay male community For Most Adults and Teens STD testing is not needed when prophylactic treatment for chlamydia and gonorrhea is given BUT FOR SOME PATIENTS IT IS BEST TO TEST AND NOT PROVIDE PROPHYLAXIS When STD would be relevant for legal issues Child Young teen - not sexually active Disabled/elderly adult Confirmatory (2 nd test) mandatory if NAAT (urine test) is positive WHAT ABOUT HIV? Relatively low risk of transmission Post-exposure medication must be taken for one month High cost of post exposure prophylactic treatment (PEP) Regimen requires patient committment Cannot usually test the source

4 Risk of transmission of HIV from Single Exposure to Known Positive Risk per 100 exposures to infected source Blood transfusion 90% Injection IVDU 0.67% Receptive anal 50 (0.5 3%) Needle stick 0.3% Receptive vaginal % Insertive vaginal 0.05% Receptive penile - oral 0.01% PEP SHOULD NOT BE OFFERED IF: Assault was more than 3 days prior Assailant and victim have prior unprotected contact within previous weeks or months (e.g., intimate partner assault) PEP SHOULD BE DISCUSSED WITH PATIENT AS AN OPTION Any sexual assault within past 72 hours, and victim wishes prophylaxis PEP SHOULD BE DISCUSSED AND OFFERED WHEN: High risk assailant Man known or suspected HIV positive (most important factor) Man who has sex with men (HIV prevalence 12-15%) Known IV drug use (HIV prevalence 2%) OR high risk assault Semen to mucosal contact, 2 or more assailants Victim is man assaulted by man Victim has grossly visible vaginal or anal tears Exposure semen to rectum Exposure blood to mucosa Exposure blood to open wound START TREATMENT AS SOON AS POSSIBLE Within 72 hours (the sooner the better) Baseline labs: CBC, creatinine, HIV serology, LFTs Begin with 5 day supply of med ( starter pack ) Have specialist follow-up arranged HIV PEP Regimen Harborview 28 days of combination therapy Truvada If high risk assailant (MSM) + atazinavir + ritonavir Some risk of drug interactions Usually well tolerated Requires one medical visit and lab in mid- treatment Cost ~ $1500 May or may not be covered by CVC High dropout rate

5 REFERENCES Sexually transmitted disease treatment guidelines MMWR Recommendations and Reports. Antiretroviral postexposure prophylaxis after sexual, injection-drug use, or other nonoccupational exposure to HIV in the United States. Recommendations from the US Department of Health and Human Services Vol 54, RR02;1 01/21/ HIV PEP Guidelines and information for patients