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Evaluation and Management of the
Sexually Assaulted or Sexually Abused Patient
Below are two commonly prescribed three-drug prophylaxis options:
Three-Drug Regimens for Adults (28-Day Treatment)
Option 1
lopinavir plus ritonavir (Kaletra)—2 tablets orally twice daily (each tab contains 200mg lpv/50mg rtv) PLUS
zidovudine/lamivudine (Combivir)—1 tablet (300mg/150mg) orally twice daily
Option 2
lopinavir plus ritonavir (Kaletra)—2 tablets orally twice daily (each tab contains 200mg lpv/50mg rtv)
PLUS
emtricitibine/tenofovir (Truvada)—1 tablet (200mg/300mg) orally once daily
An initial 3–7 day supply of a medication starter pack or prescription should be offered.
Side effects are common and multiple studies have shown low adherence to the prescribed prophylaxis regimen.
Potential side effects of antiretroviral medication include nausea, vomiting, diarrhea, abdominal pain along with
fatigue, headache, insomnia, rash, and taste alteration. In addition, lipid abnormalities, diabetes mellitus, renal
toxicity, pancreatitis, hepatitis, neutropenia, anemia and lactic acidosis, hyperglycemia and diabetic ketoacidosis have
been reported with antiretrovirals. PEP however appears to be generally well tolerated by both adults and children
and severe adverse reactions are rare. All patients should receive close follow-up. Patients should also be alerted
to possible symptoms of primary HIV infection such as fever, fatigue, sore throat, lymphadenopathy, and rash and
instructed to seek medical care if they develop these symptoms. Patients should be advised to have HIV antibody
testing repeated at 6 weeks, 3 months, and 6 months after the assault.
Recommended Emergency Contraception Medications
Levonorgesterel 1.5 mg administered orally as a one-time dose
OR
Ulipristal acetate 30 mg administered orally as a one-time dose
OR
Many Commonly Available Contraceptive Pills—Dosage depends on pills utilized
References
STI
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Special Consideration for Children
6.
Children might be at higher risk for HIV transmission, because the sexual abuse of children is frequently associated
with mul­tiple episodes of assault. Consult a pediatric HIV specialist if PEP is considered. Children should also be
reevaluated and tolerance of medication assessed. HIV is a reportable disease if neonatal transmission or other risk
factors for transmission such as blood transfusion are not present.
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8.
Emergency Contraception (EC)
The risk of pregnancy after sexual assault is estimated to be 5%. As indicated, reproductive-aged female patients who
have been sexually assaulted should be evaluated for pregnancy. Urine or serum pregnancy tests in sexual assault
patients of childbearing age should be obtained. Health care providers should discuss with the patients the option of
emergency contraception if pregnancy is not desired. Various treatment options exist for emergency contraception.
These include progestin only medications, selective progesterone receptor modulators, and off label use of commonly
available brands of oral contraceptive pills. Emergency contraception is most effective when taken as soon as possible
after the assault. Patients must understand that there is a failure rate of pregnancy prophylaxis. Patients who receive
emergency contraception should be instructed to seek care if their menstrual cycle is delayed by more than 1–2 weeks.
Side effects may include nausea, abdominal pain, fatigue, headache, breast tenderness, dizziness, early or late menses
and vaginal bleeding. Administration of an anti-emetic is suggested secondary to medication- induced nausea. If
patient vomits within 2–3hours of emergency contraception, consideration should be given to repeat dosing.
Levonorgesterel is a Progestin only emergency contraception (Plan B, One Step, Next Choice) effective within 120
hours (5 days) after unprotected intercourse. Efficacy decreases with increasing time and it is most effective if taken
within 72 hours. This type of Emergency contraception will not end an existing pregnancy, does not cause birth defects,
and can be safely used by breastfeeding women. In the United States, emergency contraception utilizing progestin-only
pills is available over-the-counter to individuals aged ≥17 years and by prescription to younger patients.
Ulipristal acetate (ella) is a selective progesterone receptor modulator (SPRM) emergency contraception effective
within 120 hours (5 days). It is available only with a prescription. Ulipristal acetate may be more effective at
preventing pregnancy than progestin-only pills, especially if it has been greater than 72 hours since the assault. Before
taking Ulipristal acetate, a pregnancy must be excluded.
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If these medications are not readily accessible, many commonly available brands of oral contraceptive pills such
as Ovral can effectively provide emergency contraception. Patients must be instructed to take an appropriate and
specified number of tablets. Prophylaxis may be achieved by administering two ethinyl estradiol/norgestrel (Ovral)
tablets within 72 hours of the assault followed in 12 hours by another two Ovral tablets. This method has been
associated with increased side effects and is less effective than the other types of emergency contraception.
Evaluation and Management of the Sexually Assaulted or Sexually Abused Patient | ACEP
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Prophylaxis Care after Sexual Assault
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