Postexposure prophylaxis after nonoccupational HIV exposure: clinical, ethical, and policy considerations

Postexposure to HIV prophylaxis

Since the reports of an international case-control study during the period 1995-1997, further evidence has accumulated supporting the use of postexposure therapy with antiretrovirals. This includes evidence from vertical transmission studies with both zidovudine and nevirapine, and animal model data. Guidelines have been developed and revised for occupational postexposure prophylaxis provision, but there remains considerable debate over postexposure prophylaxis for nonoccupational (predominantly sexual) exposures.

Emergency department characteristics of male sexual assault

OBJECTIVE

To characterize the nature, frequency, and treatment of male sexual assault encountered by physicians in an ED. A minor objective compared the lengths of time the victim knew the assailant between males and females to determine whether there were differences between male and female victims.

METHODS

Retrospective review over four years of all male patients with a diagnosis of sexual assault presenting to an urban academic ED in New York City. Demographics, types of injury, assailant/victim information, and treatment of the assault were obtained.

RESULTS

Twenty-seven male sexual assaults (approximately 12% of all sexual assaults) were documented during this time period. Forcible rectal, oral, or both rectal and oral intercourse occurred 14, 4, and 9 times, respectively. Documented physical trauma occurred in nine of 27 visits, with two admissions for head trauma. Five additional patients complained of rectal pain with no independent objective evidence of trauma. Prophylactic treatment with antibiotics for the prevention of Neisseria gonorrhoeae and Chlamydia trachomatis was offered in 26 of 27 episodes and prophylactic HIV protection was given to only two of 21 eligible patients. Documentation of HIV status and HIV counseling occurred only in ten and five visits, respectively. The male-to-female odds ratios for whether the assailant was unknown, known less than 24 hours, or known more than 24 hours were 0.43 (95% CI = 0.15 to 1.26), 2.48 (95% CI = 0.94 to 6.53), and 0.92 (95% CI = 0.31 to 2.71), respectively.

CONCLUSIONS

The percentage of total sexual assaults occurring in males who present to an ED is now more than 10% of all sexual assaults seen in this urban ED. These assaults are associated with a high proportion of patients with documented trauma. Although the treatment of traditional sexually transmitted diseases appears to be covered well, the need for HIV documentation, counseling, and possible HIV prophylaxis should be addressed more aggressively. In comparing the lengths of the relationships between the victim and the assailant, it appears twice as likely that the female victim will not know her assailant compared with the male, and twice as likely that the male victim will know his assailant less than 24 hours compared with the female.