Treatment and Follow-up : STI Prophylaxis/Empiric Treatment

STI prophylaxis is generally recommended for adolescent victims of child sexual assault, including empiric treatment for common STIs. This differs from the recommendations for prepubertal children where routine presumptive STI treatment is generally not recommended. The risk of a prepubertal child acquiring an STI as the result of a sexual assault is low and adolescent females are at a higher risk of ascending infections.

Presumptive Antibiotics

For female adolescent sexual assault survivors, the recommended empiric treatment for C. trachomatis, N. gonorrhoeae, and T. vaginalis includes:

• Ceftriaxone 500 mg IM in a single dose (1 g for persons weighing ≥150 kg) plus
• Doxycycline 100 mg orally 2 times/day for 7 days plus
• Metronidazole 500 mg orally 2 times/day for 7 days
  • Treatment for trichomoniasis can be delayed (and medications prescribed for later) to minimize drug interactions and potential side effects with co-administration of emergency contraception, or if there is a history of alcohol consumption.

For male adolescent sexual assault survivors, the recommended empiric treatment for T. trachomatis and N. gonorrhoeae includes:

• Ceftriaxone 500 mg IM in a single dose (1 g for persons weighing ≥150 kg) plus
• Doxycycline 100 mg orally 2 times/day for 7 days

For more information on diagnostic tests, see: LABORATORY: Testing for Sexually Transmitted Diseases, Diagnostic Testing.

Treatment Of Viruses

Hepatitis B

The CDC guidelines recommend that Hepatitis B vaccination be given for all unvaccinated, uninfected persons who are sexually active with multiple partners or are being evaluated or treated for an STI. The Hepatitis B series includes a vaccine at the initial examination for sexual abuse/assault, and follow-up boosters at 1-2 months and 4-6 months.

For a previously unvaccinated patient:

• If the perpetrator’s Hepatitis B status is unknown: offer the Hepatitis B vaccination (not HBIG) and series.
• If the perpetrator is Hepatitis B surface antigen positive: offer the Hepatitis B vaccination and series and HBIG.

For a previously vaccinated patient:

• If the patient has not had post-vaccination testing (proof of immunity): offer the Hepatitis B vaccine, test for immunity.
• If the patient is partially vaccinated (has an incomplete series): offer the Hepatitis B vaccine and series.

Hepatitis C

There is currently no vaccine for Hepatitis C virus prevention and no post-assault empiric treatment. Children and adolescents diagnosed with HCV infection may be treated with a direct acting antiviral. Consultation with an infectious diseases specialists may be needed. For further information, see: American Association for the Study of Liver Diseases and the Infectious Diseases Society of America (AASLD-IDSA) HCV Guidance: Recommendations for Testing, Managing, and Treating Hepatitis C.

Herpes Simplex Virus

Post-assault presumptive treatment for HSV is generally not recommended. Most patients are not treated with systemic antivirals until the onset of symptoms.

Human Papilloma Virus (HPV)

Unvaccinated or incompletely vaccinated male and female children and adolescents aged 9-45 years are recommended to receive HPV vaccination. The vaccine series includes one at the initial examination, follow-up dose at 1–2 months, and one 6 months after the first dose. A 2-dose schedule (0 and 6–12 months) is recommended for persons initiating vaccination before age 15 years. HPV vaccination prevents new infection and does not treat existing infections. See Centers for Disease Control and Prevention HPV Vaccination Recommendations for the latest recommendations.

Human Immunodeficiency Virus (HIV)

HIV Post-Exposure Prophylaxis (PEP) Recommendations

• PEP should be considered on a case-by-case basis depending on the individual’s risk of acquiring HIV.
• Consultation with an HIV specialist is recommended if PEP is being considered.
• Initiate PEP as soon as possible (ideally within 72 hours of the assault) to maximize its effectiveness.
• If PEP is offered:
  • Discuss the importance of early initiation, close follow-up, adherence to the regimen, and potential adverse effects. (Severe side effects are rare.)
  • Consider providing an initial 3–7-day course of PEP, or the entire 28-day course, at the initial visit. Providing the full course early can help improve adherence.

Factors that increase the risk of HIV infection include:

• Chronic sexual abuse
• Multiple perpetrators
• HIV-positive perpetrator
• High local HIV prevalence
• Perpetrator with a genital lesion

HIV Prophylaxis Checklist

• Check the HIV Guidelines section of New York State Department of Health Aids Institute HIV Clinical Guidelines Program for updated recommendations.
• Identify local HIV (pediatric infectious disease) experts and whom to call to obtain a consultation on appropriate treatment.
• Check to see that HIV medications are available through the hospital formulary or a local pharmacy.
• Identify whom to contact for NYS Crime Victim Board reimbursement for patient medication.
• Provide a patient packet containing a supply of medications and information regarding the HIV specialist follow-up. Provide written patient education on possible side effects/drug reactions.

For more information on HIV, see: New York State Department of Health Aids Institute HIV Clinical Guidelines Program and for more information on HIV testing, see: LABORATORY: HIV.