Prophylaxis against STIs

Encourage patients to accept prophylaxis against STIs if indicated.[1] If prophylaxis is accepted at the time of the exam, testing is usually not indicated medically. Routine preventive therapy after a sexual assault is often recommended because followup with these patients can be difficult.[2] It also may reduce the need for more expensive/extensive treatment if an STI is discovered at a later time. Meet or exceed current CDC guidelines for STI preventive therapy for your geographic area.[3] (The CDC suggests a regimen to protect against chlamydia, gonorrhea, trichomonas, and BV, as well as the hepatitis B virus.) If prophylaxis is declined at the time of the initial exam, it is medically prudent to obtain cultures and arrange for a followup examination and testing (it is recommended that all patients are reexamined—see the section on followup activities). Document patients’ decisions and rationales for declining prophylaxis in their medical records.[4]

For nonsexually active patients, taking a prophylaxis could prevent development of STIs that could be used as evidence if the suspect had an STI. Keep in mind that patients’ medical needs take priority over collection of forensic evidence. However, patients should be aware of this consequence of taking the prophylaxis against STIs and be able to make their own decisions about treatment.

If patients’ clinical presentation suggests a preexisting ascending STI, such as fever, abdominal or pelvic pain, and/or vaginal discharge, they should be evaluated and treated for the ascending infection. This treatment may differ from suggested STI prophylaxis.[5]

Hepatitis B virus (HBV) and postexposure prophylaxis. See CDC recommendations related to HBV diagnosis, treatment, prevention, postexposure immunizations, prevaccination antibody screening, postexposure prophylaxis, and special considerations.[6] Patients who have completed a full hepatitis B vaccination regimen prior to the assault are protected from HBV infection and do not need further doses. (See the CDC recommended regimen for adolescents and adults.) For those who were not fully vaccinated prior to the assault, the vaccine should be completed as scheduled. Patients unvaccinated prior to the assault or unsure of whether they have been vaccinated should receive active postexposure prophylaxis (e.g., hepatitis B vaccine alone) upon the initial clinical evaluation. Followup doses should be given 1 to 2 and 4 to 6 months after the first dose. Unless suspects are known to have acute hepatitis B, HBIG (hepatitis B immune globulin) is not required. (When HBIG is needed, use CDC recommended doses.)

Examiners must stress to patients receiving the HBV vaccine the importance of following up for administration of doses as scheduled for full protection. Advocates should also be educated about the possibility of patients receiving prophylaxis against HBV and encourage those who start the vaccine regimen to follow up for required additional doses.

Obtain informed consent from patients for treatment. (For information on this topic, see A.3. Informed Consent.) Patients should be aware of the benefits and toxicity associated with recommended regimens.
[1] Keep in mind that prophylaxis against STIs may not be appropriate for some individuals (e.g., because of a disability or other medication they may be taking). Before recommending prophylaxis, it may be helpful to talk with these patients’ primary healthcare providers (with patients’ permission).
[2] Sexually Transmitted Diseases Treatment Guidelines, 2002, p. 70.
[3] Antibiotic prophylaxes are updated periodically and are usually tailored to specific regions (because, for example, one part of the country may be resistant to a certain antibiotic).
[4] Nonphysician examiners providing STI prophylaxis typically must operate within the boundaries of a protocol and have access to medical supervision, consultation, and review.
[5] Paragraph from the California Medical Protocol for Examination of Sexual Assault and Child Sexual Abuse Victims, 2001, p. 92.
[6] Sexually Transmitted Diseases Treatment Guidelines, 2002, p. 64. This section was drawn from this document.


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