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When a patient presents to your emergency department, urgent care or clinic with a chief complaint of sexual assault within the last 24 hours, the challenge is recognizing that, along with safety and criminal justice concerns, this patient has emergent health needs. One of the most urgent of these is that the patient may have been exposed to HIV. Non-occupational post-exposure prophylaxis (nPEP) needs to be initiated as soon as possible after known or potential HIV exposure, but throughout the country, there are barriers to this treatment.
The use of Sexual Assault Nurse Examiners (SANEs) to provide specialty care to patients who have experienced sexual assault, is considered best practice, though not available in all hospitals or communities. It is not uncommon for the SANE to have initiated the process of providing nPEP post-sexual assault and subsequently, developing a multidepartment collaborative policy. However, in communities where SANE services are not available policies often do not exist, and the patient may not have this evaluation and treatment provided at all.
One of the first hurdles in policy development is educating the clinicians about the need for nPEP and how to evaluate for its use with patients experiencing sexual assault, as well as the urgency for providing the medication to patients as soon as possible. The AETC Non-Occupational Post-exposure Prophylaxis Toolkit provides guidance regarding laboratory and screening testing pre-PEP, patient education and standardized order sets of recommended PEP medications and a sample policy. The HIV/STI Post-Sexual Exposure Prophylaxis: Policy and Procedure Template provides a framework for healthcare facilities to use for creating a policy and procedure for providing medical care to patients seen following possible sexual exposures to HIV and common sexually transmitted infections.[1]
Collaboration is key when developing any policy for nPEP. In addition to emergency physicians, SANE and/or emergency nursing representatives, and pharmacy, consider connecting with other departments and experts such as laboratory to ensure that HIV testing is available to victims of sexual assault 24 hours a day, Infectious Disease specialists or primary care providers familiar with nPEP follow-up for referrals, social work and victim advocacy programs for support, and institutional financial and legal departments, to include their input and early buy-in of the policy.
It is common for individuals who have experienced sexual assault to have delayed presentation for care, often hours or days later. If they present within the 72-hour time frame for nPEP, a risk assessment needs to be quickly obtained, along with a trauma-informed explanation to the patient regarding their risk of acquiring HIV and offering nPEP. The patient should be advised of and understand the 28-day medication regime, required laboratory tests, and follow-up medical care referrals, as well as medication costs and payment options. The National Pediatric SAFE Protocol and National SAFE Protocol: Adolescent/Adult offer guidance to clinicians regarding HIV testing and patient education for nPEP. It is imperative that every patient who has experienced sexual assault or abuse, be assessed for exposure risk and provided with nPEP as appropriate. The cost of the medications can be over $2,000 for a 28-day supply. Pharmaceutical patient assistance programs for covering the cost of the medications are another resource highlighted in the Toolkit. Other forms of payment vary across the country. For example, Ohio Attorney General has instituted a new payment rate of $2,500 for the hospital initiating and dispensing the full 28 day supply of medication. Crime Victims compensation may be a viable source of payment for the medications as well as the patient’s healthcare insurance, however, substantial co-pays, or delays in medication dispensing due to the approval process may occur. Communities should research the availability of the medication at local pharmacies- as the drugs may not be readily available locally especially in rural, low HIV incidence areas.
It is quite apparent to us, as we provide education across this country, that clinicians are met with substantial barriers to providing PEP post sexual assault. For further information on the Toolkit, available resources, and considerations for HIV nPEP after sexual assault, a free webinar is available: Post-Exposure Prophylaxis to HIV: Make it Simple, by John Nelson, PhD, CNS, CPNP, AIDS Education & Training Center National Coordinating Resource Center, Program Director, and Gregory S. Felzien, MD, AAHIVS, Medical Advisor, Georgia Department of Public Health, Division of Health Protection/IDI-HIV.
[1] AIDS Education & Training Center (AETC) Program Rural Health Committee. (2018). HIV/STI post-sexual exposure prophylaxis: Policy and procedure template. François-Xavier Bagnoud Center, Rutgers University School of Nursing.
