Treatment and disease prevention for survivors of gender-based violence. I'm Kamila Alexander, assistant professor at Johns Hopkins School of Nursing. Today's objectives are, to describe how to asses symptoms, and describe the recommended prophylaxis regimens for common sexually transmitted infections and throughout the presentation I will refer to them as STIs. Also, we will asses the need for HIV post-exposure prophylaxis. Describe treatment regimens and indications for pregnancy prevention. And finally, we'll describe appropriate discharge information and follow-up for survivors of gender-based violence. The reference material used to develop this module came from the World Health Organization's guidelines for legal care of survivors of sexual violence. And also from the United States Centers for Disease Control and Prevention's Sexually Transmitted Diseases Treatment Guidelines. We'll start with STI Symptom Assessment and Prophylaxis. The most common bacterial STIs that are transmitted during acts of sexual assault are chlamydia, Neisseria gonorrhoeae, syphilis or Treponema pallidum and Trichomonas vaginalis. There are also risks for viral transmission which include human papillomavirus or HPV, herpes simplex virus, or HSV, HIV, and hepatitis B. However, we must always remember that transmission risks are also dependent on epidemiologic profiles of the communities in which the assault occurs. In terms of STI screening and testing, we should consider testing according to the community's resources in which you work. So you want to perform cultures or nucleic acid amplification tests for gonorrhoea and chlamydia, and those are recommended regardless of the sites of penetration or attempted penetration. A wet mount and culture for Trichomonas or any other point of care testing with the use of a vaginal swab is also recommended. So, during that exam we're going to examine for evidence of bacterial vaginosis and candidiasis, particularly, if the survivor reports any vaginal discharge, malodor, or itching occurring in the vaginal area. Finally, we'll want to draw a blood samples for syphillis, HIV, and hepatitis B. Decisions to perform serum testing are case-specific. There are some advantages and disadvantages to testing after an assault occurs. An advantage to immediate testing would be that it increases access to screening and treatment. Additionally, it allows for targeted treatment. So, we'll know who's positive and then be able to subsequently treat them. Some disadvantages are that we are most likely to perform a exam within 72 hours after an assault has occurred. And therefore, the results for any viral or bacterial transmission would likely be negative if a woman was exposed. Therefore, follow up for results and treatment may be delayed because sometimes women have experienced challenges to returning to any clinical setting. Prophylaxis for STIs should be considered on a case by case basis after doing a thorough history and getting a full understanding of the nature of the assault. Clinical areas should developed protocols that are based on national and local context that take into account the resources that are available. And they should really be strongly considered when assault occurs within 72 hours. Often compliance with follow up visits can be poor among sexual assault survivors. Therefore, some suggested regimens include a hepatitis B vaccine. And for that we would administer it at the initial examination, if a survivor reports that they have not received a vaccination previously. After that first dose we would then follow up or ask the survivor to follow up for doses 2 and 3. Dose 2 occurs 1 to 2 months after the initial vaccine, and dose number 3 will occur 4 to 6 months after the initial vaccine. Other treatments include, for chlamydia, we would prescribe azithromycin, 1 gram, taken by mouth in a single dose, or what's more economically feasible is a 7 days supply of doxycycline 100 milligram, and you would direct the survivor to take that by mouth twice a day. In order to treat gonorrhea, we would likely give an injection of ceftriaxone 250 milligram intramuscularly in a single dose. For Trichomonas, we would prescribe metronidazole again, in a single dose at 2 grams. The most optimal treatment would be done in a single visit upon initial examination for prophylaxis. Therefore, not requiring the survivor to follow up afterwards and can be considered treated. HIV Prevention and Treatment. Any healthcare worker prescribing post-exposure prophylaxis. So do an assessment that considers the local environment including understanding what the incidence of HIV is in that community, and specifically with the survivor a thorough history that includes understanding the characteristics of the assault. So we'll want to know what type of sexual assault occurred. Was it anal, vaginal or oral? Did ejaculation occur? And if it did, what location on the body? Did the assault include condom use? Was there trauma to the vaginal or anal area? The number of times that the survivor was assaulted. And additionally the number of assailants. All of these characteristics will determine the likelihood of whether or not we would suggest this person is a good candidate to take post-exposure prophylaxis for HIV. We would also want to consider the characteristics of the assailant. Sometimes, a survivor will know the HIV status of the assailant. Other risk factors might be known to that person, such as whether or not the assailant was had been previously incarcerated or if they've also engaged with in sex with men. Finally, we would want to take into account characteristics of the survivor. Does the survivor already have any existing sexually transmitted infections? Upon exam, we would also want to take note whether or not there were genital lesions present. This will ultimately raise the risk of HIV transmission and exposure. When should we offer HIV post exposure prophylaxis? This should certainly be a collaborative effort between the provider, as well as the survivor and we must weigh several factors. The risk assessment that we just talked about and what the profile of the survivor is. We should also discuss the uncertain benefits of treatment. So any prophylaxis regime that is provided is not a guarantee that the survivor will not become positive for HIV. Thirdly, we should discuss the side effects of the drugs, which can be a big challenge for survivors in order to complete the treatment. Additionally, the ability to obtain and follow through with the 28-day regimen. One of the biggest barriers to completing the 28-day regimen is the side effects of the drugs and providers can minimize this by at least having the conversation in order that the survivor is prepared for these kind of side effects. We also have to take into account the timing of the assault and when the person is sitting in front of you, because the prophylaxis must be offered and started within 72 hours of the assault. So time is of the essence. Pregnancy prevention. In order to prevent pregnancy, we should know that women who present within five days of an assault can receive emergency contraception and the most common form of emergency contraception are emergency contraceptive pills or an oral form. This prevents or delays ovulation, it's not an abortion and will not affect an existing pregnancy. This is very important information to relay to the survivor. Some indications for emergency contraception after an assault has occurred are to assess pregnancy risk, so we want to know what the age of the survivor is as well as their menopausal status. Whether or not the survivor reports that the assailant used a condom during the sexual assault and we'll ask the survivor to take a pregnancy test. And if it's negative, the emergency contraception can still be prescribed even if pregnancy cannot be ruled out, because we know that emergency contraception will not terminate an existing pregnancy nor affect a fetus. There are no known contraindications for emergency contraception. Some best practices relating to pregnancy prevention post assault are to offer testing, but realizing that a positive result is unlikely, if related to assault within five days, even the best over the counter pregnancy tests can only detect pregnancy within nine days. So we'll want to refer to survivor for follow up pregnancy testing. If the pregnancy test is positive, we'll definitely want to discuss options according to what the local community resources can provide. So if in your community there are options for adoption, abortion or surrogacy, we'll want to discuss all options with the survivor, so they can make a well informed decision. The practitioner should know what local guidelines and laws are governing abortion services, because some societies that disallow abortion will allow it in cases of rape. We'll also want to refer a survivor to a safe abortion facility, if indicated. So now, let's talk about dosing. Most often, emergency contraception is prepackaged, which is the preferred method for prevention. So a survivor doesn't have to figure out the amount of pills to take, because it's already prepackaged and you just take it once. However, if prepackaging is not available, oral contraceptive pills can be used. If progestin only pills are available, they can be taken in one dose up to five days post assault. And if the survivor has combined estrogen, progesterone pills, they'll need to take it in two doses 12 hours apart and up to 72 hours post assault. This regiment does not is not has high as efficacy as the other. Discharge and follow-up. Upon discharging the survivor from your care, we want to reassure her that the assault was not her fault or their fault. We want to make sure that we allow time for questions and concerns. Assess her safety, his or her safety to leave the facility. We'll also want to provide information on all testing, treatment and results. And finally, we want to describe rape trauma syndrome and any potential symptoms that go along with that. The three stages of rape trauma syndrome include, an acute stage, outer adjustment and renormalization. And these should be carefully outlined for the survivor along with the potential physiological symptoms, such as headaches and the psychological symptoms, which could include paranoia or inability to sleep. Follow-up examinations provide the opportunity to detect new infections that may have been acquired during or after the assault. Allows us to complete Hepatitis B vaccinations series, if indicated. We can also take the opportunity to complete any counseling and treatment for other STIs and we can also monitor side effects and adherence to post exposure prophylaxis medication, if it was prescribed during the initial examination. We'll want to repeat STI exams within one to two weeks of the assault, if HIV or STI post exposure prophylaxis treatment was not provided at the initial exam. So in other words, if the risk profile of the survivor did not indicate that it would be a good idea to prescribe post exposure prophylaxis, it would be best to ask the survivor to return within one to two weeks so that any kind of testing can be performed. We'll also want to counsel the survivor regarding symptoms of STIs that they can be looking for. We'll also encourage help-seeking immediately if symptoms occur. And then encourage abstinence from sexual intercourse until the entire preventive treatment is completed. If the survivor was given HIV or STI post exposure prophylactics, the follow up exam should be within one week. At that time, we'll discuss any positive test results and provide any additional treatment as a result of the testing of the results that we get. We'll also do follow-up blood tests for syphilis and HIV infection. If the initial test results are negative, that's when we'll do these follow-up blood testing. If the infection in the assailant cannot be ruled out. And at the following intervals, post assault, 6 weeks, 3 months, as well as 6 months. We do this because the time from exposure to positive test can vary for syphilis and HIV infection and go all the way up to 6 months. Two weeks post assault, during a follow up exam, we want to assess the status of the injuries that were obtained during the assault. We also want to verify that the survivor completed any medication regimens if indicated. We'll conduct STI and/or pregnancy testing if indicated. If the survivor is pregnant at this time, we'll discuss those options. We'll continue to assess the emotional state and provide counseling referrals of the survival to the survivor. We'll also remind her or him of the timeline for repeat testing and treatment for HIV and Hepatitis B, if needed. So that's for the vaccine for Hepatitis B and for testing for HIV. Three months after the assault we'll ask the survivor to return in order to test for HIV, with appropriate counseling, as well as to provide results from the last testing. At that time we'll also test for Syphilis and continue to assess for the mental state and provide referrals to the survivor. Six months out We'll again test for HIV, providing results, administer the final Hepatitis B vaccine, and continue to assess the mental state and provide referrals to the survivor. Regarding referrals, Practitioners should know your local resources and services, so that you can send the survivor to the right place that will fit his or her needs. We should create written materials, if they do not exist in your local office. We also want to include as many of the following resources as possible for the survivor to use. Any rape crisis centers, shelters or safe houses, HIV/AIDS counseling if it's not available at your center, STI screening and treatment, assistance with legal issues Victim witness programs, as well as mental health services and financial assistance. Finals, finally, social service agencies should be a big point of referral as this occurrence can often create chaos in the life of a survivor. That's it for this module. Thank you, and I put my contact information below. Feel free to contact me if you have further questions.
