Clinical Management of Survivors of Rape - A Guide to the Development of Protocols for Use in Refugee and Internally Displaced Person Situations (United Nations High Commissioner for Refugees (UNHCR) / Alto Comisionado de Naciones Unidas para los Refugiados (ACNUR) - WHO - OMS, 2001, 46 p.): Annex 6 · Protocols for post-exposure prophylaxis of HIV infection

Clinical Management of Survivors of Rape - A Guide to the Development of Protocols for Use in Refugee and Internally Displaced Person Situations (United Nations High Commissioner for Refugees (UNHCR) / Alto Comisionado de Naciones Unidas para los Refugiados (ACNUR) - WHO - OMS, 2001, 46 p.)

		(introduction...)
		Preface
		Acknowledgements
		Abbreviations and acronyms used in this guide
		Introduction
		STEP 1 - Making preparations to offer medical care to rape survivors
		STEP 2 - Preparing the survivor for the examination
		STEP 3 - Taking the history
		STEP 4 - Collecting forensic evidence
		STEP 5 - Performing the physical and genital examination
		STEP 6 - Prescribing treatments
		STEP 7 - Counselling the survivor
		STEP 8 - Follow-up care of the survivor
		Annex 1 · Information needed to develop a local protocol
		Annex 2 · Sample consent form
		Annex 3 · Sample history and examination form
		Annex 4 · Pictograms
		Annex 5 · Protocols for treatment of STIs
		Annex 6 · Protocols for post-exposure prophylaxis of HIV infection
		Annex 7 · Protocols for emergency contraception
		Annex 8 · Minimum care for rape survivors in low-resource settings
		Annex 9 · Additional resource materials

Annex 6 · Protocols for post-exposure prophylaxis of HIV infection

The following are examples of post-exposure prophylaxis (PEP) protocols used in some settings for preventing HIV infection after rape. There may be other examples. These examples do not outline all the care that may be needed. If it is possible in your setting to provide PEP, refer the survivor as soon as possible (within 72 hours) to the relevant centre.

Example 1

From: Treatment guidelines for the use of AZT (zidovudine) for the prevention of the transmission of human immunodeficiency virus (HIV) in the management of survivors of rape. The Department of Health, Western Cape Province, South Africa.

Treatment regimen (28 days)

Zidovudine (AZT), 300 mg twice a day

· Survivors are given a one-week supply of the drug and an appointment to return for reassessment in one week.
· Survivors are seen at one week for evaluation and to obtain the results of their blood tests. They are given the remainder of their 28-day course of zidovudine.
· The next visits are at 6 weeks and 3 months after the rape. HIV testing is performed at both these visits.

· Routine testing, with full blood count and liver enzymes is not recommended for patients on zidovudine. Any blood tests are performed only if indicated by the survivor's clinical condition.

Example 2

From: Bamberger, J.D. et al. Postexposure prophylaxis for human immunodeficiency virus (HIV) infection following sexual assault. American Journal of Medicine, 1999, 106: 323-326.

Treatment regimen (28 days)

Zidovudine, 300 mg twice a day or 200 mg 3 times per day, and lamivudine, 150 mg twice a day

Alternative regimen (28 days)

Didanosine, 200 mg twice a day, and staduvidine, 40 mg twice a day Consider adding:* nelfinavir, 750 mg three times a day, or indinavir, 800 mg three times a day

· Although antiretroviral medications rarely cause important laboratory abnormalities, baseline tests may be useful.
· Monitoring should include complete blood count and liver enzyme levels as clinically indicated.
· HIV antibody testing is recommended at baseline, 6 weeks, 3 months, and 6 months following the assault.

* In the rare case where the assailant is known to be infected with HIV that is resistant to reverse transcriptase inhibitors, it is recommended to add a protease inhibitor, such as nelfinavir or indinavir. An HIV specialist should be consulted to determine the appropriate regimen.

Note: Nevirapine is not recommended for use as post-exposure prophylaxis after rape.¹

¹ Updated U.S. Public Health Service guidelines for the management of occupational exposures to HBV, HCV, and HIV and recommendations for postexposure prophylaxis. Morbidity and mortality weekly report, 2001, 50(RR-11), Appendix C.