Case (30)

[Doctoor]

A15-year-old girl was brought to the casualty unit because she had been raped last night. In casualty, she was examined and the appropriate police forms were completed. She now is brought to your clinic for assistance in dealing with the threat of HIV infection.
She says that she does not know her assailant, and the police say it is unlikely they will be able to find him.

Questions:
• What are the immediate things that you should do?
• If the assailant is apprehended and found to be HIV sero-negative, what should you do?
• Other than HIV protection, to what other conditions must you give attention?
• If the victim is HIV sero-positive at the first testing, what should you do?

[Mustafa]

Assalam aleikum dear doctoor,

 It is a deplorable case and very traumatic for the woman. The physician should approach the patient in a professional manner and the history should be obtained very carefully. He should be empathetic and never be skeptical or judgmental.

1. In this case, a rapid baseline serologic test for HIV should be performed. If the test is negative, offer PEP -postexposure prophylactic -medications based on risk factors with a follow-up for repeat HIV testing. PEP is most effective when started within 72 hours after exposure.
The CDC recommends that patients be given an initial prescription for PEP for only three to seven days ( others up to four weeks), with shortterm follow-up for further counseling, since the emotional trauma experienced by patients immediately following assault may cloud decision-making at that time regarding ongoing prophylaxis. The most commonly used dual nucleoside regimens include:
ZDV plus 3TC (coformulated as Combivir) or TDF plus FTC (coformulated as Truvada)
Moreover Nelfinavir can be prescribed if it is available.

2. If the assailent is in custody and is seronegative: the patient can stop PEP.
-If he is not found; step wisely the recommended duration of PEP is four weeks, perform HIV serology at six weeks, twelve weeks and six months following the exposure. Also  re-examination for other STD and/or pregnancy within four weeks should be performed on the victim.
- If the result for HIV serology test is negative after 12 weeks; the victim is probably not infected and to be very sure one more serological test at 6 months is necessary.

3. Baseline test should include pregnancy test as well as sexual transmitted disease. she should be given emergency postcoital contraception. Furthermore the CDC recommend empiric antibiotic prophylaxis since many assault victims will not return for a follow-up visit, and treatment based upon culture results is therefore problematic . Empiric therapy includes ceftriaxone 125 mg IM for gonorrhea and either azithromycin 1 gram PO (single dose) or doxycyline 100 mg PO twice daily for seven days for chlamydia. Metronidazole 2 grams PO (single dose) is also recommended to treat trichomoniasis.

4. - When the victim is seropistive for HIV at baseline;  a psychological counselling about her rape experience should be done and a follow-up care should be planned within two weeks of the assault. At this visit, the victim can have follow up testing as well as couselling in HIV clinical setting and asses her how she is recovering. if this in two weeks is not realized, then offer the patient to come at a time when she is more at ease.
-If the patient is seropistive at either three  months or 6 months on two separate rapid HIV test; she should be enrolled in an HIV program.

[Doctoor]

Walaykum Salaam Dear Mustafa

Thanks for your professional answer!