Management of STIs/RTIs
Chapter 10. Sexual violence

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Medical and other care for survivors of sexual assault

All reproductive health facilities should have up-to-date policies and procedures for managing persons who have survived or experienced sexual violence that are in line with local law. Whether comprehensive services are provided on-site or through referral, providers need to be clear about the protocol to be followed and how to manage crisis situations. They should have the necessary supplies, materials and referral contact information in order to deal confidentially, sensitively and effectively with people who have experienced sexual violence.

 

Step 1: Be prepared

 

The following services should be available, on-site or through referral, for patients who have experienced sexual violence:

• essential medical care for any injuries and health problems;
• collection of forensic evidence;
• evaluation for STI and preventive care;
• evaluation of pregnancy risk and prevention, if necessary;
• psychosocial support (both at time of crisis and long-term);
• follow-up services for all of the above.

 

Step 2: Initial evaluation and consent

Survivors of sexual assault have experienced a traumatic event and should be rapidly evaluated to determine whether they need emergency medical, psychological or social intervention. It is important to remember that the trauma of the event may make parts of the examination difficult. Explain carefully the steps that will be taken and obtain written informed consent from the patient before proceeding with examination, treatment, notification or referral.

 

Step 3: Documentation and evidence

 

A qualified provider who has been trained in the required procedures should perform the examination and documentation of evidence. The examination should be deferred until a qualified professional is available, but not for longer than 72 hours after the incident. It is the patient�s right to decide whether to be examined. Treatment can be started without examination if that is the patient�s choice. For minors under the age of consent, local guidelines may dictate how to manage the person�usually parental consent is required. If at all possible, do not deny adolescents immediate access to medical services.

 

Where facilities or referral for a more complete examination are not available, the following minimal information should be collected: date and time of assault; date and time of examination; patient�s statement; and results of clinical observations and any examinations conducted. Such information should be collected or released to the authorities only with the survivor�s consent. Be aware of legal obligations that will follow if the assault is reported and goes to legal proceedings. Ideally, a trained health care provider of the same sex should accompany the survivor during the history-taking and examination.

A careful written record should be made of all findings during the medical examination. Pictures to illustrate findings may help later in recalling details of the examination.

 

 

 

 

Step 4: Medical management

 

 

The medical management of the survivor includes treatment of any injuries sustained in the assault, and initial counselling. Emergency contraception and STI prophylaxis should be offered early to survivors of sexual violence. For many women, the trauma of the event may be aggravated and prolonged by fear of pregnancy or infection, and knowing that the risks can be reduced may give immense relief.

 

Emergency contraception

Emergency contraceptive pills can be used up to 5 days after unprotected intercourse. However, the sooner they are taken, the more effective they are. Several regimens exist�using levonorgestrel or combined oral contraceptive pills (see Box 6.2).

A second option for emergency contraception is insertion of a copper-bearing IUD within 5 days of the rape. This will prevent more than 99% of pregnancies. The IUD may be removed during the woman�s next menstrual period or left in place for continued contraception. If an IUD is inserted, make sure to give full STI treatment as recommended in Treatment table 13.

If more than 5 days have passed, counsel the woman on availability of abortion services (in most countries, post-rape abortion is legal). A woman who has been raped should first be offered a pregnancy test to rule out the possibility of pre-existing pregnancy.

 

Postexposure prophylaxis of STI

Another concrete benefit of early medical intervention following rape is the possibility of treating the person for a number of STIs. STI prophylaxis can be started on the same day as emergency contraception, although the doses should be spread out (and taken with food) to reduce side-effects such as nausea.

The incubation periods of different STIs vary from a few days for gonorrhoea and chancroid to weeks or months for syphilis and HIV. Treatment may thus relieve a source of stress, but the decision about whether to provide prophylactic treatment or wait for results of STI tests should be made by the woman.

Treatment table 13 lists options that are effective whether taken soon after exposure or after the appearance of symptoms.

 

Treatment table 13. STI presumptive treatment options for adults

Coverage	Option 1 All single dose, highly effective. Choose one from each box (= 3 or 4 drugs)a	Option 2 Effective substitutes � possible resistance in some areas, or require multiple dosage	If patient is pregnant, breastfeeding or under 16 years old Choose one from each box (= 3 or 4 drugs)a
Syphilis	benzathine penicillin 2.4 million units by single intramuscular injection	doxycyclinec 100 mg orally twice a day for 14 days (in case of penicillin allergy only)	benzathine penicillin 2.4 million units by single intramuscular injection
Gonorrhoea/ chancroid	cefixime 400 mg orally as a single dose, or ceftriaxone 125 mg by intramuscular injection	ciprofloxacind 500 mg orally as a single dose, or spectinomycin 2 g by intramuscular injection	cefixime 400 mg orally as a single dose, or ceftriaxone 125 mg by intramuscular injection
Chlamydia/ lymphogranuloma venereum	azithromycin 1 g orally as single dose	doxycyclinec 100 mg orally twice a day for 7 days, or tetracyclinec 500 mg orally 4 times a day for 7 days	azithromycin 1 g orally as single dose, or erythromycin 500 mg orally 4 times a day for 7 days
Trichomoniasis	metronidazoleb 2 g orally as a single dose	tinidazolee 2 g orally as a single dose	metronidazoleb 2 g orally as a single dose, or 400�500 mg 3 times a day for 7 days

 

^a. Benzathine penicillin can be omitted if treatment includes either azithromycin 1 g or 14 days of doxycycline, tetracycline or erythromycin, all of which are effective against incubating syphilis.

^b. Metronidazole should be avoided in the first trimester of pregnancy. Patients taking metronidazole should be cautioned to avoid alcohol.

^c. These drugs are contraindicated for pregnant or breastfeeding women.

^d. The use of quinolones should take into consideration the patterns of Neisseria gonorrhoeae resistance, such as in the WHO South-East Asia and Western Pacific Regions.

^e. Patients taking tinidazole should be cautioned to avoid alcohol.

Additional antibiotic treatments for gonorrhoea are given in Annex 3.

 

Treatment for possible STI in children is similar to that for adults. Recommended dosages are given in Treatment table 14.

 

Treatment table 14. STI presumptive treatment options for children

Coverage	All single-dose antibiotics are highly effective. Choose one from each box (= 3 or 4 drugs)b	Older children and adolescents
Syphilis	benzathine penicillin 50 000 units/kg of body weight by single intramuscular injection, or erythromycin 12.5 mg/kg of body weight orally 4 times a day for 14 days	>45 kg, use adult protocol
Gonorrhoeaa/ chancroid	cefixime 8 mg/kg of body weight as a single dose, or ceftriaxone 125 mg by intramuscular injection, or spectinomycin 40 mg/kg of body weight (maximum 2 g) by intramuscular injection	>45 kg, use adult protocol
Chlamydia/ lymphogranuloma venereum	erythromycin 12.5 mg/kg of body weight orally 4 times a day for 7 days	12 years or older, use adult protocol
Trichomoniasis	metronidazolec 5 mg/kg of body weight orally 3 times a day for 7 days	12 years or older, use adult protocol

^a. Additional antibiotic treatments for gonorrhoea are given in Annex 4.

^b. If erythromycin is chosen for syphilis, then only 3 drugs should be used for children.

^c. Patients taking metronidazole should be cautioned to avoid alcohol.

 

Postexposure prophylaxis of HIV

The possibility of HIV infection should be thoroughly discussed as it is one of the most feared consequences of rape. At present, there is no conclusive evidence on the effectiveness of postexposure prophylaxis (PEP) in preventing infection following sexual exposure to HIV, and PEP is not widely available. If PEP services are available, rape survivors who wish to be counselled on the risks and benefits should be referred within 72 hours. The provider should assess the person�s knowledge and understanding of HIV transmission and adapt the counselling appropriately. Counselling should take into account the local prevalence of HIV and other factors (trauma, other STI exposure) that could influence transmission. If the person decides to take PEP, two or three antiretroviral drugs are usually given for 28 days.

 

Prophylactic immunization against hepatitis B

Hepatitis B virus (HBV) is easily transmitted through both sexual and blood contact. Several effective vaccines exist although they are expensive and require refrigeration. If HBV vaccine is available, it should be offered to survivors of rape within 14 days if possible. Three intramuscular injections are usually given, at 0, 1 and 6 months (see instructions on vaccine package as schedules vary by vaccine type). HBV vaccine can be given to pregnant women and to people with chronic or previous HBV infection. Where infant immunization programmes exist, it is not necessary to give additional doses of HBV vaccine to children who have records of previousvaccination. Hepatitis immune globulin is not needed if vaccine is given.

 

Tetanus toxoid

Prevention of tetanus includes careful cleaning of all wounds. Survivors should be vaccinated against tetanus if they have any tears, cuts or abrasions. If previously vaccinated, only a booster is needed. If the person has never been vaccinated, arrangements should be made for a second vaccination one month later and a third 6 months to one year later. If wounds are dirty or over 6 hours old, and the survivor has never been vaccinated, tetanus immune globulin should also be given.

 

Step 5: Referral to special services

 

Following the initial provision of care, referrals may be needed for additional services such as psychosocial support. An evaluation of the person�s personal safety should be made by a protective services agency or shelter, if available, and arrangements made for protection if needed. Referral for forensic examination should be made if this is desired but could not be adequately performed at the clinic visit.

It is essential to arrange follow-up appointments and services during the first visit. The woman should be clearly told whom to contact if she has other questions or subsequent physical or emotional problems related to the incident. Adolescents in particular may need crisis support as they may not be able or willing to disclose the assault to parents or carers.