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Postexposure Prophylaxis for HIV After Sexual Assault
To the Editor: Sexual assault nurse examiners working for the San Francisco Department of Public Health at San Francisco General Hospital have offered human immunodeficiency virus (HIV) postexposure prophylaxis (PEP) to survivors of sexual assault since April 1998. Survivors who choose to initiate PEP are given zidovudine (300 mg, twice daily) and lamivudine (150 mg, twice daily) in a combination pill for 10 days. At a follow-up visit 7 to 10 days later, an additional 18 days of the same PEP medications are offered. However, characteristics of those who choose to initiate and complete PEP have not been well described.
Methods
We conducted a retrospective review of charts of patients who were treated following sexual assault and who were offered PEP at San Francisco General Hospital between April 1998 and November 1999. We also computed the total cost of PEP medications.
Results
During the study period, 376 individuals were seen for sexual assault. Of these, 367 (98%) were seen within 72 hours of the assault. Fourteen (4%) reported that they had been previously diagnosed as HIV positive. Of the remaining 354 individuals, 213 (60%) had a documented offer of PEP. There were no statistical differences in age, race, or sex between patients who were offered PEP and those who were not.
Of the 213 patients who were offered PEP, 69 (32%) chose to initiate PEP, and 26 (12% of those initially offered PEP and 38% of those who initiated PEP) returned 1 week later to receive the additional 3 weeks of medications. Men were significantly more likely than women to initiate PEP (68% vs 28%; P<.001). Among men, those who had been anally assaulted were more likely to accept PEP. Women who accepted PEP were more likely to be white (37% vs 21%; P = .02), to have not been assaulted vaginally (38% vs 23%; P = .03), and to have housing (31% vs 12%; P = .03) (Table 1). In a multivariate model, being white (odds ratio [OR], 2.35; 95% confidence interval [CI], 1.0-5.7) and having housing (OR, 5.1; 95% CI, 1.3-34.5) were significantly associated among women with acceptance of PEP.
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Table. Acceptance of Postexposure Prophylaxis for HIV Following Sexual Assault*
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The total cost to the San Francisco Department of Public Health for antiretroviral medication during the 18-month period was $13,845. The total cost per person offered antiretroviral medication was $65.
Comment
Approximately one third of this sample of sexual-assault survivors chose to initiate PEP. Men who were anally raped are at the highest risk for HIV transmission and were most likely to initiate PEP in this sample. Because our study was based on chart review, we lacked complete data on some potential predictors of accepting PEP. It is also possible that PEP was offered to some individuals whose refusal was not documented in the medical record.
Among women, those who were nonwhite and homeless were less likely to accept PEP. Numerous studies have shown lower rates of antiviral treatment among persons of color.1-2 Two possible explanations for this are that clinicians more strongly encouraged white persons to take the medications and that negative preconceptions about antiretroviral drugs on the part of nonwhites led to fewer of them accepting treatment. Homeless women may have been less likely to accept PEP because they viewed the small risk of HIV infection from the assault as relatively minor, given other risks in their lives. Additionally, the burden of taking medication twice daily for 28 days might have appeared daunting. The lower acceptance of PEP among nonwhites and homeless women cannot be explained by lower risk of HIV exposure; nonwhite and homeless women were actually more likely than housed women to have been assaulted anally or vaginally.
The total per-person cost of medication dispensed during the study period ($65 per person offered PEP) is comparable to other medications offered routinely following sexual assault, such as azithromycin for chlamydia prophylaxis (approximately $43 per treatment). However, there is no definitive evidence that PEP is effective in preventing HIV seroconversion after sexual assault.
To develop a rational policy recommendation for offering HIV PEP after sexual assault, further studies are needed to better delineate the rates of HIV seroprevalence among sexual assailants, the efficacy of PEP after sexual exposure, and the psychological benefits or harm incurred by the sexually assaulted patient during the discussion of postexposure treatment.
Joan E. Myles, JD, MA;
Anne Hirozawa, MPH;
Mitchell H. Katz, MD;
Rachel Kimmerling, PhD;
Joshua D. Bamberger, MD, MPH
San Francisco Department of Public Health and University of California, San Francisco
1. Moore RD, Stanton D, Gopalan R, Chaisson RE. Racial differences in the use of drug therapy for HIV disease in an urban community. N Engl J Med. 1994:330763-768.
2. Palella FJ Jr, Delaney KM, Moorman AC, et al. Declining morbidity and mortality among patients with advanced human immunodeficiency virus infection. N Engl J Med. 1998;338:853-860.
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Letters Section Editors: Stephen J. Lurie, MD, PhD, Senior Editor; Phil B. Fontanarosa, MD, Executive Deputy Editor.
JAMA. 2000;284:1516-1518.
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