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Medication

Key Points on Administering

Emergency Contraception (EC)

EC should be available to all female survivors of rape who are of reproductive age, and who are: not pregnant, not consistently using a reliable form of contraception, and who show signs of secondary sexual development (Kilonzo & Taegtmeyer, 2005). A pregnancy test is not required prior to administering EC. A pregnancy test is desirable, however, to determine eligibility. It is important to reassure clients that the EC pills will cause no harm to an existing foetus or to the course of the pregnancy (WHO, 2004b). In environments where dedicated EC drugs are not available, health providers can offer combinations of oral contraceptive pills. WHO advises “there are no restrictions for use of ECPs in cases of rape” (WHO, 2004b).  EC can be administered within 120 hours of unprotected intercourse, but is most effective at an earlier stage, so provision is a priority, along with HIV prophylaxis (Kenya MoH, 2004). An antiemetic can be offered alongside EC to reduce the chance of vomiting. The most common regimens of EC include levonorgestrel and combined oral contraceptive pills. WHO (2005) also identifies the insertion of a copper-bearing IUD within 5 days of the rape as an efficient form of emergency contraception. However, this may not prove a valid option in resource-poor settings, and may cause additional trauma to the survivor.

Fact Sheet on Emergency Contraception (World Health Organization).  Available in Arabic, English, French, Mandarin (Chinese) Russian and Spanish.

Sexually Transmitted Infections (STI) prophylaxis

Survivors of sexual abuse are vulnerable to a number of sexually transmitted infections (STIs). When appropriate, WHO recommends that patients be tested for chlamydia, gonorrhoea, trichomoniasis, syphilis and hepatitis B, although this may vary according to local environments and protocols. WHO does not recommend the routine prophylactic treatment of all patients, on the understanding that survivors experience different degrees of exposure to infection and there is scant evidence on the effectiveness of STI prophylaxis provision to abuse survivors (WHO, 2003b). However, medical management protocols in high STI-prevalence settings differ on this issue. The incubation periods of different STIs vary, and follow-up tests are advisable. Treatment may relieve a source of stress, but the decision about whether to receive prophylactic treatment or wait for results of STI tests should be made by the survivor (WHO, 2005d). Post-exposure prophylaxis of STIs should be commenced at an early stage of treatment, but need not be administered at the same time as the initial doses of PEP and EC as the pill burden may prove uncomfortable, and may reduce adherence to drug courses. The STI prophylaxis should, however, be prescribed and taken within 24 hours (Kenya MoH, 2004). It has been found that many patients do not complete their PEP treatment due to side effects (Martin et al., 2007). Antiemetics can reduce feelings of nausea. When STI testing is not feasible, the Kenyan MoH recommends that post-exposure prophylaxis of STIs should be commenced at an early stage of treatment (within 24 hours). To reduce the pill burden and to encourage adherence, the doses should be spread out and taken with food and antiemetics to reduce nausea (Kenya MoH, 2004; WHO, 2005d). 

The STIs most commonly contracted by abuse survivors include chlamydia, gonorrhoea, trichomoniasis and syphilis. National protocols may differ on the drug regimens provided for each STI. Different doses are recommended for non-pregnant adults (men and women), pregnant women, and for children. A pregnancy test should be administered to women prior to prescription of prophylactics in order to determine their status. The epidemiology, diagnosis and transmission modes of STIs in children differ from those in adults (WHO, 2003b). Routine administration of STI prophylaxis is recommended in high prevalence settings, although the dosage levels are child-specific. WHO observes that STI cultures may take up to one week to emerge, and therefore recommends a follow-up visit in cases where sexual abuse has recently occurred.

Sexually Transmitted Infectionswebsite page (World Health Organization)

Post-exposure prophylaxis (PEP) for HIV

Post-Exposure Prophylaxis involves the administration of one or a combination of anti-retroviral drugs (ARVs) to HIV negative persons for a period of 28 days after exposure to the HIV virus. The administration of PEP within 72 hours of sexual penetration, followed by a course of PEP drugs, is thought to significantly reduce the likelihood of sero-conversion (Roland et al., 2001). Although there is limited evidence of the effectiveness of PEP among survivors of sexual violence, the drugs have been proved effective after consensual sex in high-risk groups (Kenya MoH, 2004). PEP is recommended for men, women, boys and girls who have experienced oral, anal or vaginal penetration. Fixed dose combinations are recommended, where available, as they reduce the number of pills to be taken and thus increase compliance (Kenya MoH, 2004).

WHO points out that PEP is an ever-changing practice, and that health workers should remain aware of current recommendations and adhere to local guidelines. Studies have demonstrated low efficacy if PEP is commenced after 72 hours from exposure (Kenya MoH, 2004). In such circumstances, survivors should be availed of all other aspects of post-rape care, with the exception of PEP.  Because of the high risk of HIV transmission in high prevalence settings, it is recommended that PEP should be available at the first point of entry to a health facility (Kilonzo & Taegtmeyer, 2005). The short window of opportunity (72 hours) also emphasizes the need for an efficient referral system if the first point of contact (FPC) is other than a health facility.

Non-availability of voluntary counseling and testing (VCT) at time of presentation may be a serious bottleneck, and because most patients present to hospital after-hours, VCT should be made available 24-hours a day (Kim et al., 2007). In rural areas, few patients are able to return to hospital after the initial presentation. Therefore, wherever possible, all diagnostic tests and treatment should be provided on the first visit. For those who are HIV negative, a full 28-day course of PEP should be dispensed on the first visit. Same-day provision of anti-emetics and medication counselling are important for encouraging adherence (Kim et al., 2007a; Ipas, Armonie and UNFPA, 2010).

Regimens for children can consist of syrups or tablets, or a combination of both (Kenya MoH 2004; WHO). Children require lower dosage than adults, and with tablets, weight bands can be used to determine paediatric doses, an approach that has “greatly simplified the appropriate and early administration of paediatric PEP” (Speight et al., 2005). Otherwise, the doses are calculated according to the child’s weight and/or surface area. The dosage must be taken two or three times a day, depending on the regimen, and thus the guidance and co-operation of a guardian is required to ensure the child’s compliance. Side-effects from ARVs are significantly less common in children than in adults (Ellis et al., 2005). Paediatric PEP protocols state that HIV testing need not precede PEP provision, to reduce delays (Malawi, Kenya and South Africa protocols). Children may be considered ineligible for PEP if they have a history of sexual assault, or if they show no physical signs of abuse. If the child tests positive for HIV, he/she should be referred for on-going medical care. If negative, the child is provided with a two-week course of PEP, followed by an appointment where the child is reviewed for side-effects and issued with another two weeks of PEP.

HIV tests are recommended at 6 weeks and 3 months (Malawi, Kenya and South Africa protocols). Low rates of completion have been observed in both high and low-income environments. Studies worldwide have observed that many patients do not return to the healthcare setting for scheduled follow-up appointments (Martin et al., 2007). The Kenyan MoH (2004) advises that ARVs be provided for one week at a time, rather than the entire period of 28 days, in order to encourage re-attendance for clinical follow-up, counselling and adherence support. They do acknowledge that exceptions may need to be made in circumstances where the survivor lives far away, or is unlikely to return.

A South African study that explored women’s preferences for services after rape concluded that patients clearly prefer to receive all of their HIV prophylaxis at the initial visit (Christofides et al., 2005). The rural test site that practised this approach observed significantly higher rates of PEP completion than the urban test site that doled out weekly doses. The study results also implied completion is positively influenced by the provision of antiemetics (to counter the side-effect of nausea), information, and – even more importantly – a home follow-up service and the provision of food supplements. HIV diagnostic testing and counselling (DTC) is recommended to precede the administration of PEP. However, in circumstances where the 72-hour deadline is approaching, it is generally recognised that PEP will precede an HIV test, and will be discontinued in the event that the patient tests positive for the virus.

The HIV test needs to be accompanied by appropriate counselling to reduce any additional trauma, and a delay of up to three days is permissible in cases where the patient is not psychologically prepared (Kenya MoH, 2004). Contrary to concerns about the potentially deterrent properties of HIV-testing, the need to test for HIV before receiving PEP did not deter South African women from seeking services (Christofides et al., 2005). Follow-up HIV testing is recommended at six weeks and three months from baseline.

Links:

Post-exposure Prophylaxiswebsite page (World Health Organization).

Post-exposure Prophylaxis to Prevent HIV Infection: Joint WHO/ILO Guidelines on Post-exposure Prophylaxis (PEP) to Prevent HIV Infection. (WHO and ILO, 2007).  Available in English and French.