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The effects of sexual assault can be devastating; we commend Fong for
raising the profile of this topic within Accident and Emergency Medicine. There are, however, a number of areas where we feel the guidance in that
paper could be improved. The data about HIV prevalence and risk groups
were out of date. We cite more recent data and guidance that may alter
readers' approach to this situation.
Up to the end of June 2001, there had been 46131 reported cases of
HIV infection in the United Kingdom. The incidence of new HIV diagnoses
has increased each year since 1994. Since 1999 heterosexual intercourse
has been the commonest route of transmission.
Fong rightly emphasises that "HIV counselling and PEP is but one
aspect of the care and treatment of the rape victim". Although HIV
infection is especially worrying, sexual assault can lead to other
sexually transmitted infections and to (unwanted) pregnancy. Staff able to
diagnose and treat STIs and able to provide emergency contraception should
care for these patients. The optimum timing of testing for STIs is 10-14
days after the rape.
All anti-retroviral drugs can have significant side effects and
dangerous drug interactions. If it is felt that post-exposure prophylaxis
(PEP) might be needed, a suitably experienced clinician must be involved:
the most recent UK guidance states "after an exposure outside the health
care setting considered to carry a high risk of HIV infection, expert
advice should be sought urgently from a physician experienced in the
management if HIV and familiar with the considerations for the use of
PEP". This guidance suggested that when starter packs were being
replaced they contain zidovudine, lamivudine and the protease inhibitor
nelfinavir (rather than indinavir, which is poorly tolerated because of
dietary restrictions needed when taking it). The guidance does not
recommend any two-drug regimen, nor does it mention a 72-hour window. It
states that PEP may be indicated up to 2 weeks after exposure.
All patients in whom HIV testing or PEP are considered require
adequate counselling. Physicians in Genito Urinary Medicine or HIV
Medicine will have more extensive experience in these areas than most
clinicians in Accident and Emergency Medicine; we feel the failure of the
review to suggest immediate referral to GUM or another specialty familiar
with HIV management is a major omission.
We strongly advise anyone working in the UK who is considering
providing PEP to first read the Expert Advisory Group on AIDS
(1) Fong C. Post-exposure prophylaxis for HIV infection after sexual
assault: when is it indicated? Emerg Med J 2001;18:242-245.
(2) CDR Weekly. AIDS and HIV infection in the United Kingdom: monthly
report July 2001. http://www.phls.co.uk/publications/CDR%20Weekly/pages/hiv.htm Accessed 10 August 2001 (update due 30 August 2001).
(3) UK Chief Medical Officers' Expert Advisory Group on AIDS. HIV post-exposure prophylaxis. Department of Health, 2000.
Dr S G Ralph
Consultant Physician in Genito Urinary and HIV Medicine
York District Hospital
Dr R D Hardern
Consultant Physician (Acute Medicine)
The General Infirmary