Exposure Risk Evaluation

Lead author: Elliot DeHaan, MD, with the Medical Care Criteria Committee; November 2021

RECOMMENDATIONS
All Exposures
  • Clinicians should complete an expeditious and comprehensive evaluation of the potential HIV exposure to determine the need for post-exposure prophylaxis (PEP). (A2)
Sexual Assault Exposure
  • Clinicians should recommend PEP to individuals reporting sexual assault as follows: (A2)
    • When the exposed individual has experienced direct contact of the vagina, penis, anus, or mouth with the semen, vaginal fluids, or blood of a source, with or without physical injury, tissue damage, or presence of blood.
    • When the exposed individual’s broken skin or mucous membranes have been in contact with the blood, semen, or vaginal fluids of an assailant.
    • When an exposed individual has visible blood, i.e., a bite has drawn blood.
  • Clinicians should administer the first dose of the human papillomavirus (HPV) vaccine for individuals aged 18 to 45 years who have not yet been vaccinated. (A3)
  • Clinicians should not routinely perform baseline STI testing of individuals exposed through sexual assault; testing may be offered on a case-by-case basis. Clinicians should provide empiric treatment for gonococcal, chlamydial, and trichomonal infections. (A3)
Exposures in Children
  • Clinicians should recommend PEP to children reporting sexual assault as follows: (A2)
    • When the exposed child has experienced direct contact of the vagina, penis, anus, or mouth with the semen, vaginal fluids, or blood of an assailant, with or without physical injury, tissue damage, or presence of blood at the site of the assault.
    • When the exposed child’s broken skin or mucous membranes have been in contact with the blood, semen, or vaginal fluids of an assailant.
    • When the assaulted child has physical evidence of sexual abuse, even if the child is unable to report the details of the abuse.
  • Clinicians should recommend PEP for children who have visible blood from trauma, i.e., a bite has drawn blood. (A2)
  • Clinicians should perform baseline STI testing for children who may have been sexually assaulted because they may have experienced long-term, repetitive abuse. (A3)
  • Clinicians should provide empiric treatment for gonococcal, chlamydial, and trichomoniasis infections. (A3)
  • Clinicians should administer the first dose of the human papillomavirus (HPV) vaccine for children aged 9 to 17 years who have not yet been vaccinated. (A3)
  • Clinicians should provide prophylaxis for hepatitis B virus (HBV) exposure in a child if indicated (see the guideline section Management of Potential Exposure to HBV). (A1)
Box 3: Risk of HIV Transmission From a Source With HIV
Meaningful risk of transmission:

  • Blood
  • Semen
  • Vaginal secretions
  • Breast milk
  • Cerebrospinal, synovial, pleural, peritoneal, pericardial, and amniotic fluids
No meaningful risk of transmission:

  • Nonbloody saliva
  • Tears
  • Sweat
  • Nonbloody urine
  • Nonbloody feces

Occupational Exposure Risk Evaluation

PEP is indicated whenever an occupational exposure to blood, visibly bloody fluids, or other potentially infectious material occurs through percutaneous or mucocutaneous routes or through non-intact skin. Figure 2, below, illustrates the steps in determining whether ongoing PEP is indicated after the first emergency dose.

Occupational exposures for which PEP is indicated include the following:

  • Break in the skin by a sharp object (including hollow-bore, solid-bore, and cutting needles or broken glassware) that has been in the source’s blood vessel or is contaminated with blood, visibly bloody fluid, or other potentially infectious material.
  • Bite from a patient with visible bleeding in the mouth that causes bleeding in the exposed individual.
    • PEP is not indicated for an exposure to saliva, including from being spat on, in the absence of visible blood.
  • Splash of blood, visibly bloody fluid, or other potentially infectious material to the mouth, nose, or eyes.
  • A non-intact skin (e.g., dermatitis, chapped skin, abrasion, or open wound) exposure to blood, visibly bloody fluid, or other potentially infectious material.

Evaluation for other bloodborne pathogens: See the following sections of this guideline: Management of Potential Exposure to Hepatitis B Virus and Management of Potential Exposure to Hepatitis C Virus.

Figure 2: Occupational HIV Exposure: Post-Exposure Prophylaxis (PEP) and Exposure Management When Reported Within 72 Hours [Download full PDF]

Non-Occupational Exposure Risk Evaluation

In many cases of non-occupational exposure, the source is not available for testing. The HIV status of the source should not be the focus of the initial evaluation; determination of whether the exposure warrants PEP and, when indicated, prompt initiation of PEP, should be the focus. Figure 3, below, illustrates the steps in determining whether ongoing PEP is indicated after the first emergency dose.

KEY POINTS
  • The decision to recommend PEP is based on the nature of the exposure and not on the geographic location at which an assault occurred or the location of the source’s or the exposed individual’s residence.
  • When an individual presents for PEP, evaluation and PEP services should be delivered in combination with patient education, with a strong emphasis on prevention of future exposures [Golub, et al. 2008].

Risk of transmission: Box 1: Risk per 10,000 Exposures of Acquiring HIV From an Infected Source and Factors That Increase Risk, above, provides the risk of HIV infection following various types of non-occupational exposure to an individual known to have HIV and factors that may increase risk. HIV transmission occurs most frequently during sexual or drug use exposures; however, many factors can influence risk.

Exposure to a source with acute HIV: Due to the presence of high HIV viral load levels, the probability of transmission when the source is in the acute and early stage of HIV infection (first 6 months) is 8- to almost 12-fold higher than it is once a source’s viral set point has been established, typically about 6 months after infection [Pilcher, et al. 2004; Wawer, et al. 2005]. The presence of STIs in either the source or the exposed individual also increases risk of HIV transmission [Advisory Committee for HIV and STD Prevention 1998; Johnson and Lewis 2008; CDC 2017]. Conversely, transmission risk with sexual exposure is significantly decreased when a source is taking effective antiretroviral therapy (ART) and has an undetectable viral load [Cohen, et al. 2011] (see NYSDOH AI U=U Guidance for Implementation in Clinical Settings).

Box 4, below, lists non-occupational exposures that should prompt consideration of PEP and those that do not warrant PEP.

Box 4: Non-Occupational Exposure Risks and Indications for Post-Exposure Prophylaxis (PEP)
  • Higher-Risk: PEP is Recommended:
    • Receptive and insertive vaginal or anal intercourse [a].
    • Needle sharing [a].
    • Penetrating injury, such as a needlestick with a hollow-bore needle, with exposure to blood or other potentially infected fluids [a].
    • Bite with visible bleeding in the mouth that causes bleeding in the exposed individual.
  • Lower-Risk: Assess Factors that Increase Need for PEP:
    • Exposure: Oral-vaginal and oral-anal contact, receptive and insertive; receptive and insertive penile-oral contact, with or without ejaculation.
    • Factors that increase risk: 1) Source is known to have HIV with high viral load. 2) Non-intact oral mucosa, e.g., oral lesions, gingivitis, wounds. 3) Blood exposure—may be minimal and not recognized by the exposed individual; if frank blood exposure is reported, then PEP is indicated. 4) Presence of genital ulcer disease or other sexually transmitted infections.
  • PEP is Not Indicated [b]:
    • Kissing: Remote risk associated with open-mouthed kissing if blood is exchanged due to sores or bleeding gums [Kaplan and Heimer 1992].
    • Oral-to-oral contact in the absence of mucosal damage, e.g., mouth-to-mouth resuscitation.
    • Human bites not involving blood.
    • Exposure to solid-bore needles or sharps not in recent contact with blood: Examples of solid-bore needles include tattoo needles and lancets used to measure blood-sugar levels.
    • Mutual masturbation without skin breakdown or blood exposure.
    • Exposure to saliva, including if spat on, in the absence of visible blood.

 

  1. Source is known to have HIV or source’s HIV status is not known.
  2. See also NYSDOH AI U=U Guidance for Implementation in Clinical Settings.

A frank discussion between the clinician and an exposed individual regarding sexual activities, needle sharing, and other drug-using activities that have the potential for exposure to blood and other body fluids can help determine a patient’s need for PEP (see Boxes 1 and 4). The behaviors that confer the highest risk are needle sharing and receptive unprotected anal intercourse with an individual who has HIV [DeGruttola, et al. 1989; CDC 1997; Varghese, et al. 2002].

Clinicians should also assess factors that have been associated with increased risk of HIV infection, including:

  • Trauma at the site of exposure, especially if there was contact with blood, semen, or vaginal fluids.
  • Presence of genital ulcer disease or other STIs [LeGoff, et al. 2007; CDC 2017].
  • High plasma viral load in a source with HIV [Patterson, et al. 2002; Tovanabutra, et al. 2002].
  • Exposure in an uncircumcised male [Patterson, et al. 2002; Bailey, et al. 2007; Gray, et al. 2007].

Factors that may significantly decrease transmission of HIV include exposure to a source who is taking effective ART (see NYSDOH AI U=U Guidance for Implementation in Clinical Settings) or use of daily PrEP and use of condoms during sexual exposures [Weller and Davis 2002]. After consensual sexual exposures that meet NYSDOH U=U Guidance criteria in the source, there is no evidence to support the use of PEP by the exposed individual. Furthermore, there is no evidence that a 3-drug PEP regimen provides any additional benefit to an exposed individual who adheres to a daily PrEP regimen; consistent use of PrEP has been shown to be 99% effective when taken appropriately (see the NYSDOH AI guideline PrEP to Prevent HIV and Promote Sexual Health > PrEP Efficacy). Correct condom use is highly effective in preventing transmission of HIV; however, during the post-exposure evaluation, it often is not possible to reliably ascertain whether condoms were used correctly or whether breakage, slippage, or spillage occurred.

Evaluation for exposure to STIs other than HIV: Risk behaviors leading to HIV infection also confer risk or exposure to other STIs. Patients who present for PEP after a consensual sexual exposure should be evaluated for other STIs.

Baseline testing generally cannot detect STIs that were acquired as a result of the exposure, but it may detect infections present prior to the exposure that prompted the evaluation for PEP. Presentation for PEP provides an opportunity to screen individuals at risk of STIs and treat infections as indicated. High rates of concomitant STIs at the time of presentation for PEP have been found in men who have sex with men [Hamlyn, et al. 2006; Jamani, et al. 2013].

Routine empiric treatment for STIs is not recommended for consensual sexual exposures. Education about STI symptoms should be provided, and patients should be instructed to call their healthcare provider if symptoms occur. Follow-up STI screening should be considered at 2 weeks post exposure to definitively exclude STIs [Mayer, et al. 2008; Tosini, et al. 2010; Annandale, et al. 2012; Mayer, et al. 2012; Oldenburg, et al. 2015; Mayer, et al. 2017; McAllister, et al. 2017].

Evaluation for other bloodborne pathogens: See the following sections of this guideline: Management of Potential Exposure to Hepatitis B Virus and Management of Potential Exposure to Hepatitis C Virus.

Emergency contraception: For individuals who can but who do not desire to become pregnant, and who consent, emergency contraception should be initiated immediately. There are a range of methods (copper intrauterine device, levonorgestrel, and ulipristal acetate) that can be taken within 5 days of a sexual exposure. Of note, emergency contraception is not an abortifacient and will generally not disrupt an ongoing healthy pregnancy. For more information, see Bedsider: Emergency Contraception.

Figure 3: Non-Occupational HIV Exposure: Post-Exposure Prophylaxis and Management When Reported Within 72 Hours [Download full PDF]

Sexual Assault Exposure Risk Evaluation

The decision to recommend PEP to an individual who may have been exposed to HIV through sexual assault should not be based on the geographic location of the assault but rather on the nature of the exposure during the assault and the HIV status of the defendant, if known. Although the seroprevalence of HIV in different New York State communities may vary, the HIV status of an individual accused of sexual assault remains unknown until that individual has been tested.

KEY POINTS
  • The decision to offer PEP should be based on evaluation of the exposure, not on the perceived or assumed risk behavior of a defendant or the geographical location.
  • If a significant exposure has occurred during an assault, then PEP should be recommended.

Risk of HIV transmission: The risk of HIV transmission in sexual assault is greater due to the presence of genitorectal trauma, which may be present in as many as 50% to 85% of sexual assault patients [Sachs and Chu 2002; Jones, et al. 2009; Sommers, et al. 2012]. Studies on sexual assault document high rates of unprotected receptive anal intercourse (10% to 15%) and unprotected vaginal penetration (55% to 80%) [Draughon Moret, et al. 2016]. Studies also demonstrate a wide range (20% to 85%) of incidence of anogenital trauma [Riggs, et al. 2000; Grossin, et al. 2003; Jones, et al. 2003; Sugar, et al. 2004; Laitinen, et al. 2013; Larsen, et al. 2015]. In one study, 1% of men convicted of sexual assault in Rhode Island had HIV when entering prison [Di Giovanni, et al. 1991], higher than the general male population (0.3%).

The absence of visible trauma does not rule out sexual assault; microabrasions and bruising are common, and the appearance of these manifestations following sexual assault may be delayed. Oral trauma may also occur during sexual assault, with potential exposure to blood, semen, or vaginal fluids from the defendant, which may carry a potential risk for HIV exposure. Bites or trauma may be inflicted during an assault and are indications for prophylaxis if there is the possibility of contact with blood, semen, or vaginal fluids from the defendant. A bite from a source with visible bleeding in the mouth that causes bleeding in the exposed individual is an indication for PEP.

HIV testing of the sexual assault patient should be performed in the emergency department setting. HIV testing may be performed on excess blood specimens obtained in the emergency department for other reasons, but only if informed consent has been obtained. In the absence of a baseline HIV test result, it may not be possible to establish that the assault resulted in HIV infection if the patient is later confirmed to have HIV.

If PEP is initiated, then responsibility for monitoring and follow-up should be coordinated by the treating clinician. If the baseline screening HIV test is reactive, then the assault patient should continue the PEP regimen until the result is confirmed with a differentiation immunoassay or HIV RNA and linkage to care with an experienced HIV care provider has been made. If the patient is not under the care of a primary care clinician, the emergency department clinician who has obtained the HIV test is responsible for ensuring that the patient is informed of the result promptly. If HIV infection has been diagnosed, the PEP regimen may be altered by the HIV care provider or continued in this case as ART.

Every hospital that provides emergency treatment to a sexual assault patient must adhere to and fully document services provided, consistent with the following standards of professional practice and Public Health Law 2805-P:

  • Counsel sexual assault patients about options for emergency contraception to prevent pregnancy. Prompt access improves efficacy.
  • Provide sexual assault patients with written information about emergency contraception that has been prepared or approved by the NYSDOH.
  • Consider a urine pregnancy test to diagnose unplanned pregnancy, similar to STI screening in individuals who may be at risk. Inform the individual that a pregnancy test is being performed.

The following websites offer more information about the use of emergency contraception:

NEW YORK STATE LAW
  • If a sexual assault exposure is assessed as high-risk:
    • Provide a 7-day starter pack of medications if the patient is ≥18 years old.
    • Provide the full 28-day course of PEP medications if the patient is <18 years old.
    • Arrange a follow-up appointment with an experienced HIV care provider.
    • If the sexual assault patient is not able to make a timely decision about PEP, provide a starter pack and arrange for a follow-up appointment within 24 hours to review indications for PEP.
  • Notify the sexual assault patient, verbally and in writing, of their right to decline to provide private health insurance information for billing for a forensic rape examination.

STI prophylaxis: Clinicians should offer all sexual assault patients prophylactic medication to prevent gonorrheal and chlamydial infections and trichomoniasis. Rates of STIs have increased in all populations in the United States through a combination of increased incidence of infection and changes in diagnostic, screening, and reporting practices. Surveillance data for the United States indicate that between 2014 and 2018, rates increased for chlamydia (by 19%), gonorrhea (by 64%), primary and secondary syphilis (by 71%) and congenital syphilis(by 185%) [CDC 2018, 2019]. Trichomoniasis can be diagnosed or excluded in the emergency department if microscopy is available; otherwise, empiric treatment should be administered.

In cases of sexual assault, routine testing for gonorrhea, chlamydia, and syphilis is not recommended because test results would only determine whether the patient had an STI prior to the assault, and this information can be used to bias a jury against a survivor of sexual assault in court [NYSDOH 2020].

Evaluation for exposure to HBV: See guideline section Management of Potential Exposure to Hepatitis B Virus.

Evaluation for exposure to HCV: See guideline section Management of Potential Exposure to Hepatitis C Virus.

RESOURCES

Figure 4, below, illustrates the steps in determining whether ongoing PEP is indicated after the first emergency dose.

Figure 4: Sexual Assault HIV Exposure: Post-Exposure Prophylaxis and Exposure Management When Reported Within 72 Hours [Download full PDF]

Considerations for Sexual Assault in Children

Lead authors: Aracelis Fernandez, MD, with Lisa-Gaye Robinson, MD, and Ruby Fayorsey, MD, with the Medical Care Criteria Committee; June 2020

Care providers with experience in managing childhood sexual assault should assist in evaluating children who have been sexually assaulted to best assess the comprehensive needs of the child. Clinicians should assess children who are sexually assaulted for possible exposure to other STIs, including gonorrhea, syphilis, chlamydia, hepatitis B, hepatitis C, and trichomoniasis. Indications for laboratory evaluation and antimicrobial prophylaxis depend on the nature of the assault.

Once the initial, emergency dose of PEP has been administered, care for children exposed to HIV through sexual assault should be managed by a multidisciplinary team that includes the following:

  • Clinicians with expertise in providing care for children who have been sexually assaulted.
  • Child protective services, which are mandated by law to conduct an initial assessment and investigation of reported assault/abuse.
  • Law enforcement officials to gather and evaluate evidence.
  • Rape crisis counselors or advocates to provide support to the child and family.
  • Mental health workers to provide immediate services as needed and who can provide long-term follow-up of the child and family, if appropriate.

For more information, see The New York State Child Abuse Medical Provider Program > Education for Child Abuse Medical Providers.

Children who are sexually assaulted should be managed in an emergency department or other setting where appropriate resources are available to address the resulting medical, psychological, and legal issues. Children who present for care following sexual assault may have been victims of multiple exposures over time. PEP is indicated only for a sexual exposure that occurred within the 72 hours prior to the report of sexual assault. However, HIV testing may be indicated if a high-risk exposure occurred after the 72-hour cut-off for PEP efficacy.

For children who may have been exposed to HIV through sexual assault, the decision to continue PEP beyond the first emergency dose should be made based on the exposure evaluation; all sources of sexual exposure in children should be assumed to have HIV unless and until negative status can be confirmed. Clinicians should not delay initiating PEP in an exposed child pending results of the source’s HIV test.

KEY POINTS: SEXUAL ASSAULT IN CHILDREN
  • See NYSDOH Requirements to Report Instances of Suspected Child Abuse or Maltreatment.
  • Inquiries regarding child/adolescent sexual assault can be directed to: Child and Adolescent Sexual Assault Medical Protocol, Rape Crisis Program, NYSDOH, ESP Corning Tower, Albany, NY 12237. To request a copy of the protocol, call 518-474-3664.
  • Clinicians should ensure that the evaluation of and treatment for sexual assault of a child is managed by a multidisciplinary team that is experienced in the care of children who have been sexually assaulted.
  • Clinicians should ensure that a Sexual Assault Forensic Examiner who is trained to perform pediatric examinations is included on the team to assist in the medical examination, coordination of care, and discussions about treatment regimen. Clinicians should involve a rape crisis counselor and/or child advocacy team in all cases of sexual assault to assist the child and the family in dealing with the trauma and to assist with referrals.
SELECTED GOOD PRACTICE REMINDERS
All Exposures
  • Bites: If a bite exposure has been reported, evaluate the exposure in the biter and in the individual who was bitten. If an individual with bleeding in the mouth causes bleeding in someone who they have bitten, the bitten individual is a candidate for PEP.
  • If an exposure is assessed as high-risk: Inform the patient of the need to complete a 28-day course of PEP, confirm the patient’s access to the PEP medications, and provide a starter pack of medications.
  • Describe the signs and symptoms of acute retroviral syndrome: Stress the need for immediate medical attention if these symptoms occur, and provide the exposed individual with appropriate access to HIV testing that includes HIV RNA testing if indicated.
  • If an exposure is assessed as high-risk and completion of a 28-day PEP is indicated but declined:
    • Inform the exposed individual of the results of the source’s HIV test.
    • Explain the 72-hour window period for PEP efficacy.
    • Describe the symptoms of acute retroviral syndrome.
    • Provide contact information for access to medical care if the exposed individual decides to pursue PEP.
    • Provide a referral for counseling and trauma care.
    • Arrange for serial HIV testing.
    • Document refusal of PEP in the exposed individual’s medical record.
Non-Occupational Exposures
  • Comprehensive evaluation: Identify and assess all specific behaviors that may have resulted in exposure to HIV.
  • High-risk exposure: Provide counseling and educating about risk reduction, including the availability of PrEP. Individuals who report a high-risk sexual exposure are candidates for PrEP, immediately if PEP is not indicated or upon completion of PEP once a negative HIV status is confirmed. Provide a referral for PrEP care if it is not available on site.
Sexual Assault Exposures
References

Advisory Committee for HIV and STD Prevention. HIV prevention through early detection and treatment of other sexually transmitted diseases–United States. Recommendations of the Advisory Committee for HIV and STD prevention. MMWR Recomm Rep 1998;47(RR-12):1-24. [PMID: 9701544]

Annandale D, Richardson C, Fisher M, et al. Raltegravir-based post-exposure prophylaxis (PEP): a safe, well-tolerated alternative regimen. J Int AIDS Soc 2012;15 (Suppl 4):18165.

Bailey RC, Moses S, Parker CB, et al. Male circumcision for HIV prevention in young men in Kisumu, Kenya: a randomised controlled trial. Lancet 2007;369(9562):643-656. [PMID: 17321310

CDC. Transmission of HIV possibly associated with exposure of mucous membrane to contaminated blood. MMWR Morb Mortal Wkly Rep 1997;46(27):620-623. [PMID: 9218647

CDC. Sexually transmitted diseases (STDs): treatment and screening. 2017 Apr 19. https://www.cdc.gov/std/treatment/ [accessed 2017 Jun 30]

CDC. Sexually transmitted diseases (STDs): Sexually transmitted disease surveillance 2017. 2018 Sep. https://www.cdc.gov/std/stats17/2017-STD-Surveillance-Report_CDC-clearance-9.10.18.pdf [accessed 2021 Apr 14]

CDC. Sexually transmitted disease surveillance 2018. 2019. https://www.cdc.gov/std/stats18/default.htm [accessed 2020 May 24]

Cohen MS, Chen YQ, McCauley M, et al. Prevention of HIV-1 infection with early antiretroviral therapy. N Engl J Med 2011;365(6):493-505. [PMID: 21767103

DeGruttola V, Seage GR, 3rd, Mayer KH, et al. Infectiousness of HIV between male homosexual partners. J Clin Epidemiol 1989;42(9):849-856. [PMID: 2789269

Di Giovanni C, Jr, Berlin F, Casterella P, et al. Prevalence of HIV antibody among a group of paraphilic sex offenders. J Acquir Immune Defic Syndr 1991;4(6):633-637. [PMID: 2023104]

Draughon Moret JE, Hauda WE, 2nd, Price B, et al. Nonoccupational postexposure human immunodeficiency virus prophylaxis: Acceptance following sexual assault. Nurs Res 2016;65(1):47-54. [PMID: 26657480]

Golub SA, Rosenthal L, Cohen DE, et al. Determinants of high-risk sexual behavior during post-exposure prophylaxis to prevent HIV infection. AIDS Behav 2008;12(6):852-859. [PMID: 17682938

Gray RH, Kigozi G, Serwadda D, et al. Male circumcision for HIV prevention in men in Rakai, Uganda: a randomised trial. Lancet 2007;369(9562):657-666. [PMID: 17321311

Grossin C, Sibille I, Lorin de la Grandmaison G, et al. Analysis of 418 cases of sexual assault. Forensic Sci Int 2003;131(2-3):125-130. [PMID: 12590050]

Hamlyn E, McAllister J, Winston A, et al. Is screening for sexually transmitted infections in men who have sex with men who receive non-occupational HIV post-exposure prophylaxis worthwhile? Sex Transm Infect 2006;82(1):21-23. [PMID: 16461596

Jamani S, Gulholm T, Poynten IM, et al. Timing and frequency of chlamydia and gonorrhoea testing in a cross-sectional study of HIV postexposure prophylaxis recipients. Sex Transm Infect 2013;89(7):604-606. [PMID: 23698512

Johnson LF, Lewis DA. The effect of genital tract infections on HIV-1 shedding in the genital tract: a systematic review and meta-analysis. Sex Transm Dis 2008;35(11):946-959. [PMID: 18685546

Jones JS, Rossman L, Diegel R, et al. Sexual assault in postmenopausal women: epidemiology and patterns of genital injury. Am J Emerg Med 2009;27(8):922-929. [PMID: 19857408]

Jones JS, Rossman L, Hartman M, et al. Anogenital injuries in adolescents after consensual sexual intercourse. Acad Emerg Med 2003;10(12):1378-1383. [PMID: 14644791]

Kaplan EH, Heimer R. A model-based estimate of HIV infectivity via needle sharing. J Acquir Immune Defic Syndr 1992;5(11):1116-1118. [PMID: 1403641

Laitinen FA, Grundmann O, Ernst EJ. Factors that influence the variability in findings of anogenital injury in adolescent/adult sexual assault victims: a review of the forensic literature. Am J Forensic Med Pathol 2013;34(3):286-294. [PMID: 23835534]

Larsen ML, Hilden M, Lidegaard Ø. Sexual assault: a descriptive study of 2500 female victims over a 10-year period. BJOG 2015;122(4):577-584. [PMID: 25315463]

LeGoff J, Weiss HA, Gresenguet G, et al. Cervicovaginal HIV-1 and herpes simplex virus type 2 shedding during genital ulcer disease episodes. AIDS 2007;21(12):1569-1578. [PMID: 17630552

Mayer KH, Jones D, Oldenburg C, et al. Optimal HIV postexposure prophylaxis regimen completion with single tablet daily elvitegravir/cobicistat/tenofovir disoproxil fumarate/emtricitabine compared with more frequent dosing regimens. J Acquir Immune Defic Syndr 2017;75(5):535-539. [PMID: 28696345

Mayer KH, Mimiaga MJ, Cohen D, et al. Tenofovir DF plus lamivudine or emtricitabine for nonoccupational postexposure prophylaxis (NPEP) in a Boston Community Health Center. J Acquir Immune Defic Syndr 2008;47(4):494-499. [PMID: 18176318

Mayer KH, Mimiaga MJ, Gelman M, et al. Raltegravir, tenofovir DF, and emtricitabine for postexposure prophylaxis to prevent the sexual transmission of HIV: safety, tolerability, and adherence. J Acquir Immune Defic Syndr 2012;59(4):354-359. [PMID: 22267017

McAllister J, Towns JM, McNulty A, et al. Dolutegravir with tenofovir disoproxil fumarate-emtricitabine as HIV postexposure prophylaxis in gay and bisexual men. AIDS 2017;31(9):1291-1295. [PMID: 28301425

NYSDOH. Sexual Assault Forensic Examiner (SAFE) Program. 2020 Feb. https://www.health.ny.gov/professionals/safe/ [accessed 2020 Jun 12]

Oldenburg CE, Jain S, Mayer KH, et al. Post-exposure prophylaxis use and recurrent exposure to HIV among men who have sex with men who use crystal methamphetamine. Drug Alcohol Depend 2015;146:75-80. [PMID: 25482500

Patterson BK, Landay A, Siegel JN, et al. Susceptibility to human immunodeficiency virus-1 infection of human foreskin and cervical tissue grown in explant culture. Am J Pathol 2002;161(3):867-873. [PMID: 12213715

Pilcher CD, Tien HC, Eron JJ, Jr, et al. Brief but efficient: acute HIV infection and the sexual transmission of HIV. J Infect Dis 2004;189(10):1785-1792. [PMID: 15122514

Riggs N, Houry D, Long G, et al. Analysis of 1,076 cases of sexual assault. Ann Emerg Med 2000;35(4):358-362. [PMID: 10736122]

Sachs CJ, Chu LD. Predictors of genitorectal injury in female victims of suspected sexual assault. Acad Emerg Med 2002;9(2):146-151. [PMID: 11825841]

Sommers MS, Brown KM, Buschur C, et al. Injuries from intimate partner and sexual violence: Significance and classification systems. J Forensic Leg Med 2012;19(5):250-263. [PMID: 22687765]

Sugar NF, Fine DN, Eckert LO. Physical injury after sexual assault: findings of a large case series. Am J Obstet Gynecol 2004;190(1):71-76. [PMID: 14749638]

Tosini W, Muller P, Prazuck T, et al. Tolerability of HIV postexposure prophylaxis with tenofovir/emtricitabine and lopinavir/ritonavir tablet formulation. AIDS 2010;24(15):2375-2380. [PMID: 20729709

Tovanabutra S, Robison V, Wongtrakul J, et al. Male viral load and heterosexual transmission of HIV-1 subtype E in northern Thailand. J Acquir Immune Defic Syndr 2002;29(3):275-283. [PMID: 11873077

Unger ER, Fajman NN, Maloney EM, et al. Anogenital human papillomavirus in sexually abused and nonabused children: a multicenter study. Pediatrics 2011;128(3):e658-665. [PMID: 21844060]

Varghese B, Maher JE, Peterman TA, et al. Reducing the risk of sexual HIV transmission: quantifying the per-act risk for HIV on the basis of choice of partner, sex act, and condom use. Sex Transm Dis 2002;29(1):38-43. [PMID: 11773877

Wawer MJ, Gray RH, Sewankambo NK, et al. Rates of HIV-1 transmission per coital act, by stage of HIV-1 infection, in Rakai, Uganda. J Infect Dis 2005;191(9):1403-1409. [PMID: 15809897

Weller S, Davis K. Condom effectiveness in reducing heterosexual HIV transmission. Cochrane Database Syst Rev 2002;(1):CD003255. [PMID: 11869658

Figure 2: Occupational HIV Exposure: PEP and Exposure Management When Reported Within 72 Hours

Lead author: Elliot DeHaan, MD, with the Medical Care Criteria Committee; November 2021

Download figure PDF

Figure 3: Non-Occupational HIV Exposure: PEP and Management When Reported Within 72 Hours

Lead author: Elliot DeHaan, MD, with the Medical Care Criteria Committee; November 2021

Download figure PDF

Figure 4: Sexual Assault HIV Exposure: PEP and Exposure Management When Reported Within 72 Hours

Lead author: Elliot DeHaan, MD, with the Medical Care Criteria Committee; November 2021

Download figure PDF