Risk of Infection Following an Exposure to HIV

Lead author: Elliot DeHaan, MD, with the Medical Care Criteria Committee, June 2020

Factors that increase the risk of transmission: Many factors that contribute to HIV infection are shared by the 4 PEP scenarios outlined below. HIV transmission risk depends on the viral load of the source with HIV and the type of exposure [Sultan, et al. 2014]. Factors that increase the risk of HIV transmission include early- and late-stage untreated HIV infection and a high level of HIV RNA in the blood [Cardo, et al. 1997], the presence of genital or anorectal ulcers from sexually transmitted infections (STIs), and direct blood-to-blood exchange, such as syringe sharing during injection drug use [Kaplan and Heimer 1992; Blank 2005; Johnson and Lewis 2008; Mayer and Venkatesh 2011; Wall, et al. 2017].

Factors that decrease the risk of HIV transmission: Similarly, across the 4 PEP scenarios, there are shared factors that decrease the risk of HIV infection. HIV transmission risk is low and often negligible when the source of the exposure has a low or undetectable viral load [Rodger, et al. 2016; Rodger, et al. 2019] and is lower if the source is circumcised (if a cis-gender male and the circumcision is healed) [Auvert, et al. 2005; Bailey, et al. 2007; Gray, et al. 2007] or is taking antiretroviral medications as pre-exposure prophylaxis (PrEP) [Grant, et al. 2010; Baeten, et al. 2012]. In the context of sexual exposure, there is a robust body of evidence that individuals do not sexually transmit HIV if they are taking antiretroviral therapy (ART) and have an undetectable viral load (HIV RNA <200 copies/mL); see NYSDOH AI U=U Guidance for Implementation in Clinical Settings. Data are insufficient to make recommendations regarding HIV transmission via breastfeeding.

References

Auvert B, Taljaard D, Lagarde E, et al. Randomized, controlled intervention trial of male circumcision for reduction of HIV infection risk: the ANRS 1265 Trial. PLoS Med 2005;2(11):e298. [PMID: 16231970]

Baeten J, Donnell D, Ndase P, et al. Antiretroviral prophylaxis for HIV prevention in heterosexual men and women. N Engl J Med 2012;367(5):399-410. [PMID: 22784037]

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]

Blank S. Ulcerating STDs and HIV: A cause for concern. 2005 Jun. https://www.prn.org/index.php/coinfections/article/ulcerating_stds_and_hiv_79 [accessed 2020 Jun 1]

Cardo DM, Culver DH, Ciesielski CA, et al. A case-control study of HIV seroconversion in health care workers after percutaneous exposure. Centers for Disease Control and Prevention Needlestick Surveillance Group. N Engl J Med 1997;337(21):1485-1490. [PMID: 9366579]

Grant RM, Lama JR, Anderson PL, et al. Preexposure chemoprophylaxis for HIV prevention in men who have sex with men. N Engl J Med 2010;363(27):2587-2599. [PMID: 21091279]

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]

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]

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]

Mayer KH, Venkatesh KK. Interactions of HIV, other sexually transmitted diseases, and genital tract inflammation facilitating local pathogen transmission and acquisition. Am J Reprod Immunol 2011;65(3):308-316. [PMID: 21214660]

Rodger AJ, Cambiano V, Bruun T, et al. Risk of HIV transmission through condomless sex in serodifferent gay couples with the HIV-positive partner taking suppressive antiretroviral therapy (PARTNER): final results of a multicentre, prospective, observational study. Lancet 2019;393(10189):2428-2438. [PMID: 31056293]

Rodger AJ, Cambiano V, Bruun T, et al. Sexual activity without condoms and risk of HIV transmission in serodifferent couples when the HIV-positive partner is using suppressive antiretroviral therapy. JAMA 2016;316(2):171-181. [PMID: 27404185]

Sultan B, Benn P, Waters L. Current perspectives in HIV post-exposure prophylaxis. HIV AIDS (Auckl) 2014;6:147-158. [PMID: 25368534]

Wall KM, Kilembe W, Vwalika B, et al. Risk of heterosexual HIV transmission attributable to sexually transmitted infections and non-specific genital inflammation in Zambian discordant couples, 1994-2012. Int J Epidemiol 2017;46(5):1593-1606. [PMID: 28402442]

Occupational Exposure Risk

Lead author: Elliot DeHaan, MD, with the Medical Care Criteria Committee, June 2020

The risk of HIV transmission in a healthcare setting has been reported as 0.3% through percutaneous exposure to the blood of a source with HIV [Cardo, et al. 1997] and 0.09% after a mucous membrane exposure [Kuhar, et al. 2013]. In the Centers for Disease Control and Prevention (CDC) Needlestick Surveillance Group study, use of zidovudine (as post-exposure prophylaxis [PEP]) by healthcare workers reduced the risk of HIV acquisition by 81% overall for percutaneous exposures [Cardo, et al. 1997]. With the use of potent antiretroviral (ARV) medications that have increased bioavailability, it is presumed the use of a 3-drug PEP regimen would significantly reduce this risk further.

In the current era of increasing viral suppression in patients with HIV, early and appropriate PEP initiation, and improved infection control protocols, these rates may be lower. In one cohort of 266 healthcare workers who had percutaneous or mucocutaneous injuries and exposure to HIV-contaminated body fluids, there were zero seroconversions over a 13-year period (seroconversion rate 0%). In addition to their internal findings, the authors compared their results to a calculated overall HIV seroconversion rate of 0.13% after a literature review conducted in October 2016 yielded 17 articles that documented 10 seroconversions among 7,652 healthcare-related exposures [Nwaiwu, et al. 2017].

The mean risk may be significantly higher in cases of percutaneous exposure in which more than 1 risk factor is present (e.g., in individuals who incur a deep injury with a hollow-bore needle from a source with HIV and a high viral load). Although the effect of viral load level has not been studied in the patients with occupational exposures, there is evidence that the probability of sexually transmitting HIV is correlated with the source’s HIV viral load [Quinn, et al. 2000; Modjarrad, et al. 2008; Attia, et al. 2009]. 

Prevention of occupational exposure: As part of the employer’s plan to prevent transmission of bloodborne pathogens, the following measures can be taken to avoid injuries:

  • Eliminate unnecessary use of needles and other sharps.
  • Ensure use of and compliance with devices with safety features.
  • Eliminate needle recapping.
  • Ensure safe handling and prompt disposal of needles in containers for sharps disposal.
  • Provide ongoing education about and promote safe work practices for handling needles and other sharps.

For more information about prevention of needlestick injuries, refer to the NIOSH Alert: Preventing Needlestick Injuries in Health Care Settings [National Institute for Occupational Safety and Health 1999].

RESOURCES

Even when effective prevention measures are implemented, exposures to blood and bodily fluid still occur. Employers of personnel covered by the OSHA Bloodborne Pathogen Standard are obligated to provide post-exposure care, including prophylaxis, at no cost to the employee. The employer may subsequently attempt to obtain reimbursement from Workers’ Compensation. See Employer Responsibilities in Management of Post-Exposure Prophylaxis (PEP) to Prevent HIV Infection Following an Occupational Exposure for more information.

References

Attia S, Egger M, Muller M, et al. Sexual transmission of HIV according to viral load and antiretroviral therapy: systematic review and meta-analysis. AIDS 2009;23(11):1397-1404. [PMID: 19381076]

Cardo DM, Culver DH, Ciesielski CA, et al. A case-control study of HIV seroconversion in health care workers after percutaneous exposure. Centers for Disease Control and Prevention Needlestick Surveillance Group. N Engl J Med 1997;337(21):1485-1490. [PMID: 9366579]

Kuhar DT, Henderson DK, Struble KA, et al. Updated US Public Health Service guidelines for the management of occupational exposures to human immunodeficiency virus and recommendations for postexposure prophylaxis. Infect Control Hosp Epidemiol 2013;34(9):875-892. [PMID: 23917901]

Modjarrad K, Chamot E, Vermund SH. Impact of small reductions in plasma HIV RNA levels on the risk of heterosexual transmission and disease progression. AIDS 2008;22(16):2179-2185. [PMID: 18832881]

National Institute for Occupational Safety and Health. Preventing needlestick injuries in health care settings. Publication no. 2000-108. 1999 Nov. https://www.cdc.gov/niosh/docs/2000-108/ [accessed 2017 Jul 5]

Nwaiwu CA, Egro FM, Smith S, et al. Seroconversion rate among health care workers exposed to HIV-contaminated body fluids: The University of Pittsburgh 13-year experience. Am J Infect Control 2017;45(8):896-900. [PMID: 28449921]

Quinn TC, Wawer MJ, Sewankambo N, et al. Viral load and heterosexual transmission of human immunodeficiency virus type 1. Rakai Project Study Group. N Engl J Med 2000;342(13):921-929. [PMID: 10738050]

Non-Occupational Exposure Risk

Lead author: Elliot DeHaan, MD, with the Medical Care Criteria Committee, June 2020

Box 1: Risk per 10,000 Exposures of Acquiring HIV From an Infected Source and Factors That Increase Risk

Modified from the Centers for Disease Control and Prevention [CDC 2015].

Parenteral Exposure Risk:

  • Needle sharing during injection drug use: 63
  • Percutaneous (needlestick): 23

Factors that increase risk of transmission through parenteral exposure:

  • Hollow-bore needle
  • Deep injury (penetration)
  • Needle placed in an artery or vein [Cardo, et al. 1997]
  • Presence of blood on needle; however, risk through exposure to dried blood on discarded needles is extremely low [Zamora, et al. 1998].

Sexual Exposure Risk:

  • Receptive anal intercourse: 138
    [European Study Group on Heterosexual Transmission of HIV 1992; Varghese, et al. 2002; Patel, et al. 2014]
  • Receptive penile-vaginal intercourse: 8
    [European Study Group on Heterosexual Transmission of HIV 1992; Leynaert, et al. 1998; Varghese, et al. 2002]
  • Insertive anal intercourse: 11
    [European Study Group on Heterosexual Transmission of HIV 1992; Varghese, et al. 2002]
  • Insertive penile-vaginal intercourse: 4
    [European Study Group on Heterosexual Transmission of HIV 1992; Varghese, et al. 2002]
  • Oral sex: Low. HIV transmission has been documented, but rarely. Accurate estimates of risk are not available. It is prudent to consider non-occupational PEP for receptive oral sex with ejaculation, although discussion about the low risk should occur [Page-Shafer, et al. 2002; Varghese, et al. 2002].

Factors that increase risk of transmission through sexual exposure:

  • Source with known HIV who is not taking ART or has incomplete viral suppression; risk of transmission increases with higher source HIV viral load levels [Quinn, et al. 2000; Tovanabutra, et al. 2002], most notably during acute HIV infection, when the probability of transmission is 8- to almost 12-fold higher than exposures that take place after the viral set point is established [Pilcher, et al. 2004; Wawer, et al. 2005].
  • Absence of barrier protection, such as male/insertive or female/receptive condoms.
  • Presence of genital ulcer disease or other STIs [LeGoff, et al. 2007; CDC 2017].
  • Trauma at the site of exposure.
  • Blood exposure, which can be minimal and therefore not recognized by the exposed individual; if the exposed individual reports frank blood exposure, PEP is indicated.
  • Lack of male circumcision [Bailey, et al. 2007; Gray, et al. 2007].
  • Non-intact oral mucosa (e.g., oral lesions, gingivitis, wounds) in oral sexual exposure.

Other Exposure Types:

  • Biting: Negligible
    [Richman and Rickman 1993; Pretty, et al. 1999; Bartholomew and Jones 2006; Cresswell, et al. 2018]
  • Spitting: Negligible
    [Cresswell, et al. 2018]
  • Throwing bodily fluids, including semen or saliva: Negligible
  • Sharing sex toys: Negligible

Factors that increase risk of transmission through other exposures:

  • Source with high HIV viral load [Quinn, et al. 2000; Tovanabutra, et al. 2002].
  • Activity involving exposure to blood.

Sexual exposures (consensual): Exposures that may prompt a request for non-occupational PEP include condom slippage or breakage; lapse in condom use by serodiscordant or unknown status partners; or other episodic exposure to blood or other potentially infectious body fluids, including semen, vaginal secretions, or body fluids with visible blood contamination. In addition to the viral load of a source with HIV, other factors that influence transmission and acquisition risk include [Sultan, et al. 2014]:

  • Genitorectal trauma.
  • Type of sexual exposure, i.e., receptive anal, receptive vaginal, insertive anal, insertive vaginal, receptive oral.
  • Presence of STIs and genital/anal ulcers.
  • Circumcision status.

Condomless receptive anal sex with and without ejaculation carries a risk of 1.43% and 0.65%, respectively. Condomless insertive anal intercourse carries a risk of 0.62% in uncircumcised men and 0.11% in circumcised men [Jin, et al. 2010]. In one European study, the risk associated with condomless receptive and insertive vaginal intercourse was 0.08% and 0.04%, respectively [Mastro and de Vincenzi 1996]. Information for patients is available about correct male (insertive) and female (receptive) condom use.

Needle sharing and needlestick injuries: Needle sharing among injection drug users is a common reason to request PEP, as the associated risk has been estimated to be as high as 63 per 10,000 exposures based on a study among injection drug users in Thailand [Hudgens, et al. 2001; Hudgens, et al. 2002]. For this reason, PEP should always be considered in this scenario provided the potential exposure was within 72 hours.

Another route of exposure that prompts requests for PEP is needlestick injury in the community. Factors associated with risk from needlestick injuries include the potential source of the needle, type of needle, presence of blood, and skin penetration.

Individuals who incur needlestick injuries from discarded needles are often concerned about potential HIV exposure. Consideration of potential risk from discarded needles should include the prevalence of HIV in the community or facility where the exposure occurred and the prevalence of injection drug use in the surrounding area. However, the risk of HIV transmission through exposure to dried blood found on syringes is extremely low [Zamora, et al. 1998]. Discarded needles should not be tested for HIV because of low yield and the risk of injury to personnel involved in the testing.

Vaccination to prevent tetanus and administration of hepatitis B vaccine are indicated for needlestick injures resulting in puncture wounds, based on immunization history and hepatitis B virus status of the source [Bader and McKinsey 2013; Stobart-Gallagher 2017]. Hepatitis B immunoglobulin may also be necessary (see the guideline sections Management of Potential Exposure to Hepatitis B Virus and Management of Potential Exposure to Hepatitis C Virus).

Bite wounds: An estimated 250,000 human bites occur annually in the United States in a variety of settings [American Academy of Pediatrics 1997]. Although possible, HIV transmission through bites is thought to be extremely rare. Though many reported instances of bites have occurred, few cases of associated HIV infection have been established. Cases of possible HIV transmission have been documented following bites in adults exposed to blood-tinged saliva [Vidmar, et al. 1996; Pretty, et al. 1999]. A systematic review found no cases of HIV transmission through spitting and 9 possible cases of HIV transmission through a bite (6 occurred between family members, and 2 involved untrained first responders who placed their fingers in the mouth of an individual who is experiencing a seizure). Only 4 of the 9 cases were confirmed or classified as highly plausible [Cresswell, et al. 2018].

A bite wound that results in blood exposure should prompt consideration of PEP. When a human bite occurs, it is possible for both the individual who was bitten and the biter to incur blood exposure (see scenarios listed below). Use of PEP in such a case may be indicated if there is significant exposure to deep, bloody wounds. A bite is not considered a risk exposure to either party when the integrity of the skin is not disrupted.

Scenarios in which bites may result in blood exposure:

  • Blood exposure to the biter: When the biter inflicts a wound that breaks the skin and blood from the bitten individual enters the biter’s mouth.
  • Blood exposure to the bitten individual: When the biter has blood in his or her mouth (e.g., from bleeding gums or lesions) and inflicts a wound that breaks the skin of the individual bitten.
  • Blood exposure to both parties: A break in the skin of the individual who was bitten and the biter has blood in his/her mouth (e.g., from bleeding gums or lesions).

Prevention of non-occupational exposure: Transmission of HIV can be prevented through use of condoms and safer drug injection techniques. HIV infection can be prevented with use of antiretroviral medications as PrEP to protect an individual who engages in behaviors that may result in exposure to HIV. See the NYSDOH AI guideline PrEP to Prevent HIV and Promote Sexual Health > Candidates for PrEP. “Treatment as prevention (TasP)” and “undetectable equals untransmittable (U=U)” are evidence-based strategies for greatly reducing the risk of HIV transmission through sexual exposure; see in NYSDOH AI U=U Guidance for Implementation in Clinical Settings.

References

American Academy of Pediatrics. Hepatitis B. 1997 Red Book: The Report of the Committee on Infectious Diseases. Elk Grove Village: American Academy of Pediatrics; 1997.

Bader MS, McKinsey DS. Postexposure prophylaxis for common infectious diseases. Am Fam Physician 2013;88(1):25-32. [PMID: 23939603]

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]

Bartholomew CF, Jones AM. Human bites: a rare risk factor for HIV transmission. AIDS 2006;20(4):631-632. [PMID: 16470132]

Cardo DM, Culver DH, Ciesielski CA, et al. A case-control study of HIV seroconversion in health care workers after percutaneous exposure. Centers for Disease Control and Prevention Needlestick Surveillance Group. N Engl J Med 1997;337(21):1485-1490. [PMID: 9366579]

CDC. HIV risk behaviors. 2015 Dec 4. https://www.cdc.gov/hiv/risk/estimates/riskbehaviors.html [accessed 2018 Feb 22]

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

Cresswell FV, Ellis J, Hartley J, et al. A systematic review of risk of HIV transmission through biting or spitting: implications for policy. HIV Med 2018. [PMID: 29687590]

European Study Group on Heterosexual Transmission of HIV. Comparison of female to male and male to female transmission of HIV in 563 stable couples. European Study Group on Heterosexual Transmission of HIV. BMJ 1992;304(6830):809-813. [PMID: 1392708]

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]

Hudgens MG, Longini IM, Jr, Halloran ME, et al. Estimating the transmission probability of human immunodeficiency virus in injecting drug users in Thailand. J Royal Stat Soc Series C (Appl Stat) 2001;50(1):1-14.

Hudgens MG, Longini IM, Jr, Vanichseni S, et al. Subtype-specific transmission probabilities for human immunodeficiency virus type 1 among injecting drug users in Bangkok, Thailand. Am J Epidemiol 2002;155(2):159-168. [PMID: 11790680]

Jin F, Jansson J, Law M, et al. Per-contact probability of HIV transmission in homosexual men in Sydney in the era of HAART. AIDS 2010;24(6):907-913. [PMID: 20139750]

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]

Leynaert B, Downs AM, de Vincenzi I. Heterosexual transmission of human immunodeficiency virus: variability of infectivity throughout the course of infection. European Study Group on Heterosexual Transmission of HIV. Am J Epidemiol 1998;148(1):88-96. [PMID: 9663408]

Mastro TD, de Vincenzi I. Probabilities of sexual HIV-1 transmission. AIDS 1996;10 Suppl A:S75-82. [PMID: 8883613]

Page-Shafer K, Shiboski CH, Osmond DH, et al. Risk of HIV infection attributable to oral sex among men who have sex with men and in the population of men who have sex with men. AIDS 2002;16(17):2350-2352. [PMID: 12441814]

Patel P, Borkowf CB, Brooks JT, et al. Estimating per-act HIV transmission risk: a systematic review. AIDS 2014;28(10):1509-1519. [PMID: 24809629]

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]

Pretty IA, Anderson GS, Sweet DJ. Human bites and the risk of human immunodeficiency virus transmission. Am J Forensic Med Pathol 1999;20(3):232-239. [PMID: 10507789]

Quinn TC, Wawer MJ, Sewankambo N, et al. Viral load and heterosexual transmission of human immunodeficiency virus type 1. Rakai Project Study Group. N Engl J Med 2000;342(13):921-929. [PMID: 10738050]

Richman KM, Rickman LS. The potential for transmission of human immunodeficiency virus through human bites. J Acquir Immune Defic Syndr (1988) 1993;6(4):402-406. [PMID: 8455145]

Stobart-Gallagher MA. Needle-stick Guideline. 2017 Oct 13. https://emedicine.medscape.com/article/784812-overview [accessed 2018 Jun 14]

Sultan B, Benn P, Waters L. Current perspectives in HIV post-exposure prophylaxis. HIV AIDS (Auckl) 2014;6:147-158. [PMID: 25368534]

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]

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]

Vidmar L, Poljak M, Tomazic J, et al. Transmission of HIV-1 by human bite. Lancet 1996;347(9017):1762. [PMID: 8656918]

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]

Zamora AB, Rivera MO, Garcia-Algar O, et al. Detection of infectious human immunodeficiency type 1 virus in discarded syringes of intravenous drug users. Pediatr Infect Dis J 1998;17(7):655-657. [PMID: 9686738]

Sexual Assault Exposure Risk

Lead author: Elliot DeHaan, MD, with the Medical Care Criteria Committee, June 2020

Statistics on sexual assault in the United States show high rates of attempted or completed rape among several populations, including cisgender women, men, children, and transgender individuals:

  • 21.3% of women reported attempted or completed rape* in their lifetime, with the first assault occurring [Smith, et al. 2018]:
    • Before age 18 years in 43.2% (~11 million)
    • Between the ages of 11 and 17 years in 30.5% (~7.8 million)
    • At age 10 or younger in 12.7% (~3.2 million)
  • 1.4% of men reported attempted or completed rape in their lifetime, with their first experience1 occurring [Smith, et al. 2018]:
    • Before age 18 years in 26% (~2 million)
    • Between the ages of 11 and 17 years in 19.2% (~1.5 million).
  • 26% of women and 15% of men who were victims of sexual violence, physical violence, or stalking by an intimate partner in their lifetime first experienced these or other forms of violence by that partner before age 18 years [CDC 2019].
  • 10% of 27,715 respondents to the 2015 U.S. Transgender Survey reported that they had been sexually assaulted in the 12 months prior to survey completion; 47% reported that they had experienced sexual assault during the course of their lives. [James, et al. 2016].

*See How NISVS Measured Sexual Violence for definitions. Smith SG, Zhang X, Basile KC, et al. National Intimate Partner and Sexual Violence Survey: 2015 Data Brief – Updated Release. 2018 Nov. https://www.cdc.gov/violenceprevention/pdf/2015data-brief508.pdf [accessed 2019 Mar 11].

Risk of HIV infection: Increased risk of infection in cases of sexual assault has been associated with trauma at the site of exposure and absence of barrier protection:

  • Genitorectal trauma has been documented in 50% to 85% of sexual assault patients [Sachs and Chu 2002; Jones, et al. 2009; Sommers, et al. 2012], and anogenital trauma has been observed in 20% to 85% [Riggs, et al. 2000; Grossin, et al. 2003; Jones, et al. 2003; Sugar, et al. 2004; Laitinen, et al. 2013; Larsen, et al. 2015].
  • High rates of unprotected receptive anal intercourse (88%) and vaginal penetration (>60%) have been reported [Draughon Moret, et al. 2016]. Perpetrators of intimate partner violence are not likely to use condoms (or use condoms inconsistently), are likely to force sexual intercourse without a condom and to have sexual intercourse with other partners [Raj, et al. 2006; Casey, et al. 2016; Stephenson and Finneran 2017].

PEP is the only proven method of reducing HIV acquisition after exposure, and it should be offered in cases of sexual assault. There are published reports of HIV seroconversion following sexual assault [Murphy, et al. 1989; Claydon, et al. 1991; Albert, et al. 1994; Myles, et al. 2000].

References

Albert J, Wahlberg J, Leitner T, et al. Analysis of a rape case by direct sequencing of the human immunodeficiency virus type 1 pol and gag genes. J Virol 1994;68(9):5918-5924. [PMID: 7520096]

Casey EA, Querna K, Masters NT, et al. Patterns of Intimate Partner Violence and Sexual Risk Behavior among Young Heterosexually Active Men. J Sex Res 2016;53(2):239-250. [PMID: 26158212]

CDC. Violence prevention: Preventing teen dating violence. 2019 Mar 12. https://www.cdc.gov/violenceprevention/intimatepartnerviolence/teendatingviolence/fastfact.html [accessed 2019 Jul 3]

Claydon E, Murphy S, Osborne EM, et al. Rape and HIV. Int J STD AIDS 1991;2(3):200-201. [PMID: 1863649]

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]

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]

James SE, Herman JL, Rankin S, et al. The Report of the 2015 U.S. Transgender Survey. 2016 Dec. https://transequality.org/sites/default/files/docs/usts/USTS-Full-Report-Dec17.pdf [accessed 2018 Apr 25]

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]

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]

Murphy S, Kitchen V, Harris JR, et al. Rape and subsequent seroconversion to HIV. BMJ 1989;299(6701):718. [PMID: 2508885]

Myles JE, Hirozawa A, Katz MH, et al. Postexposure prophylaxis for HIV after sexual assault. JAMA 2000;284(12):1516-1518. [PMID: 11000643]

Raj A, Santana MC, La Marche A, et al. Perpetration of intimate partner violence associated with sexual risk behaviors among young adult men. Am J Public Health 2006;96(10):1873-1878. [PMID: 16670216]

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]

Smith SG, Zhang X, Basile KC, et al. National Intimate Partner and Sexual Violence Survey: 2015 Data Brief – Updated Release. 2018 Nov. https://www.cdc.gov/violenceprevention/pdf/2015data-brief508.pdf [accessed 2019 Mar 11]

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]

Stephenson R, Finneran C. Receipt and perpetration of intimate partner violence and condomless anal intercourse among gay and bisexual men in Atlanta. AIDS Behav 2017;21(8):2253-2260. [PMID: 28176169]

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]

Exposure Risk in Children

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

Although there is evidence to support HIV prophylaxis for perinatal exposure, there are no randomized clinical trials of PEP in children beyond the perinatal period. Types of exposures that may be reported in children include sexual assault, needlesticks, or bite from a child who has HIV, but as noted below, this last type of exposure is no longer likely to occur.

Biting: Biting is a common occurrence among young children and in daycare settings. The levels of HIV detected in saliva alone are very low. The few documented cases of possible HIV transmission following bites occurred in adults exposed to blood-tinged saliva [Vidmar, et al. 1996; Pretty, et al. 1999; Andreo, et al. 2004]. As mentioned previously, a recent systematic review found no cases of HIV transmission through spitting and 9 possible cases of transmission through biting [Cresswell, et al. 2018]. A bite is not considered a risk exposure to either party when the integrity of the skin is not disrupted. Because there are so few children with HIV now, it is unlikely that a child would be the source of an HIV exposure.

Sexual abuse: HIV transmission has been described in children who have been sexually abused, and this abuse was identified as the only risk factor for infection [Gellert, et al. 1993; Lindegren, et al. 1998]. Children might be at increased risk of becoming infected with HIV due to the cervical ectopy in adolescent girls and to the thinness of the vaginal epithelium in prepubertal girls [Kleppa, et al. 2015]. In addition, children who experience abuse multiple times over an extended period by the same perpetrator are at increased risk due to mucosal trauma with bleeding [Dominguez 2000; Smith, et al. 2005; CDC 2016].

Discarded needles: Risk of transmission from discarded needles is thought to be low. In 2 cohorts of children (1 with 59 children and the other with 249) exposed to needlesticks from discarded needles, there was no HIV transmission [American Academy of Pediatrics 1999]. HIV could not be isolated from the washings of 28 discarded needles from public places and 10 needles collected from a needle exchange program [American Academy of Pediatrics 1999]. In a Canadian study evaluating 274 pediatric community-acquired needlestick injuries, only 30% of those exposed received PEP, but there were no seroconversions in 189 children tested for HIV after 6 months [Papenburg, et al. 2008]. These studies, as well as the intolerance of HIV to environmental conditions through exposure to air over time, provide reassuring data regarding the low risk of transmission from this type of exposure. (See Table 1: Baseline Testing Based on Age of Exposed Individual and Type of Exposure and Table 6: Recommended Monitoring after Post-Exposure Prophylaxis Initiation for recommendations regarding laboratory testing, including for hepatitis C virus, based on type of exposure.)

KEY POINTS
  • Exposures that DO NOT warrant PEP: Kissing, spitting, oral-to-oral contact in the absence of mucosal damage (e.g., mouth-to-mouth resuscitation); human bites not involving blood; exposure to needles or sharps that have not been in contact with an individual with or at risk of HIV.
  • Exposures for which PEP should be considered (promptly): Condomless vaginal or anal intercourse during sexual abuse; oral sex with ejaculation or blood exposure during sexual abuse; injuries with exposure to blood from a source known to have HIV; injuries with exposure to blood from a source of unknown HIV status (including needlesticks and human bites).
References

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Andreo SM, Barra LA, Costa LJ, et al. HIV type 1 transmission by human bite. AIDS Res Hum Retroviruses 2004;20(4):349-350. [PMID: 15157352]

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