Teen sexual assault survivors seldom complete HIV prevention therapy

Fewer than one-half of adolescent sexual assault survivors who are prescribed medications to prevent contraction of human immunodeficiency virus (HIV) may return for follow-up visits and only about 15 percent complete the therapy, according to a report in the July issue of Archives of Pediatrics & Adolescent Medicine, one of the JAMA/Archives journals.

As many as 10 percent of adolescent females experience sexual assault in their lifetimes, according to background information in the article. The risk of contracting HIV after a single exposure is low, but transmission has been reported after sexual assault. National guidelines published in 2005 recommend that physicians consider prescribing a 28-day course of antiviral medications after sexual assault to reduce the risk of contracting HIV, an extension of a practice first used by health care workers exposed to the virus by needle sticks.

Elyse Olshen, M.D., M.P.H., then at Boston University School of Medicine and now at Columbia University Medical Center, New York, and colleagues reviewed the charts of 145 adolescents ages 12 to 22 years who visited one of two pediatric emergency departments in Boston within 72 hours of a sexual assault. During the years of the study--2001 to 2003--both academic medical centers followed protocols directing that medications to prevent HIV be considered on a case-by-case basis following sexual assault and that adolescents prescribed these therapies visit their primary care providers or follow-up clinics for continuing treatment.

Of the 145 adolescents, 129 (89 percent) were offered prophylactic (preventive) therapy and 110 (76 percent) agreed to take it. Of the 86 of those 110 who were referred for follow-up treatment at one of the two hospitals in the study, only 37 (38 percent) returned for at least one follow-up visit and 13 (15 percent) completed the full 28 days of prophylactic therapy.

The results highlight the difficulties associated with prescribing such therapies to adolescent sexual assault survivors, including the challenge of determining which survivors should receive a prescription. "In many cases of adolescent sexual assault, the risks of HIV transmission cannot be determined," the authors write. "Among patients in our study, 21 percent reported having blacked out during the assault, 54 percent were unsure whether ejaculation had occurred and 27 percent were unsure whether a condom had been used." In addition, many teen sexual assault survivors also have psychiatric conditions that may decrease the likelihood that they will adhere to prophylactic therapy.

"We agree with published recommendations that postexposure prophylaxis be offered to adolescent sexual assault survivors for exposures that pose a risk of HIV transmission," the authors conclude. "Patient education and a comprehensive follow-up system with extensive outreach and case management are necessary to encourage postexposure prophylaxis adherence and return for follow-up care among adolescent sexual assault survivors."

(Arch Pediatr Adolesc Med. 2006;160:674-680. Available pre-embargo to the media at www.jamamedia.org.)

Editor's Note: This study was supported by the Aerosmith Endowment Fund for the Prevention and Treatment of HIV, Leadership Education in Adolescent Health Project, Maternal and Child Health Bureau, U.S. Department of Health and Human Services, and the Boston University School of Medicine Summer Research Scholarship Program.

Editorial: Use HIV Preventive Therapy Judiciously

Given the lack of adherence to HIV prophylactic therapy demonstrated in this and other studies, the risks of viral resistance associated with failure to finish the course of treatment may outweigh the benefits of these medications for many adolescent sexual assault victims, writes Jonathan M. Ellen, M.D., The Johns Hopkins School of Medicine, in an accompanying editorial.

"Although the saliency of HIV is great and the desire to offer treatment with any hope of benefit to someone traumatized by sexual assault is high, data support a restrained position," Dr. Ellen concludes.

(Arch Pediatr Adolesc Med. 2006;160:754-755. Available pre-embargo to the media at www.jamamedia.org.)

For more information, contact JAMA/Archives Media Relations at 312/464-JAMA (5262) or e-mail mediarelations@jama-archives.org. To contact editorialist Jonathan M. Ellen, M.D., call Katerina Pesheva at 410-516-4996 or Kim Hoppe at 410-516-4934.