Session 10 Clinical care for survivors of sexual assault/rape, part 2: treatment and care - PowerPoint Presentation

1. Session 10Clinical care for survivors of sexual assault/rape, part 2: treatment and care1

2. Learning objectiveDemonstrate clinical skills appropriate to one’s profession and specialty to respond to VAWCompetencies Know how to provide appropriate treatment/care to survivors of sexual assault, including rape and abuse2

3. Treatment for injuriesUrgent hospitalization if: extensive injury neurological deficits respiratory distress swelling of joints on one side of the body (septic arthritis)Less severe injuries can usually be treated on site. The following medications may be indicated: antibiotics to prevent wound infection tetanus booster or vaccination medications for pain relief medication for insomnia (for short-term use in exceptional cases)3

4. Offer emergency contraception (EC)Offer EC to all women who have been rapedNo need to screen for health conditions or test for pregnancy“Return if your next menstrual period is more than 1 week late”4

5. Instructions for taking ECTake EC pills up to 5 days after sexual assaultMay cause nausea and vomiting. If you vomit within 2 hours after taking EC pills, return for another dose as soon as possible.May have spotting or bleeding a few days after taking EC pills. This is normal.EC pills, antibiotics for STIs and PEP for HIV prevention can be taken at same time without harm (but may want to take an anti-vomiting medication)5

6. Counselling on ECExplain EC and how it works – by stopping release of the egg.EC can help avoid pregnancy, but it is NOT 100% effective.EC will NOT cause abortion. If she is already pregnant, EC pills will not harm the pregnancy. EC pills will NOT prevent pregnancy the next time she has sex.EC pills are NOT meant for regular use. More effective continuing contraceptive methods are available.A pregnancy test may show if she was already pregnant. She can have a test if she wishes, but it is not necessary before taking EC.For those who are already pregnant as a result of rape, discuss options including for accessing safe abortion to the full extent of the law6

7. Offer PEP for HIV preventionFirst, test for HIV. Do not give PEP (pre-exposure prophylaxis) to those who test positive for HIV.Start PEP as soon as possible up to 72 hours after possible exposure to HIVChoose drugs based on national guidelines/ current WHO ARV guidelinesIn settings of high HIV prevalence, it may be appropriate to offer PEP to all survivorsA 28-day prescription of ARVs should be provided7

8. 8PEP procedure depends on situationSituation/risk factorSuggested procedurePerpetrator is HIV-infected or of unknown HIV status.Give PEPHer HIV status is unknownOffer HIV testing and counsellingHer HIV status is unknown and she is NOT willing to testGive PEP; plan follow-upShe is HIV-positiveDo NOT give PEPShe has been exposed to blood or semen (through vaginal, anal or oral intercourse or through wounds or other mucous membranes)Give PEPShe was unconscious and cannot remember what happenedGive PEPShe was gang-rapedGive PEPHandbook page 55

9. Deciding about PEPDiscuss these points to help her decide whether HIV PEP is appropriate:Whether HIV is common in that settingWhether she knows if perpetrator is HIV-positiveWhether there was more than one perpetratorWhether the exam found lacerationsPEP lowers chances of HIV infection but is not 100% effectiveMedicine must be taken daily for 28 daysHalf of people who take PEP have side-effects (nausea, tiredness, headaches). For most, these decrease after a few days.9

10. PEP follow-up and adherence supportRetest for HIV at 3 or 6 months or at both times. If test result is positive: Refer for HIV treatment and care Ensure follow-up at regular intervalsSupport adherence to treatment10

11. Offer STI prophylaxis/treatment11Job aid,handbook page 53Give antibiotics to prevent or treat these STIs: chlamydia, gonorrhoea, trichomonas and, if common in the area, syphilis Also give preventive treatment for other STIs common in the area (such as chancroid)Offer STI treatment on first meeting with the womanTest if lab available, even if treating for STIsGive the shortest courses available in national protocol

12. Prevent hepatitis B and, for adolescent girls, offer HPV vaccination12Has she been vaccinated for hepatitis B?NO ORdoes NOT know and test not possible1st dose: at 1st visit2nd dose: 1–2 months after the 1st dose3rd dose: 4–6 months after the 1st doseSTARTED but has not completed seriesComplete the series as scheduledYES, completed seriesNo need to re-vaccinateHas girl age 9–14 been vaccinated for HPV?NO ORdoes NOT know1st dose: at 1st visit 2nd dose: 6–12 months after 1st doseSTARTED but has not completed seriesComplete the series as scheduledYES, completed seriesNo need to re-vaccinate

13. Discuss self-care and plan follow-upsExplain examination findings and treatment Invite her to voice questions and concernsCare of injuriesShow how to care for any injuriesDescribe signs & symptoms of wound infection. Ask her to return if these signs develop.Explain importance of completing the course of medicationsDiscuss likely side-effects and what to do about themTreatment of STIsDiscuss signs & symptoms of STIs. Advise her to return if they occur.Avoid sexual intercourse until STI treatments finish13

14. Exercise 10.1: Sexual assault treatment decisionsLearning objective of this exercise: To improve clinical decision-making on treatments for sexual assault survivors.Each group selects a rapporteur to present back to plenaryGroups have 7 minutes per case study to discuss and fill out tables describing treatments to prescribe, tests to do and referrals to make and why After groups reconvene in plenary, rapporteurs will present one of their case studies (in 3–4 minutes) and explain their decisions14

15. Key messages Immediate treatment includes first-line support and, as needed, treatment of injuries, EC, HIV PEP, STI prophylaxis and hepatitis B prevention Most survivors don’t come in time for PEP (first 72 hours) or EC (first 120 hours)All survivors still need first-line support (LIVES), and some may need additional mental health careProviders need to determine the history of the assault, and what has happened since, to decide on tests and treatments15