What is the recommended post‑exposure prophylaxis for a survivor of sexual assault?

Medical Advisory BoardAll articles are reviewed for accuracy by our Medical Advisory Board
Educational purpose only • Exercise caution as content is pending human review
Article Review Status
Submitted
Under Review
Approved

Last updated: April 30, 2026 • View editorial policy

Have a follow-up question?

Our Medical A.I. is used by practicing medical doctors at top research institutions around the world. Ask any follow up question and get world-class guideline-backed answers instantly.

Ask Question

Sexual Assault Prophylaxis

Sexual assault survivors should receive routine presumptive antimicrobial prophylaxis with ceftriaxone 250 mg IM, azithromycin 1 g orally, and metronidazole 2 g orally (or tinidazole 2 g orally) as a single-dose regimen, along with hepatitis B vaccination, HPV vaccination (if age-appropriate), emergency contraception for reproductive-aged females, and individualized HIV nPEP based on risk assessment within 72 hours of assault. 1

Antimicrobial Prophylaxis

The 2015 CDC STD Treatment Guidelines provide the most current comprehensive recommendations for post-sexual assault care 1. Given poor follow-up compliance among survivors (often <20%), presumptive treatment is strongly recommended rather than a test-and-treat approach.

Recommended Antimicrobial Regimen:

  • Ceftriaxone 250 mg IM (single dose) - covers gonorrhea including pharyngeal infection
  • Azithromycin 1 g orally (single dose) - covers chlamydia
  • Metronidazole 2 g orally OR Tinidazole 2 g orally (single dose) - covers trichomonas and bacterial vaginosis

Important caveat: If alcohol was recently ingested or emergency contraception is provided, delay metronidazole/tinidazole administration until the patient goes home to minimize drug interactions and GI side effects 1. Counsel patients that GI side effects are common with this combination but the benefits outweigh risks given the difficulty with follow-up.

Note that older 1998 guidelines recommended ceftriaxone 125 mg 2, but this was updated to 250 mg in 2015 guidelines due to rising gonorrhea resistance 1.

Hepatitis B Vaccination

Administer hepatitis B vaccine at initial examination if the survivor is unvaccinated or incompletely vaccinated 1. Follow-up doses should be given at 1-2 months and 4-6 months.

Key distinction: HBIG is NOT needed unless the assailant is known to be HBsAg-positive 1. For unknown assailant status, vaccine alone is sufficient.

HPV Vaccination

HPV vaccine should be offered at the initial examination 1:

  • Females aged 9-26 years
  • Males aged 9-21 years
  • MSM through age 26 years (if not previously vaccinated or incompletely vaccinated)

Follow-up doses at 1-2 months and 6 months after the first dose.

Emergency Contraception

For reproductive-aged females with vaginal penetration or ejaculate contact with genitalia, offer emergency contraception 3. The preferred regimen is levonorgestrel 1.5 mg (two 0.75 mg tablets) taken as a single dose, which is more effective and has fewer side effects than taking tablets 12 hours apart 3.

Perform baseline urine pregnancy testing before administration.

HIV Nonoccupational Post-Exposure Prophylaxis (nPEP)

HIV nPEP requires individualized risk assessment and should be offered within 72 hours (ideally within 24 hours) when risk is substantial 1, 4.

Risk Assessment Algorithm:

Assess the following factors 1:

  1. Type of penetration: Vaginal or anal penetration carries higher risk than oral
  2. Ejaculation on mucous membranes: Increases transmission risk
  3. Multiple assailants: Increases exposure risk
  4. Mucosal trauma/bleeding: Significantly increases risk
  5. Presence of genital lesions in survivor or assailant
  6. Assailant characteristics: Known HIV-positive status, MSM, injection drug use
  7. Local HIV epidemiology: High prevalence areas warrant lower threshold

When to Offer nPEP:

Offer nPEP if:

  • Vaginal or anal penetration occurred with ejaculation
  • Significant mucosal trauma with bleeding
  • Multiple assailants
  • Assailant known or suspected to be HIV-positive
  • High-risk assailant characteristics in high-prevalence area

Consider nPEP even for lower-risk exposures given the psychological benefit and difficulty with follow-up 1.

nPEP Regimen (2025 Guidelines):

The most recent 2025 CDC nPEP guidelines 4 recommend:

Preferred regimens:

  • Bictegravir/emtricitabine/tenofovir alafenamide (single tablet daily)
  • Dolutegravir plus (tenofovir alafenamide OR tenofovir disoproxil fumarate) plus (emtricitabine OR lamivudine)

Duration: 28 days total

Timing: Initiate as soon as possible, ideally within 24 hours but no later than 72 hours post-exposure 4.

nPEP Counseling Points:

  • Emphasize early initiation optimizes benefit
  • Severe adverse effects are rare 1
  • Provide 3-5 day supply initially if survivor is distressed and unable to make informed decision, with follow-up scheduled before medication runs out 1
  • Baseline CBC and serum chemistry required 1
  • Consider transition to PrEP if ongoing HIV exposure risk 4

Common Pitfall:

Do NOT delay nPEP initiation for laboratory results. Start immediately based on clinical assessment 4.

Initial Testing

At the initial examination, perform 1:

  • NAATs for chlamydia and gonorrhea from sites of penetration (vaginal, anal, pharyngeal)
  • NAAT or point-of-care testing for trichomonas from vaginal specimen
  • Wet mount if vaginal discharge, malodor, or itching present
  • Serum testing for HIV, hepatitis B, and syphilis (baseline)
  • Urine pregnancy test for reproductive-aged females

Follow-Up Schedule

Despite poor compliance, structured follow-up is essential 1:

Within 1 week: Review test results, assess medication tolerance, provide additional counseling

1-2 weeks: Repeat STI testing if prophylaxis was not given (infections may not be detectable initially)

4-6 weeks: HIV testing, syphilis testing

3 months: HIV testing, syphilis testing

6 months: HIV testing (final test)

For nPEP recipients: Additional visits at 24 hours (remote or in-person), 4-6 weeks, and 12 weeks 4

Follow-Up Testing Note:

If prophylactic treatment was given, post-treatment STI testing is only needed if symptoms develop 1. This reduces unnecessary testing burden.

Additional Counseling

At initial and follow-up visits, counsel survivors on 1:

  • Symptoms of STDs requiring immediate evaluation
  • Abstinence from sexual intercourse until prophylactic treatment completed
  • Importance of follow-up despite feeling well
  • Availability of ongoing psychosocial support

Special Populations

Adolescents: Same regimens apply. Ensure hepatitis B and HPV vaccination status is current 3.

Pregnant survivors: Expert consultation recommended for nPEP regimen modification 5.

Children (prepubertal): Management differs significantly; detection of STIs strongly suggests abuse and requires specialized protocols 1.

References

1
Guideline

sexually transmitted diseases treatment guidelines, 2015.

MMWR Recommendations and Reports, 2015

Related Questions

In an attempted rape with no penetration and no visible external injuries, is post‑exposure HIV prophylaxis (PEP) required?
1. What is the major health problem resulting from a pulse deficit? (A) Bradycardia (B) Activity intolerance (C) Decreased cardiac output (D) Impaired tissue perfusion. 2. What should the nurse do when a pulse deficit is suspected? (A) Measure the radial pulse for one minute, then measure the apical pulse for one minute (B) Measure the radial pulse for 30 seconds, then measure the apical pulse for 30 seconds (C) Measure the radial pulse for one minute, wait five minutes, then measure the apical pulse for one minute (D) Ask another health‑care provider to count the radial pulse while the nurse counts the apical pulse. 3. After identifying a pulse deficit, which action should the nurse perform? (A) Reassess the apical‑radial pulse in five minutes (B) Assess the patient for signs of decreased cardiac output (C) Notify the primary health‑care provider of the pulse deficit (D) Initiate interventions directed toward managing the patient’s symptoms. 4. A patient has oral temperature 36.8 °C, radial pulse 112 weak and thready, apical pulse 117 regular, respirations 24 regular, blood pressure 104/56 right arm, 102/50 left arm; what is the pulse deficit? (A) 2 (B) 5 (C) 6 (D) 48. 5. Which of the following is an early manifestation of decreased cardiac output? (A) Fatigue (B) Substernal pain (C) Nail‑bed cyanosis (D) Shortness of breath.
In a 24-year-old woman who experiences severe nausea, shakiness, and dizziness lasting about 30 minutes after sexual intercourse, what are the possible differential diagnoses?
What are the recommended two‑drug and three‑drug regimens for HIV post‑exposure prophylaxis, including dosing for adults and children?
What is the appropriate management for a 10‑month‑old infant with cough, wheezing, coarse breath sounds, and diarrhea?
Is neurosurgery classified as a high‑risk operation in the Revised Cardiac Risk Index (RCRI)?
Is Arnuity (fluticasone furoate) Ellipta safe to use during pregnancy for asthma control?
Does atomoxetine (Strattera) carry a higher risk of inducing mania than viloxazine (Qelbree)?
In a CT report describing a large anterior abdominal wall incidental and periinsular hernia containing large and small bowel loops and omental fat, does this indicate intestinal contents, and what is the recommended management?
What concerns should be considered when prescribing duloxetine (Cymbalta) to a patient with chronic obstructive pulmonary disease (COPD)?
What are the most common causes of isolated proteinuria in a healthy young adult?

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.