What are the health risks and recommendations for someone who has engaged in unprotected intercourse?

Red Flags After Unprotected Intercourse

After unprotected intercourse, immediate evaluation should focus on three critical time-sensitive interventions: emergency contraception within 72 hours, HIV post-exposure prophylaxis (nPEP) within 72 hours if substantial exposure risk exists, and comprehensive STI screening with empiric treatment consideration. 1

Immediate Time-Sensitive Actions (Within 72 Hours)

Emergency Contraception

• Offer levonorgestrel emergency contraception immediately—effectiveness decreases with each passing hour, and it must be taken within 72 hours (3 days) of unprotected intercourse 1, 2
• If vomiting occurs within 2 hours of taking the medication, repeat the dose 2
• Perform baseline urine pregnancy test before administration 1
• The 5% pregnancy rate per rape among females aged 12-45 years makes this intervention critical 1

HIV Post-Exposure Prophylaxis (nPEP) Assessment

• nPEP is recommended when exposure occurred <72 hours ago AND the source partner is known to be HIV-positive 1
• Substantial HIV exposure risk includes: vaginal, rectal, eye, mouth, or other mucous membrane contact with blood, semen, vaginal secretions, rectal secretions, or breast milk 1
• For source partners of unknown HIV status, make case-by-case determination based on risk factors 1
• After >72 hours since exposure, nPEP is not recommended 1

Comprehensive STI Risk Assessment

Immediate Screening Priorities

Collect specimens for gonorrhea, chlamydia, syphilis, and consider HSV-2 serologic testing at the initial visit 1

For All Patients:

• Gonorrhea and chlamydia: Use urine NAAT (males) or vaginal swab NAAT (females—preferred over cervical swab to avoid traumatic speculum exam) 1
• Syphilis: Both nontreponemal (RPR, VDRL) and treponemal tests (EIA, CIA) 1
• HSV-2: Type-specific glycoprotein G-based serology 1

For Females:

• Trichomoniasis: Vaginal swab NAAT (preferred over culture) 1
• Avoid speculum examination in adolescents or those who have not had prior pelvic exams, as this may be retraumatizing and lead to future healthcare avoidance 1

For Patients Reporting Receptive Anal Sex:

• Rectal gonorrhea and chlamydia NAAT (if laboratory has validation) 1

For Patients Reporting Receptive Oral Sex:

• Pharyngeal gonorrhea culture or NAAT (if laboratory has validation) 1

Empiric STI Treatment Consideration

The CDC recommends empiric treatment for gonorrhea, chlamydia, and trichomoniasis in sexual assault victims, as these are the most common STIs reported and waiting for results delays critical treatment 1

• This approach is particularly important when follow-up is uncertain 1
• The prevalence of these infections in the general population makes presumptive treatment cost-effective 1

Hepatitis B Vaccination

• Offer hepatitis B vaccine to all unvaccinated or incompletely vaccinated patients—sexual transmission is well-documented 1
• HBV is highly infectious, remains viable on surfaces for 7 days, and can be transmitted through semen and vaginal secretions 1
• Initiate or complete the series; coordinate with primary care for follow-up doses 1

HPV Vaccination

• Initiate HPV vaccination series for patients aged ≥9 years who have not completed all 3 doses 1
• While not specifically recommended by CDC for acute sexual assault, the AAP recommends this as standard preventive care 1

Critical Partner and Exposure History Questions

Essential Risk Stratification Questions (from CDC Guidelines):

• "In the past 2 months, how many partners have you had sex with?" 1
• "In the past 12 months, how many partners have you had sex with?" 1
• "Have you had vaginal sex? Do you use condoms: never, sometimes, or always?" 1
• "Have you had anal sex? Do you use condoms: never, sometimes, or always?" 1
• "Have you had oral sex?" 1
• "What do you do to protect yourself from STDs and HIV?" 1
• "Have you or any of your partners ever injected drugs?" 1
• "Have you or any of your partners exchanged money or drugs for sex?" 1

Source Partner HIV Status

• If source partner is known HIV-positive, this substantially changes management and makes nPEP strongly indicated 1
• If source partner is unknown or cannot be tested, assess risk based on exposure type and partner risk factors 1

Mental Health Red Flags (Especially in Sexual Assault Context)

Immediate Psychiatric Assessment Required:

• Screen immediately for suicidal ideation, self-harm behaviors, homicidal ideation, or other self-harm behaviors such as self-mutilation and eating disorders 1, 3
• Sexual assault victims have significantly elevated rates of depression and suicide attempts 1, 3
• If any suicidal or homicidal ideation is present, refer urgently to an experienced mental health professional—this cannot be delayed 1, 3

Trauma-Focused Intervention:

• Initiate trauma-focused cognitive behavioral therapy (TF-CBT) immediately without prolonged stabilization phase—current evidence shows this is safe and effective 3
• Outdated phase-based approaches delaying trauma work are contradicted by evidence 3

Follow-Up Testing Schedule

Repeat STI Screening:

• Repeat gonorrhea, chlamydia, and syphilis testing at 2 weeks post-exposure 1
• Many STIs have incubation periods requiring repeat testing to detect infections not present at initial visit 1

HIV Testing Schedule:

• Baseline HIV test at initial visit 1
• Repeat at 6 weeks, 3 months, and 6 months post-exposure 1
• If nPEP was initiated, testing schedule may be modified based on treatment completion 1

Hepatitis B and C:

• Baseline testing for hepatitis B surface antigen (HBsAg) and hepatitis C antibody 1
• Repeat at 6 months if baseline negative 1

Prevention Counseling (Critical for Future Risk Reduction)

Condom Education:

• Consistent and correct condom use significantly reduces HIV transmission risk and gonorrhea risk in men 1, 4
• Latex condoms are impermeable to HIV and other viral pathogens in laboratory studies 4
• However, condoms are less effective against STIs transmitted by skin-to-skin contact (HSV, HPV) if the infected area is not covered by the condom 1, 4

Behavioral Risk Reduction:

• The most effective prevention strategy remains avoiding sexual intercourse with infected partners 1
• Both partners should be tested for STDs including HIV before initiating sexual intercourse 1
• Use a new condom for each act of intercourse 1
• Abstinence from sexual activity if STD-related symptoms develop 1

Common Pitfalls to Avoid

• Do not delay emergency contraception—every hour matters, and effectiveness drops significantly after 72 hours 1, 2
• Do not miss the 72-hour window for nPEP in high-risk exposures—after this window, prophylaxis is not recommended 1
• Do not perform traumatic speculum exams when urine or self-collected vaginal swabs are adequate for NAAT testing 1
• Do not dismiss mental health screening—sexual assault victims have markedly elevated suicide risk requiring immediate assessment 1, 3
• Do not rely on initial negative STI tests alone—repeat testing at 2 weeks is essential due to incubation periods 1
• Do not assume patient will return for follow-up—consider empiric STI treatment at initial visit 1
• Do not forget hepatitis B vaccination—sexual transmission is common and vaccine is highly effective 1