Thank you, everyone, for being present today for this webinar. We will be talking about the role of the forensic nurse in sexual assault with HIV and PEP through the review of a case study. My name is Tammy Scarlett. I am a forensic nursing specialist with the International Association of Forensic Nurses where I provide technical assistance, and I also practice currently as needed as a forensic nurse on a local hospital-based forensic nursing team. I've practiced as a forensic nurse for almost seven years, and I'm hoping that through reviewing this case study today that we will be able to openly talk about this patient population and the care provided to them. And upon attending the course in its entirety, due to the criticality of the content, and completing the course evaluation, you will receive a certificate that documents the continuing nursing education contact hours for this activity. The International Association of Forensic Nurses is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation. At the end of this presentation, the learner will be able to discuss the forensic nurse's role in the encounter of sexual assault patients who need HIV and PEP. They'll be able to formulate a plan for when this patient population presents to their facility or program, and they'll be able to implement ways to improve care of these patients in their practice. We will be reviewing a case study of a patient who did experience sexual assault and was given HIV and PEP, as mentioned earlier. She was seen and treated at a local hospital by a forensic nurse. This patient did have a signed release of information and a photography consent. This data is also given to UC Health Memorial Hospital Central in Colorado Springs, Colorado. They have given permission to demonstrate the care given to their patient by reviewing their forms, charting, and information. The EPIC charting system was used with this patient, and therefore, this is the type of documentation that will be seen. The following slides contain detailed body surface and anogenital photographs and documentation with varying degrees of injury. Be mindful of others who might be around who can see or hear the following slides. We'll be addressing patients who present after experiencing sexual assault, specifically in adult and adolescent populations. Pediatric patients in this group have other considerations that we just will not be addressing today. So, looking at the definition of sexual assault, we see that sexual violence, according to the World Health Organization, is any sexual act, attempt to obtain a sexual act, or other act directed against a person's sexuality using coercion by any person, regardless of the relationship to the victim, in any setting. It includes rape, defined as the physically forced or otherwise coerced penetration of the vulva or anus with a penis, of the other body part or object, attempted rape, unwanted sexual touching, and other non-contact forms. Sexual violence is a public health problem on a global level. According to RAINN, one out of every six women in America have experienced an attempted or completed rape at some point in their lifetime. In the United States, one in ten people who experience rape is a male. Now, according to the World Health Organization, one in three women around the world have experienced sexual violence, either by an intimate partner or a non-partner, or even by both. There are not only immediate concerns, such as injuries and emotional pain, but there are long-term effects of sexual assault that we can address. Again, according to RAINN, 33% of women who've been sexually assaulted think about suicide, and 13% have attempted to complete this. There's also an increased risk of drug use, along with an increased risk of pregnancy, sexually transmitted infections, and negative effects on sexual and reproductive health. We've all seen how violence impacts our patients, and we see how devastating it can be for those even caught in the ripple effect. Addressing sexual violence is not just about addressing the criminal justice aspect, but it is about understanding the public health implications. We as sexual assault nurse examiners are perfectly positioned to understand how to best help our patients. There's a lot to consider when a patient is sexually assaulted, and walking through a patient case study will hopefully help us understand some of the moving parts of someone who presents after this has happened. As of now, you will see times on the left side of some of the charts. This corresponds to the documentation for the scene in this patient encounter. We'll use this documentation to discuss the care provided to the patient. Patients who experience sexual assault might present differently to each facility. In this case, an initial call was received from a local freestanding emergency department stating that the patient was reporting a sexual assault. The forensic nurse was placed on the phone with the patient, and the role of the forensic nurse was discussed. She reported she was presented with her mother, and she was agreeable to her mother being present. The patient disclosed the sexual assault to the nurse examiner, and states that this occurred while she was intoxicated. She was agreeable to come to the main hospital, where the SANE was located, in order to receive the medical forensic exam. Reporting options were initially discussed, and the patient stated she did wish to report to law enforcement. She denied any acute medical concerns. So a report was given to the nurse at the facility, the patient was to be medically cleared, and then discharged to come to the main hospital. Now, this is a brief introduction and discussion with the patient, but it affords time for the patient to then come to the main hospital and discuss options further, and to receive the actual physical part of the exam. Sometimes patients might get transferred to a facility and not know why they are being sent. It's always a good idea to let them make that decision by hearing it from you as the SANE, as well as to make sure they are medically stable prior to being transferred or discharged, as, of course, we want to make sure all medical concerns are being addressed. The patient arrived at the main hospital, where the forensic nurse was located. The patient was seen in triage initially, had vital signs completed, and then was placed in a private room. The SANE went to the private room, introduced herself, and the patient was asked in private if she was still agreeable to her mother being present, to which the patient stated that she did, in fact, want her mother there. So after this, the sexual assault medical forensic exam was reviewed with the patient to make sure that all questions were able to be asked and that the patient was still agreeable to this and agreeable to reporting to law enforcement. As of now, in this state where the patient was seen, there are a few reporting options, and of course, all of these should be discussed, including possible outcomes if the patient declines certain options. So we will talk about that a little bit more in a bit in further slides. Consents were reviewed, and verbal and written consent were obtained. Let's look a little more closely at what occurred during that part of the encounter. So when we first go into the room, it's a good idea to see who's present and to document who's in the room. As noted, the patient's mother was present at the time of the forensic nurse's arrival to the room. It's important to document who's in the room and when they leave. And then at this time, the SANE did ask the mother to step out or to speak with the patient in private. This allows for the patient to speak confidentially if she wishes, but it also makes sure that she can have anyone back in the room if she wants. Sometimes I find that it's hard for patients to ask family members to leave, but if I give them that opportunity, saying it's my normal practice, then the pressure is removed from the patient. Taking a step back, we want to make sure we get some information about the patient. She is a 26-year-old female, and a chart reveal showed that she had no significant visits to the hospital in the past. Her only diagnoses are anemia, depression, anxiety, and PTSD. She has never been pregnant and is having regular periods. One thing not asked at this time was if she was using any form of birth control. This can be important for many reasons, such as understanding health diagnosis, considering medications we might offer, and possibly addressing reproductive coercion. So these are things, of course, that we will discuss later, the birth control. It just came up in a different portion of the documentation. Now, I mentioned reporting options earlier. This patient opted to report to law enforcement, but we must be aware of what all reporting options are in our jurisdictions and states. Not only this, but we must also make sure that the patients are aware of all the possibilities that would arise from any reporting options, like we discussed, including the consequences, such as what might happen if someone chooses to not report or have evidence collected. We must also be aware of mandatory reporting in our jurisdiction or state. The importance of being upfront and honest is also imperative. Sometimes patients might also be apprehensive about an exam due to payment considerations. This is something you must be prepared to speak to. Payment TA has information broken down by state and is accessible on the IAFN website, something that can definitely help guide your discussion. Now, overall, these are things that are important to talk about with your patient and will help lead to patient-centered decisions. In my practice, I like to find out who, what, where, and when. That's a good way of understanding what kind of exam we'll be doing. So if we will see a patient for intimate partner violence or sexual assault, where is kind of understanding the jurisdiction, who we're going to report to. And the when helps me know timeframes for the exam, such as if I can offer evidence collection, medications, or other considerations. From asking initial questions, we find out this was a friend, not an intimate partner. We know the patient was sexually assaulted in her apartment, and it was after midnight. The patient stated initially, in quotes, after midnight is what the SANE nurse wrote, and the SANE had her clarify further that she was not sure specifically what happened to her between 11 p.m. the night before and 9 a.m. that morning of reporting. So it was a good idea to get a better clarification if you can. At this time in the nurse's charting, we see that the advocate arrived and stepped in to speak with the patient. The SANE made introductions and then stepped out for privacy. At that time, the SANE tried to manage her time well and called law enforcement, and an officer was dispatched. The advocate finished speaking with the patient and stepped out. Advocacy is a very important part of the response to sexual assault. There is much that can be done in the moment for safety and talking, to follow up later with counseling, safe housing, crisis intervention, wraparound services, and assisting the patient through the judicial process. Community advocate might be able to be in-house, face-to-face, or through a 24-hour hotline. They were able to provide services before, during, and or after an exam. Community advocates are a confidential resource, whereas system-based, such as law enforcement advocates, are a wonderful resource as well, but just aren't confidential. The distinction is something that needs to be made clear to the patient, but both are very important aspects of the response. Now, after advocacy was finished speaking with the patient, the SANE was able to obtain psych, social, history, and a SANE or an AFNI assessment. We'll go into detail of these in the next few slides. The SANE added a brief summary of what led up to the patient coming to see the SANE, and other specific details that the patient reported during these assessments. The nurse clarified if there was any intimate relationship with the patient in order to assess the need for specific screenings and assessments. The patient denied this, like discussed earlier, and medications and further details of the medical forensic exam were discussed. The patient opted for ELLA, or the emergency contraception. She did want gonorrhea and chlamydia prophylaxis, as well as HIV and PEP. She also agreed to evidence collection and wanted this to be sent out for analysis. Sometimes I ease on into an exam with information that the patient knows, something that's easier for them to talk about, and sometimes this is a psych, social. Psych, social will help us understand what resources we might need, what safety planning will have to do, and way more about the patient. We found out the patient lived with roommates, and she was not in a relationship. She was currently working as a full-time administrative assistant, and she had good support with family and friends. She denied any drug use and reported alcohol use just a few times a week. She didn't have any weapons in the home, nor did she have any pets. She did have a phone number that she verbalized was safe to call and to leave messages on for follow-up, and she did have her own car. And for you in your own communities, you might find other details more important, such as is there military? Is this something, does someone need tribal advocacy? So you might need to tweak your psych, social questions for your individual communities, and that's totally fine. Know what's important to you. After getting psych, social information, we needed to understand more of what happened. Asking the patient about the history of events is important, as this guides our exam, and it's for the purpose of treatment and diagnosis. This will let us know where to look for injury, what medical care might be needed, and more. This was discussed with the patient, and she was also informed that the SANE would be putting the event history in quotes in order to not leave anything out or misinterpret what she said. The patient was also made aware that she can choose to stop or pause the exam at any time if she wished. There's something about the whole ongoing consent aspect, and we have to keep that in mind. Now, for some programs, you might summarize or paraphrase, just know what you're doing, be consistent, and be able to speak to that, but for this program, they did put everything in quotes. Here we have that documented history. So, according to the patient, she stated, we were with a whole bunch of friends and all drinking, and I reached my limit, and I decided I need to leave, and so I grabbed my stuff, and I don't remember him asking, but he walked me upstairs to my room. I remember opening up my apartment door. I remember opening up my room door. I don't remember him being in my apartment or my room. I do remember taking off my swimsuit. I walked into my room and took off my swimsuit, and when I woke up in bed, that's it. I don't even remember climbing into my bed. He proceeded to tell me this morning over text that I answered the phone for the food guy, and he asked me if I was sure that I wanted to sleep with him, and one other thing, but I have no memory. Now, after obtaining the history, there's more information that needs to be gathered. Sometimes this is called the SANE assessment or F&E assessment. This allows for further details about what occurred during the assault and since the assault. Here, the patient reported she was 26 years old, was never pregnant, and is having a normal period. Her last sexual encounter was months prior. She is not on birth control at the time, and when asked specifically about what occurred during the assault, she stated unknown. Now, I find it helpful to walk through each question individually, explaining why I'm doing that, because I have had patients where a specific question jogged their memory, and they were able to then answer further. I also want to make sure I'm not filling in an answer that I actually have not specifically asked the patient. I also ask, is there anything else that happened during the assault that you think would be important for me to know? This question elicited the patient to state to the forensic nurse that I'm on my period. The nurse and the patient then moved on to the since the assault questions. The patient stated she had not douched, bathed, or showered, and it appears the forensic nurse left it blank on whether or not she changed clothes. Later on down in the slide, we see that it auto-populated to where the patient stated I was naked when I woke up. We could have alerted law enforcement about any clothing that was left at the house from when she went to bed, or we could have collected her underwear that she put on from when she woke up. But we'll talk more about this when we get to evidence collection. Now, after clothing, we see she had something to eat, and she had something to drink since the assault. But she had not smoked, brushed her teeth, or gargled. When asking about urination, the patient stated yes. I always find this a great opportunity to ask about any dysuria, burning, or frequency in order to assess for any urinary symptoms. Then she reported she had not defecated, and this is also a good opportunity to ask about last bowel movement prior to or since the assault, as this will help speak to any anal injury findings. As this will help speak to any anal injury found, or provide treatment and education for possible constipation or other complaints. While the patient reported she did have a pad on and that she was unsure where her tampon was from last night, which she covered earlier in the statement as well. Now, the extra comments were put in the little notes section. As you can see, I kind of highlighted them. I try to put any extra details there as they will help capture what the patient said and give a fuller picture. This can help guide our treatment and care as well. The meter and appearance documentation allows for good representation of the patient in that moment. It allows us to remember how the patient was that day, if we have to recall it further down the line, say for testimony. Also, understanding how the patient is presenting will help us clearly document how the patient is acting. For example, if a patient is tangential, speaking with someone else in the room who's clearly not there and is speaking rapidly, we might want to have the patient seen by our behavioral health team and provider prior to proceeding with an exam, if that's even what's appropriate for them. So, knowing how the patient is dressed or kept is also important. For example, if the patient ran out of the house without articles of clothing and shoes, and he or she has dirt on their feet with chip nails, this might be something consistent that they gave with the history, and this is something we can capture in our documentation, photo documentation. This also allows us to assess things like malnutrition and care of children or elderly patients. So, we will be doing this throughout our exam, but this is also a perfect place to capture certain things like that. For our patient today that we're discussing, she was flat, spoke easily with the same, but did not make eye contact. She was wearing clean clothing and had clean hair. This all can be consistent with history she gave us, and it's important to try to document objectively as well and give unbiased representation of the patient. Once law enforcement arrived, it was a good opportunity for them to discuss their role with the patient and allow her to ask questions. They were in agreeance with having the patient finish her exam and then speak with her further after the exam was completed. Now we see in the nurse's charting that after the officers were finished speaking with the patient, it was a good time for them to move to the exam room. A urine sample was collected for a urine pregnancy test. The pad was collected per national and state guidelines. As it was not dried all the way at time of evidence packaging, we note that it was placed in a breathable, sterile cup and then in a brown paper bag, which was the local evidence collection guidelines. Law enforcement followed their protocol later for storage and handling of evidence and handing it over to the crime lab. Now a urine pregnancy test was completed as the patient was of childbearing age. Blood was also drawn for labs associated with providing HIV and PEP. We will discuss all the labs and everything later on too. So after lab collection, a physical assessment was completed with photo documentation capturing many bruises. We will also walk through photo documentation in the next slides. Now the sexual assault nurse examiner documented that the exam was completed at 1545. Injury had been noted to the fascia navicularis with positive T blue uptake. Education on this was discussed, including that the dye might be noted for up to a few days later in her underwear when she wiped, and that positive T blue update indicated that there could be an acute injury or finding. So as the dye adheres to the acute exposed nucleated cells, that's what we So we'll look at the injuries further in just a bit. We also note that medications were provided along with something to eat and drink after getting some specific lab results back, such as our creatinine and liver functions. The labs were a negative pregnancy test, a CBC and a CMP that were within defined limits. And as we want to make sure the liver functions and creatinine were good, like I mentioned prior to administration, administration especially of the HIV NPEP, we wanted to get those back. And then the anti-nausea medication was provided at the same time. Let's review the last few slides of the nurse's documentation. Now walking through the physical assessment, we see that all body systems were addressed in order to make sure nothing was missed, especially since in this program, the nurse is the one who medically clears the patient. The patient did not have any abnormalities except for the genital, anus, rectum, and of course in the anal genital assessments. Again, we'll walk through those in more detail. But as of note, Tanner staging was also documented as a five and a five. During the physical assessment, evidence was collected. My process is something I'm consistent with every single time in my collection, knowing that I assess the body for any areas that were acknowledged during the history and epiphany or SANE assessment as areas that evidence should be collected. And then I collect prior to touching any part of the body and after photo documentation. So we talked earlier about the collection of clothing. Although we can glean from the chart that new clothing was put on after the assault, something that should have been added in the chart with documentation that I don't necessarily think that the nurse did, we can at least discuss the collection of underwear with the patient. And that's something that we want to collect. The clothing again is something that we could have alerted law enforcement to that they could have collected on their own too if they were able to. And so regardless, swabs were collected from the following sites. Oral, external genital, anal, vaginal, cervical, fingernails, and buccal. The famine pad was also collected as discussed earlier. Now per guidelines, the following labs were collected. We note that the complete blood count, complete metabolic panel, pregnancy tests, and HIV half antibody are all negative. They all came back prior to the patient leaving. However, the gonorrhea and chlamydia cultures, vaginosis panel, hepatitis B and C labs, as well as the RPR for syphilis, were all resulted after the patient was discharged. The SANE did speak with the patient later to discuss her positive bacterial vaginosis, and we'll see how this was handled later. She would follow up with an infectious disease provider later on as well for their testing and counseling. Here we see that this was the positive bacterial vaginosis result. Medications were provided to the patient upon standing orders that were written based on the CDC guidelines at that time. Since then, of course, the guidelines have been updated. Now the patient was provided Truvada and Isentris along with nausea medication to prevent the patient acquiring HIV. She was also given Zithromax and Rocephin for gonorrhea and chlamydia prevention, and Ella was provided for emergency contraception. Now in this program, trichomoniasis prophylaxis was not provided at the time, as opposed to the patient following up for further testing and treatment as needed. The updated guidelines would see that instead of the Zithromax, 1,000 milligrams by mouth, and the Rocephin, 250 milligrams IM, both being given at one time, we can now provide Cetraxone or Rocephin, 500 milligrams IM, one-time dose, with a doxycycline, 100 milligrams, twice a day orally for seven days, as opposed to the Zithromax that was provided. So knowing your updated guidelines and what your program is offering is very important, as we will most likely be getting these to some of our patients. Now after all was done, discharge instructions and a resource folder were both provided with detailed education on sexual assault and HIV and PEP, including specific information on follow-up and the medication. The patient reported she felt safe to return home and was going to be driven by her mother. She felt safe knowing she would be following up with law enforcement as well. A discussion about how to keep safe in the meantime would have also been discussed, such as locking doors, making sure she had a working cell phone, or staying at her mother's house for the night. All things that should be considered and reviewed with the patient, or even further detailed discharge instructions as needed. The nurse's chart notes that after the patient left, the SANE packaged all the evidence according to guidelines and then called law enforcement to come pick up the sexual assault evidence collection kit, like we discussed earlier. It was signed over to law enforcement and documented in order to maintain chain of custody. So in the next few slides, we'll review the body diagrams and photos that capture the injuries and findings of the patient. The body surface injuries that the patient indicated were from the assault were documented in this diagram. We note there are two injuries on her arms, so let's break down each injury in the corresponding photo series. Here we have our first injury. We can see that it is clearly documented on the body diagram on the left, which is the same one we saw on the previous slide. It was documented with a corresponding 0.5 centimeter by 0.5 centimeter purple, blue, brown bruise. We also see a good progression of proper series of photo documentation from orientation to close up, then a measured photo of the injury with the measuring tool. Body injury number two, as pointed out on the body diagrams, is a 2.5 centimeter by 2.5 centimeter area of swelling with blue bruising and a red abrasion. You can see that the injury is photographed in an orientation photo, a close-up photo, and then a measured photo. The measurement standard tool does not cover the injury. The standard is at an L and is flush with the skin as well as in focus. All these considerations allow for an accurate representation of the injury. One thought with these photos is to have more lighting, as it's difficult to see the injury fully, and sometimes different lighting and positioning can help with viewing that injury better. Here we have the anogenital diagram with corresponding findings. Note that is a good standard of practice to do photo documentation with or without injury in the anogenital assessment for many reasons, such as someone going behind to make sure nothing was missed and that all documentation is correct, or for education or possible criminal justice proceedings. Also, a good reason is for health care implications. At times, patients might have a finding or not have a finding that will help the patient and health care in the future. So, in the next series of photos, we'll go through all the documentation and photos of the anogenital assessment. Here is the initial set of photos of gross visualization from Mons pubis to the buttocks. This allows us a generalized view of the genitalia prior to separation, traction, or any other interventions such as evidence collection, toluidine blue dye, or Foley catheter. Here we have an initial gross visualization of the anal assessment on the top left, and then a more direct visualization with separation on the bottom right. One thing I'd like to see more of is separation of the top half of the anal assessment in the bottom right photo. Overall, just note that we don't see any injury at this site. I like to do, of course, least invasive to most invasive. And so, for me, this is the initial gross visualization, then the anal assessment, and then moving back into separation and traction for the vulva and vestibule. So, from top left picture down to the bottom right, we see the progression of all the structures from the clitoris and clitoral hood, to the top left picture, and then to the bottom right, we see the progression of the clitoral all the structures from the clitoris and clitoral hood, urethral meatus, which is difficult to see in this position, fascia navicularis, posterior foreshed, perineum, and hymen. We can see here some blood noted around three o'clock on the internal aspect of the right labia minora, as well as the fascia navicularis. So, let's take a closer look at all of this. Now, here we see that blood is at three o'clock, and that's cleaned up, wiped off in the middle picture. We don't see it as anymore. A toluidine blue dye was added to the fascia navicularis to highlight that injury. This is documented at four to eight o'clock, but we see that there are dark adherences of that t-blue, specifically at six o'clock. The rest of the t-blue could have been tried to have been wiped away more. But also, sometimes it's hard to wipe all that away if it's poor positioning or, say, pain. So, we discussed that the use of t-blue earlier in the slides is a unique dye used to highlight, and it's not to search for injury. But upon finding a possible injury, we can place it at that spot on the non-mucosal surface, wipe away, and in this case, it was wiped away with lubrication in a baby wipe. And the difficulty is that we want to make sure we are sticking to the true picture of the injury. With this picture, we see light blue surrounding the dark blue area of six o'clock. This is not always easy to wipe away the dye like discussed, but we want to make every reasonable effort to adhere to a true representation of the injury, regardless of being able to wipe off the excess or not. We know that the true injury is at six o'clock on the fossa navicularis, and we can speak to the rest of the blue not being true uptake. These photos show good view of separation and traction, which allows the hymen to open for better visualization. We can also see the urethral meat as opening in the two pictures at the top. A Foley catheter or cotton swab could have been used to see the edges of the hymen more clearly, especially from 6 to 12 o'clock. Now, moving down in the pictures, we see that after the insertion of the speculum, we have a good view of both sides of the vaginal canal and a good view of the cervix. A closer inspection with magnification from the colposcope allows for a better view of that cervix. Now, after evidence was collected, a swab can be used to clean off the cervix and the vaginal wall of that pooling blood. The SANE noted that the frank blood was coming from the os, supporting that this is not injury, but from the patient's period. Now, with a closer look at the cervical os, which is at the center of the cervix, we see ectropion tissue, which is a normal finding of cells from the cervical canal that extends externally, giving it that deeper red color. This can be mistaken for injury, but it's not. Now, to recap, things that we can make sure we think about during the anogenital assessment is using a Foley catheter or swab technique to assess the full edges of the hymen to make sure that there's absolutely no injury missed there. Also, to make sure to clean off that cervical face and vaginal wall in order to, again, assess for injury in those areas. And positioning. This patient was assessed in the lithotomy position, using separation and traction, as well as in supine knee chest for the anal assessment. All these techniques should be documented if used. Discharge. Instructions were provided on sexual assault and HIV NPEP, along with the prescriptions for the HIV NPEP medications. Side effects to watch out for and when to return to the emergency department or follow up with your primary care provider were also discussed at length. The patient reported she was going to go home with her mother, and again, she felt safe with this. She made plans to follow up with a community advocate in order to continue safety planning and to look at other wraparound services. All questions were answered, and she was encouraged to call with any questions or concerns. Selective care can be follow up or follow up calls. So, later that night, the patient had called the sexual assault nurse that was on. She had discussed that she was unable to pay for the HIV NPEP medications out of pocket. She also stated she did not believe she was high risk, and therefore was not going to pursue taking the medications. The SANE encouraged her to follow up with the infectious disease provider in the morning, to which the patient was agreeable to. At this program, a referral is made to the infectious disease provider who called the patient the next morning to establish that continued follow up. It's sadly not uncommon for patients to not adhere to the medications for multiple reasons, and we'll talk about that more. Now, two days later, the patient's cultures resulted, and she noted she had a positive bacterial vaginosis result on her medical application on her phone. This was about the same time that she would have been called by the SANE to discuss the results for a follow up. Now, the SANE that was on that time discussed the positive result, as well as her other negative results. All education pertaining to positive bacterial vaginosis was discussed. The patient reported at this time she was not going to continue taking the HIV NPEP, and she was choosing to not follow up with infectious disease. Now, this is always something we try to consider when providing discharge instructions to the patient. HIV NPEP can be complicated, and this is something we'll be talking about in depth shortly. However, all attempts to make the adherence to HIV NPEP easier should be considered, such as, did we as a SANE discuss if the patient could even afford the medication? If not, what resources were available to her at that time, and what education could we have provided to her upon her calling state that she could not afford the medication initially? Well, let's look a little deeper into that process of providing HIV NPEP, or human immunodeficiency virus, non-occupational post-exposure prophylaxis. As sexual assault nurse examiners, we encounter patients who are at risk of acquiring HIV due to the sexual assault. We need to understand that this is a standard of care for anyone who has this risk and falls within the recommendations. We need to know about HIV and HIV NPEP. We need to be able to assess the risks associated with HIV transmission in order to be able to educate our patients on the risk and benefits, as well as be able to identify the risk of HIV transmission and benefits, as well as be able to identify the patients who need this intervention. There are many things to know about this process, and it could be an entire presentation in itself, but what we can do in this webinar is discuss the basics to get started. According to CAN Community Health, HIV is a virus spread through certain body fluids that attacks the body's immune system, specifically the CD4 cells, often called T-cells. Over time, HIV can destroy so many of these cells that the body can't fight off infections and disease. These special cells help the immune system fight off infections. Untreated, HIV reduces the number of CD4 cells, or T-cells, in the body. This damage to the immune system makes it harder and harder for the body to fight off infections and some other diseases. Opportunistic infections, or cancers, take advantage of very weak immune systems and signal that the person has AIDS. This is a devastating outcome, and we need to be aware of the measures we as SANEs can take to combat this. And what we have at our disposal to combat this is HIV MPEP. HIV MPEP is, like discussed earlier, human immunodeficiency virus, non-occupational post-exposure prophylaxis, meaning medication provided to prevent HIV that might be acquired while not on the job, such as a nurse, but in the course of something else, such as a sexual assault. This medication is indicated in our field after someone has presented reporting a sexual assault, and there is a risk due to possible exposure from body fluids. Being aware of the risks that do come with this type of encounter in your individual patients and in your community is imperative to allowing your patient to make a fully informed decision. Here we see the Center for Disease Control and Prevention's recommendation for initial MPEP evaluation and follow-up. This is a summary of what the whole process entails, but is a good rundown to look at. We're going to walk through some more detail. I'll give you a few seconds to look at this. When we have a patient present after a sexual assault, we want to go back to that basic information. When we have a patient present after a sexual assault, we want to go back to that basic information, understanding that the same thing that will guide our exam will also guide us if HIV NPEP is indicated. So we want to know the following things. Who, what, where, when, which can also be gathered through the event history, which will be elaborated upon in the same assessment. Basically, what we want to know is, is HIV NPEP indicated? This algorithm from the Center for Disease Control and Prevention allows everyone a good understanding of the breakdown of what we need to be considering when wanting to know if there's a substantial or negligible risk for HIV acquisition. Again, I'll give everyone a few seconds to look at this. Another thing to look at is understanding risks of exposure by act. This is helpful for when a patient tells you the nature of the assault. This will lead us to being able to inform our patients a little more in their decision. Also, we can educate ourselves on knowing that our communities look like, knowing what they look like. For example, looking at the local health department and state risks and epidemiological data. This also extends to knowing the research and data on the medications. Like whether or not HIV mpep will be effective for our patients. This is a big conversation and digging into on your own part or a conversation with your local infectious disease doctors or providers to help advise in your program. When offering HIV mpep, we want to make sure our patient is in a healthy place to take them. We want to complete the following lab work. A pregnancy test, hepatitis B antigen and antibody, hepatitis C antibody, rapid HIV, complete blood count, complete metabolic panel. We want to make sure we're not just doing a basic metabolic panel and leaving out liver function tests. A baseline gonorrhea and chlamydia test, whether this is PCR or a NAT test and a wet prep. We also want to make sure we're offering GCCT, hep B, and trichomoniasis prophylaxis. We know that in the presence of STIs, there can be an increased risk in acquiring HIV. And in some programs, it's something to consider for addressing these other healthcare needs as we might be the only healthcare visit some of these patients have received in a while. Here's a list of the recommended centers for disease control and prevention. And the World Health Organization guidelines, they make recommendations for adult and adolescents stating that a three-drug antiretroviral regimen is preferred. We're not covering pediatric dosing, of course, in this presentation, but know that there are recommendations within the CDC and World Health Recommendations. Now, different regions have different combinations. Reach out to your local experts who are able to guide you in the best approach for your patients and community. But if you recall, we discussed how this patient we reviewed earlier had received Truvada and Isentris or Raltagravir, which is pointed to up at the top in the blue arrows. Since then, the program has changed to Truvada and Dalyutagravir, which you will notice is in that same box. These changes and decisions were made based on a multidisciplinary team discussion between infectious disease providers, medical supervisors, the emergency department and infectious disease pharmacists, local community pharmacies, and the same team among others. That being said, there's a lot to know about these medications. Now, we won't be going to all the side effects or benefits and risks of each medication, as again, this can be an entire presentation itself. But be sure to know what you're giving and why. When we know which medications we're giving, then we can provide that appropriate education. We want to educate that medication is recommended to be given within 72 hours after exposure to body fluids that would put the patient at risk. This is where the timeframe of the assault comes in helpful in more ways than one. Then, educate about the names and types of medications, such as that three-drug regimen, and how we prescribe them all together, as this is recommended. Stressing the fact that these are imperative to be taken together is important. Getting these medications as soon as possible, and the need for taking them as prescribed for the full 28 days is something that must be stressed as well. Now, side effects and contraindications or cautions can be a hindrance at times. This is why we ask past medical history and current medications to make sure these are all right for the patient to take. And we want to instruct them on normal side effects to watch out for, and for the things that they should immediately stop the medications for in return for follow-up. In this slide, we're going to discuss a lot of other considerations surrounding HIV and PEP. First, we want to acknowledge and be able to relate to our patients that there truly is an unknown efficacy for HIV and PEP. According to the CDC guidelines, we know that there has never been a randomized placebo controlled clinical trial, but there has been data pulled from animal transmission models, perinatal clinical trials, and observational studies after healthcare occupational exposures. Along with some observational and case studies. Overall, the CDC recommends that the continued 28-day adherence to the medication can reduce the risk acquiring HIV in cases of non-occupational post-exposure. Now, when patients understand this information and are able to make an informed decision on this, as well as the benefits and risks, it's very helpful. This should help inform our patient's decision to take the medication. This should help inform our decision education as well when we give this all to the patient. We have to keep in the back of our mind the immediate initiation if we're going to be giving this medication, as well as discussing the frequent dosing of the medication, as discussed earlier. As this can be difficult for some patients to adhere to. Well, I'll talk about adherence a little bit more in a bit, and of course, the difficulty of this regimen taking it so often. But not only all this, but the cost, monitoring, and follow-up need to be addressed. Because these can also be barriers to adhering to the medication. And we need to educate on this up front. In the end, we can also consider providing anti-nausea or anti-diarrheal medications to help decrease the effects of these adding to the difficulty of adhering. Now, some things to consider when starting the discharge and follow-up process is making sure that the patient understands all the education surrounding adhering to the medications for the 28 days. Now, some things to help with this process are the following. Being able to provide the first dose as soon as you get those imperative lab results back. And then upon discharge, are we able to give a starter pack, such as a three-day pep pack provided to them, especially over holidays or weekends, in order to make accessing the medications easier. Now, some states or facilities don't have this capability, and that's definitely something to consider. We also want to make sure we discuss how to contact or get set up with follow-up, whether this is with infectious disease, your program, or the patient's primary care, or someone else. Now, this should be discussed prior to them leaving, as having an appointment or process in place will make this easier for the patient to make. Counseling and advocacy should go hand-in-hand with this, as it is imperative for adherence. Advocacy and counseling can help walk our patients through some of the emotional and daily struggles that come along with taking these medications. Sometimes a ride is needed, or emotional support when the medication reminds them of the assault. Now, not only are follow-ups important, but financial considerations can be a huge barrier, just like we saw with the patient encounter earlier in the presentation. We need to be able to speak to this prior to the patient leaving the facility. So, knowing your resources will help, and we will talk about that in the next few slides, too. Finally, discharge instructions must reflect all pertinent information about the medications, follow-up, and more. I tend to highlight a lot of areas that are the most important for them to follow, and encourage them to review the discharge instructions again, once they've gotten home and gotten some rest. Now, as discussed throughout the presentation, there are great resources that can be reviewed to help strengthen your process for providing these medications. Here we have the National Protocol for Sexual Assault and Medical Forensic Examiners, Adult and Adolescents. Section 8 specifically covers this topic. Then, the guidelines put out by the World Health Organization support the CDC's recommendations, and speak to this process outside of the United States view. The Center for Disease Control and Prevention has a thorough section on STI and HIV and PEP after a sexual assault. The AIDS Education and Training Center Program has a great NPEP guide, and the PEP line at the National Clinician's Consultation Center, which are good resources to use in starting this process as well. So, there are many more resources and lots of literature out there regarding this topic. So, make sure you utilize evidence-based recommendations, and reach out to your experts in your community. After knowing the basics of providing the medications, there's still more to consider. So, at the time of discharge is when I tend to see barriers come up the most. At that time, patients tend to say, how am I going to pay for this? There are many things to consider, such as if insurance can cover this, or even if they don't even have insurance at all, what will we do? Some hospitals are able to give out the 28 days worth of medication, which is the recommendation to provide this, but not every program or clinic or even state is able to do this based on laws and capabilities. So, my recommendations are to get to know your local hospital infectious disease providers, local health clinics that treat patients who do have HIV, or local primary providers who see these patients, as they may be able to partner with you. Or consider grant funding, as this might be a possibility for your program. There are indigent programs through Gilead and Merck, the pharmaceutical companies that provide Icentris and Truvada, for example. And I encourage you to look up their process and reach out to them. But this has its limitations as well, such as housing income, insurance, and even time in accessing the medications. There are tools such as the medicine assistant tool at medicineassistantstool.org, which might be a good resource. Or if you're able to work with your victim, your crimes victim compensation program through the U.S. Department of Justice, this could bring some relief on the back end for the patient. Overall, there are many barriers to access the medications at times, and financial considerations can be one. Working with your local community, hospital, clinic, or local pharmacy, and knowing your tools and resources can help decrease the difficulty at time of discharge. One thought is to have a binder available with all these resources and the steps available to your nurses to help them, because it is very difficult in the middle of the night to recall all these details. So when you're by yourself, this will just help decrease all the difficulties in getting your patient through this process. Since we've discussed barriers to adherence, I want to go a little more into detail about this. According to the World Health Organization, enhanced adherence counseling is suggested for all individuals initiating HIV NPEP. Discharging patients is part of the normal process for any patient care, and something we do all the time is educate our patients. So much so that I even find myself having it be so commonplace, or even just basic and not adequate enough in my practice, let alone with such a complicated discharge topic such as this. There can be a myriad of reasons as to why our patients might not be able to adhere to the meds. For example, if they cannot let their partner know they are taking the medications, or if the medications remind them daily of the salt, or if they're struggling to even make it up out of bed or make it to work. These are all reasons someone might be having difficulty in adhering. So let's talk a little bit more about adherence. We'll look at non-adherence and teach back specifically to help with this. Sometimes the hardship is more than just having difficulty recalling information, but the problem is with overall non-adherence. We might see the following types of non-adherence when it comes to these medications. There is primary non-adherence. This is where the prescription is never filled or even initiated. Then there's non-persistence, where the patient stops taking the medication after starting without even being advised to by a physician or prescriber. And finally, non-conforming, which is when the medications are not taken as prescribed, such as skipping doses, taking medications at inaccurate times or dosing, or taking more than prescribed. When we translate that to how this specifically pertains to our patients who receive HIV impact, we see non-adherence as the patient still not having filled the HIV and PEP prescription two days later, and then they return to ask, how do you do this? Or non-persistence is seen as side effects from the medications, such as nausea and diarrhea, leading to the patient discontinuing the medications on their own. And finally, with non-conforming, we see the patient taking all their pills once a day, even though Isentris or Raltagravir is taken twice a day. There are many ways we can help address these problems from the beginning. A lot can be decreased in proper discharge education, and that can be successful through teach-back. Now, we all inherently know how to use teach-back, and some of us might be doing it with every discharge, but I know I myself tend to get caught up in just teaching and not really making sure things get through, especially when you're busy. So teach-back is an evidence-based health literacy intervention that promotes patient engagement, patient safety, adherence, and quality. This low-cost and low-technology intervention can be the gateway to better communication, better understanding, and ultimately shared decision-making according to the Agency for Healthcare Research and Quality. But how do we do teach-back and make sure it's effective, especially for our patients? Now, the goal of teach-back is for patients or the family to explain in their own words in order to ensure that you've explained this information clearly, and that you can validate you explained the information appropriately and fully, and that they've understood what you've said. This has been shown to be successful with medication adherence. When we make it easy to understand, we engage the patient, and we make it easy to implement. And it's been shown to take two minutes on average, and we can incorporate this not only into our HIV and PEP discharge instructions, but any other discharge instructions we use as nurses. Overall, it's a matter of thinking about actively applying this to our process and following through with it. Some ways to see that through is discussed in the next few slides. Now, we want to start with what's important. Again, I know you are all-season nurses, know a lot of this, but looking at things from a new perspective and understanding how to incorporate it in our patient populations might just have a better impact than we expect. So, start with what's important. A few sentences to highlight the parts you want the patient to take away, which will be probably two to four main points, or maybe more with HIV and PEP discharge instructions. We want to use simple language, such as changing words for better comprehension. Key phrases are important and easy to remember, and recall later for us and them. So, we'll go over some of those in a bit. And then one important thing is to make sure the patient knows this is all, so that we can make sure we presented the information right, and that this is not a quiz or punishment for them. When having them repeat back, make sure they try their own words and encourage that. Usually, actions require a demonstration back. I know we don't really do much for actions, but sometimes this is a helpful point also for discharge instructions. Be super aware of your body language. Make sure you are engaging and open, and at their level when possible, physically. And when possible, bring in family or friends who can help. If, for example, the patient is exhausted, then the family can help make sure some information is recalled later. And of course, this is if the patient gives permission. Print out some visuals, such as highlighting our discharge instructions, or writing important things in the margins for visual cues, can definitely be beneficial. And try to avoid questions such as, did you get that? Instead, we're going to go over key phrases that we can use. The flow is pretty simple, but important. We want to share information, confirm the patient's or family member's understanding, rephrase and clarify if necessary, and then continue back on with that process. You might find it easier to do this after each specific point, or do key phrases at the end. For example, some key phrases that can be used are, just to make sure I explained it well, can you repeat back to me how often you take the medication? Or, this can be a lot of information. Just to make sure I covered everything, I'm going to have you repeat a few things back. And then have them answer each of the following questions individually. When did you need to take your next dose? How often do you take your medications? When did you need to take your medications? Which side effects are normal? Forensic nurses are perfectly placed to be the person to explain these discharge instructions to our sexual assault patients. Know that what you do can make a difference in how the patient may take their medication. So go slow, highlight or write notes as needed, and make time for that teach back and overall encourage understanding. Some last things to consider. What are the implications for your individual practice and your program or team? How does this work within your world? Also, what do other programs do? Sometimes what works for one program, like in this case presentation, does not make sense in your program. Be aware of what your resources are and how to access them in order to provide the best care possible for your patient. Consider what do other policies say? How can we learn from them and incorporate them in our process and our program? Or consider toolkits and other education resources for further education on how to access and assess and treat these patients. Peer review should also be a part of your process. For example, this chart was reviewed by another peer on the team, where this nurse learned how to improve upon her practice in the future and areas for quality improvement, overall care to this patient population were evaluated based on this case review we did. And lastly, hindsight is 20-20. All we can do is continue to learn and improve our process. Now, I hope this has been helpful to give you a good perspective on how to approach a patient who has experienced sexual assault and who received HIV and PEP. I know there are many areas we're not able to get into specific details on, but hopefully this will point you in the right direction. Now, keep in mind that this is a huge undertaking, seeing patients who have experienced sexual assault and then specifically also adding HIV and PEP. This is something that you must familiarize yourself with and be able to guide an education provided through to your patients, the whole process. But know that you are not alone. There are other programs and resources out there that are able to help and offer guidance. I'm always happy to help as well. So if you have any questions, please feel free to reach out.

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