Ethical Assessment of Post-Exposure Prophylaxis Guidelines in Sexual Assault Patients Suspected of Hepatitis B Viral Infection

Abstract

More than 400,000 sexual assaults are reported annually in the United States in females and males above the age of 12. Victims are likely to include members of vulnerable populations such as the disabled, homeless persons, and immigrants. Victims of such assaults are at heightened risk of contracting the Hepatitis B virus (HBV) from their assailant. Unfortunately, approximately two-thirds of people with chronic HBV are unaware of their own status, exposing for victims the risk viral transmission, disease-related cirrhosis, and hepatocellular carcinoma. Victims are also at increased risk for posttraumatic stress disorder (PTSD). Although immediate vaccination of the assaulted victim is recommended, protective levels of antibody are not present for fourteen days post vaccination. Complementary treatment with a Hepatitis B immune globulin (HBIG), however, may provide immediate protective serum concentrations. Prompt prophylactic therapeutic intervention may not only protect patients from risk of infection but may also prevent the effects of PTSD by providing victims with psychological and emotional benefit. Yet, existing Centers for Disease Control and Preventions (CDC) recommendations for suspected HBV infection in sexual assault patients recommend initiating immunoprophylaxis only in cases where the perpetrator’s HBsAg status is known, a guideline that perpetuates inequities and injustice for those equally subject to the harms of sexual assault. This paper presents an ethical assessment of prophylactic treatment for sexual assault patients suspected of HBV exposure. In the absence of equitable guidelines, we argue for the clinician’s duty to rescue sexually assaulted patients from future harm and to protect the public through mitigation of transmission using currently available and evidence-based treatment modalities. The paper concludes with an ethical foundation to advocate for modification of current guidelines in view of existing prophylactic regimens.