1. Sexually Transmitted Infections in Child Sexual Abuse - Update on the Evidence Base
Dr Deb Wardle

2. Medical Evidence – Forensic Evidence
One piece of the jigsaw.
‘findings’ present in less than 10% (‘supportive’)
‘Conclusive’ ‘Probable’ findings less than 5% .
Forensically significant STI’s are not common – important to be clear on interpretation when they are.
Narrative and other evidence tends to play larger part.

3. British Association Sexual Health & HIV BASHH
Adolescent Special interest group – current work in revising management of STI’s in children and young people

4. Girls and boys - NAAT testing
Self /clinician taken vulvo-vaginal (‘introital’)swab- avoiding hymen in pre pubertal
Urine –boys
Urine option in girls if above problematic-less sensitive in girls.

5. Chlamydia testing kit

6. Diagnostic kit Gonorrhoea testing kit
This lists different techniquies with swabs, NAAT and culture plates

7. HSV testing kit

8. Syphilis Testing kit

9. Routine testing – non -invasive
Sometimes type of testing non-routine –consider reasons for testing and discuss with Gum / microbiology/ virology

10. Prophylaxis for STI’s – purple book
Bacterial –low risk test & treat as required
Gonococcal resistance patterns increasing

11. ..one possible exception
IUD insertion as emergency contraception consider prophylactic antibiotics to cover PID

12. FSRH – emergency contraception guidance
…should be considered

13. Viral STIs
Hep B
Herpes
HIV
Hep C
HPV

14. Hepatitis B Vaccination within 6 weeks of exposure- prophylaxis
Global shortgage-? Link to WHO BBV reduction

15. Introduction of hexavalent vaccine into the routine childhood programme
From 1 October 2017 all babies born on or after 1 August 2017 become eligible for a hexavalent vaccine which includes protection against hepatitis B (HepB). The hexavalent vaccine will be offered in the routine childhood immunisation schedule at 8, 12 and 16 weeks of age.
The hexavalent vaccine, Infanrix hexa®, will replace the pentavalent infant vaccines, Infanrix®-IPV+Hib and Pediacel®, currently used in the routine childhood programme. This will mean babies continue to receive protection against diphtheria, tetanus, pertussis (whooping cough), polio and Haemophilius influenzae type b (Hib) as well as protection against HepB

16. Hep A
Increase in MSM
Not noted any impact on risk in assault cases- child/adult
…however if in contact with an index case hep A vax within ???3 weeks

17. ‘’Young people, particularly women aged under 25, are the group most at risk of being diagnosed with an STI. ‘’
HPS Genital chlamydia and gonorrhoea infection in Scotland: laboratory diagnoses

19. Males 9-21 years (unless msm then up to 26 years)
CDC recommendations for HPV vaccination following sexual assault
Females 9-26 years
Males 9-21 years (unless msm then up to 26 years)
Vaccination over the age of 26 years not recommended as it is less effective in reducing HPV related diseases (Saslow et al 2016)
2016 Scannell CDC 2015 HPV Recommendations for sexually assaulted patients a review and update

20. Case example
‘s’ awaiting results of x3 biopsies from extensive warts present since early 20’s.?AIN/VIN
Sexually assaulted as a teenager – now in her 50’s – bleeding from some of lesions triggered attendance.
Confident warts as a result of assault as no other partners before assault or before warts first appeared.
Continues , as always has, to adversely impact on self image and relationships

21. HPV vaccination HPV commonest STI worldwide
Lifetime acquisition 80% women 90% men
Risk factors:smoking, multiple partners,injuries during sex, concurrent STI, immunocompromised.

22. HPV Double stranded DNA virus 150 strains sexually transmitted
In many, virus dormant/transient and doesn’t lead to disease
40 mucosal strains –
High risk oncogenic strains 16,18
Low risk 9,11 warts

23. 9vHPV- Gardasil 9
6,11,16,18,31,33,45,52,58
Vaccine activates an immune response against the specific strains
Side effects usually local site specific reactions

24. Scotland
Gardasil
Secondary school girls – link on SCRRS that vaccine administered
Since Sept 17 MSM to age 45

25. HIV testing
HIV bloods (4th generation P24 antigen plus HIV antibody) 95% at 4 weeks 99.9% 12 weeks
Point of care test limited use
IF 12 WEEKS POST INCIDENT – FINGER PRICK – REPEAT WITH SEROLOGY IF POSITIVE

26. PEP CHIVA PEP guidelines Most not require Pep
Consider in all presenting less than 72 hours and assess risk- prevalence rate considering perpetrators demographics, injuries, number of assailants,liklihood of compliance…

27. Case examples
Chlamydia

28. C and chlamydia
‘c’
Mum
Step dad perpetrator

29. Mum 6 weeks post natal

30. ‘C’ 14 years old- same age male ‘friend’

31. Chain of evidence forms

32. C results
Chlamydia positive –vulvo-vaginal sample

33. Let’s go over things now results back…….14 year old friend
‘friend’ more than a friend –Chlamydia positive

34. Peripheral Child protection issue
Risk of transmission to newborn

35. Court orders, tests & results
‘C’ Chlamydia positive
‘friend’ more than a friend –Chlamydia positive
Mum – negative (baby not reqd to test)

36. Step dad- result
Positive

37. Step dad’s reaction?

38. Likely Transmission route

39. Summary- likely BASHH guidance
Prophylaxis – not antibiotics
Vaccine
– childhood routine Hep B
-HPV if not already vaccinated
Continued risk assessment for PEPSE if within 72 hours- hopefully continued low level recommended use.

40. HSV
serology

41. Questions?? 

42. Thanks for listening