"I just want to make sure that I am okay." Those are the first words I hear from a sexual assault patient when they arrive at a health care facility for a medical forensic exam. In the aftermath of rape and trauma, long-term health concerns are one of many challenges survivors face. As a health care provider and forensic nurse, it's our job to care for a patient who has experienced sexual violence. The issues faced in the medical response can be overwhelming and daunting not only for the forensic nurse but more importantly, the patient.
One of the issues that causes a great deal of stress for patients is the concern of contracting HIV. I have worked with and cared for numerous sexually assaulted patients whose primary concern is acquiring HIV from the assailant. Anti-HIV medication treatment is available in the form of non-occupational post exposure prophylaxis (nPEP). This vital antiviral treatment is an intensive regimen for patients and can be very heard to complete. Therefore, it is important that forensic nurses evaluate the risks and benefits for each patient and help them to understand their options.
Treatment options can be overwhelming for the patient, especially one in crisis. This makes the role of a sexual assault advocate and social worker critical to the process. A patient who experiences sexual violence and trauma may not be thinking long-term and understand the importance of receiving the antivirals within the maximum of 72 hours and continued for 28 days as recommended by the Center for Disease Control (CDC). They might be focused on just getting through today and through the exam, which can be very invasive and difficult.
Once a sexual assault patient is determined to have experienced a substantial risk of exposure to HIV, I recommend nPEP to the patient. I discuss how the medication works, its side effects, cost, the importance of compliance, and barriers to accessing antivirals. Recommending a medication is complex, and therefore, it's important to consider effectiveness, harmful reactions, and medication burden/ease of use, potential interactions, cost, and pregnancy risk. The numerous side effects of the antivirals are common reason for discontinued use of medication before the recommended 28 days. Follow-up appointments and support from health care providers and advocates can help patients complete the treatment plan, but even when patients have access to anti-HIV medication it is a challenging process.
There are many barriers that can prevent a follow-up visit, and forensic nurses work to address these issues. Challenges range from cost or medication and follow-up care to lack of transportation, difficulties getting time off from work or inability to lose wages, to safety concerns. During the follow-up visit medication compliance, side effects, cost issues with antivirals, and crisis intervention needs are discussed. It's not uncommon for patients to have many more questions or difficulty remembering what was discussed during the initial encounter. Forensic nurses can be supported by social workers and advocates who can assist in crisis intervention and can also support accessing antiviral therapy. Although meeting these needs helps to ensure antiviral treatment is properly implemented, not all medical facilities are equipped to provide this support.
The cost of the medication (upwards of $4,000 in some places) can be very difficult for patients to afford. This is especially true for people with high co-pay insurance or if they are receiving government assistance such as Medicare or Veterans' Affairs (VA) insurance. If a patient has no insurance, the best option is often to obtain the medications through the drug company at no cost. This hinges upon the patient meeting eligibility requirements for the free medication and a social worker or advocate being available to initiate this process. Even patients with Medicaid are required to pay $3 co-pay for each drug. Even this amount is difficult for patients to pay at times when obtaining over 20 days of antivirals. As you can see, maneuvering through the cost issue of obtaining the antivirals is difficult for me as a forensic nurse; it is overwhelming for the patient.
I work in a health care institution that provides 24/7 coverage forensic services caring for patients who have experienced all aspects of interpersonal violence, including sexual assault Unfortunately, not all health care providers and facilities are able to respond to the medical needs of sexual assault survivors. Access to anti-HIV medication, and the comprehensive support that makes this medication effective should be available to all patients. Consistent medical support, sensitive to trauma, should be the standard, but many healthcare institutions are not even equipped to offer a forensic nurse.
At our facility, we are able to provide a five-day starter pack for sexual assault patients. We are incredibly fortunate to have a pharmacy social worker who is instrumental in obtaining the additional antivirals. I have follow-up appointments where I discuss the patient's test results, medications, counseling and any safety issues that concern them. This is hard work. For forensic nurses, the rewards for this work can be found in knowing they have provided their patients with the best care possible, and that they are working for the best possible health care outcomes for their patients.
Even when all of these resources are in place, the process of responding to patients' medical needs with sensitivity to trauma is an incredible challenge. Yet many healthcare institutions do not have forensic nurses to care for patients of interpersonal violence. Can you imagine how difficult the experience is for these patients? I can't. It's time for us to ensure the best care possible.