CONTRIBUTION The Provision of HIV Post-Exposure Prophylaxis in the Context of Child Sex Trafficking CHRISTINE E. BARRON, MD; JESSICA MOORE, BA; GRAYSON BAIRD, PHD; ERICA HARDY, MD; AMY GOLDBERG, MD ABSTRACT Child sex trafficking (CST) victims are at risk for HIV infection due to a convergence of both social and bio- logical factors. However, sparse recommendations and guidelines exist for providers on the provision of HIV non-occupational post-exposure prophylaxis (nPEP) for CST patients. We evaluated whether pediatricians would provide HIV nPEP in a clinical vignette where a patient disclosed ongoing involvement in CST. Participants were relatively divided regarding whether they would provide HIV nPEP; 58.8% responded yes and 41.2% responded no. This highlights the need for medical guidelines to address the complex and case specific considerations of providing nPEP to these victims. KEYWORDS : child sex trafficking, human immuno- deficiency virus, non-occupational post-exposure prophylaxis INTRODUCTION Commercial sex work is widely recognized as a high-risk behavior for the transmission of human immunodeficiency virus (HIV) infection. Those entering sex work via traffick- ing are thought to face elevated HIV vulnerability due to increased violence and sexual risk exposures. 1 Sex traffick- ing is the force, fraud, coercion, or deceitful entry into sex work, or entry into such work under age 18. 1 Child sex traf- ficking (CST) is a subset of child sexual abuse that involves “crimes of a sexual nature committed against juvenile vic- tims for financial or other economic reasons.” 1 Multiple studies demonstrate that up to 40% of female sex workers entered as minors, with the average age of entry being 12 to 14 years old. 2 Due to the convergence of both social and biological fac- tors, youth involved in CST appear to be at significant risk for HIV infection and subsequent transmission. 2-7 Adoles- cent victims of CST commonly have multiple high-risk sex- ual partners and experience violence, unprotected sex, and injection drug use (IDU). Further, these youth engage in risky sexual behaviors (e.g. anal sex, violently abusive sex), creat- ing susceptibility to sexually transmitted infections. 2-6 Prior studies have found that when compared to non-trafficked adult sex workers, CST victims experience greater levels of HIV risk due to compromised ability to refuse sex or nego- tiate condom use, limited knowledge of HIV transmission, higher numbers of sexual clients, and violent sexual initi- ation. 6 In addition, there is greater sex-buyer demand for younger children due to the false belief that there is less risk of HIV transmission with a younger partner. 2 As a result, child victims are being recruited into sex trafficking ear- lier, which provides a longer period during which they have increased potential exposure and infection. 3,4 Biological factors may also heighten vulnerability to children involved in sex trafficking; larger areas of cervical ectopy pose increased opportunity for infection. 6 Addition- ally, repeated trauma to the immature genital tract during sexual intercourse increases the likelihood of microabrasions and microtears, consequentially increasing the potential for infection. 4,5 While involvement in CST concurs with risk of HIV infec- tion, no clinical guidelines exist for medical providers in addressing the provision of HIV non-occupational post-ex- posure prophylaxis (nPEP) specifically for CST youth. Given the paucity of guidelines available, our hypothesis was that pediatric attending physicians would be relatively divided in regard to whether they should either provide HIV nPEP or not when a patient disclosed ongoing involvement in CST. METHODS We constructed a survey that assessed knowledge, comfort, barriers, and medical decision making of physicians when caring for a CST population. 7 Pediatric attending physicians practicing in community/hospital-based clinics, the pediat- ric emergency department, and hospital inpatient units were asked to participate from November 2014 through January 2015. Participation in the study was both voluntary and anon- ymous. The final sampling frame was 267 physicians who were listed in the Rhode Island Hospital staff services and/ or the Department of Pediatrics at Rhode Island Hospital. All research procedures were approved by the Institutional Review Board. This study focused on one clinical vignette within the sur- vey listed below: A 17-year-old female patient presents to the emergency depart- ment. She reports an acute sexual assault by an unknown person 23 NOVEMBER 2018 RHODE ISLAND MEDICAL JOURNAL RIMJ ARCHIVES | NOVEMBER ISSUE WEBPAGE | RIMS