HIV/AIDS Overview

HIV (human immunodeficiency virus) infection has now spread to every country in the world. Statistics show that approximately 40 million people are currently living with HIV infection, and an estimated 25 million have died from this disease. The scourge of HIV has been particularly devastating in sub-Saharan Africa and South Africa, but infection rates in other countries remain high. In the United States, approximately 1 million people are currently infected. Here are a few key points about the disease: y y Globally, 85% of HIV transmission is through heterosexual intercourse. In the United States, approximately one-third of new diagnoses appear to be related to heterosexual transmission. Male-to-male sexual contact still accounts for more than half of new diagnoses in the U.S.Intravenous drug use contributes to the remaining cases. Because the diagnosis may occur years after infection, it is likely that a higher proportion of recent infections are due to heterosexual transmission. Infections in women are increasing. Worldwide, 42% of people with HIV are women. In the United States, approximately 25% of new diagnoses are in women, and the proportion is rising. There is good news on one front. New HIV infections in U.S. children have fallen dramatically. This is largely a result of testing and treating infected mothers, as well as establishing uniform testing guidelines for blood products. In order to understand HIV and acquired immunodeficiency syndrome (AIDS), it is important to understand the meanings behind these terms: y HIV stands for the human immunodeficiency virus. It is one of a group of viruses known as retroviruses. After getting into the body, the virus kills or damages cells of the body's immune system. The body tries to keep up by making new cells or trying to contain the virus, but eventually the HIV wins out and progressively destroys the body's ability to fight infections and certain cancers. The virus structure has been studied extensively, and this has helped scientists develop new treatments for HIV/AIDS. Although all HIV viruses are similar, small variations or mutations in the genetic material of the virus create drug-resistant viruses. Larger variations in the viral genes are found in different viral subtypes. Currently, HIV-1 is the predominant subtype that causes HIV/AIDS. AIDS stands for the acquired immunodeficiency syndrome. It is caused by HIV and occurs when the virus has destroyed so much of the body's defenses that immune-cell counts fall to critical levels or certain life-threatening infections or cancers develop.

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HIV/AIDS Transmission
HIV is transmitted when the virus enters the body, usually by injecting infected cells or semen. There are several possible ways in which the virus can enter. y Most commonly, HIV infection is spread by having sex with an infected partner. The virus can enter the body through the lining of the vagina, vulva, penis, rectum, or mouth during sex. Although intercourse is the primary risk factor, oral sex transmission is also possible. HIV frequently spreads among injection-drug users who share needles or syringes that are contaminated with blood from an infected person.

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Women can transmit HIV to their babies during pregnancy or birth, when infected maternal cells enter the baby's circulation, or through breastfeeding. HIV can be spread in health-care settings through accidental needle sticks or contact with contaminated fluids. Very rarely, HIV spreads through transfusion of contaminated blood or blood components. If tissues or organs from an infected person are transplanted, the recipient may acquire HIV. HIV has been spread when organs from an infected person are transplanted into an uninfected recipient. People who already have a sexually transmitted infections, such as syphilis,genital herpes, chlamydial infection, human papillomavirus (HPV), gonorrhea, or bacterial vaginosis, are more likely to acquire HIV infection during sex with an infected partner. The virus does not spread through casual contact such as preparing food, sharing towels and bedding, or via swimming pools, telephones, or toilet seats. The virus is also unlikely to be spread by contact with saliva, unless it is contaminated with blood.

DIFFERENCE BETWEEN HIV & AIDS

AIDS is the final stage of the HIV infection. A person is said to have AIDS when the cd4 counts drops below 200 and or a person has 1 or more opportunistic infections. The OIs, as they are called, are normal infections that a healthy person would be able to fight off. The four stages of the HIV infection are as follows: 1) The period following infection is called the window. It is called this because it reflect the window of time between infection and that which antibodies are devlop in a person. The HIV test looks for antibodies not the virus. 2) The second stage is called seroconversion. This is when the body begins to develop lots of antibodies to fight off the virus in the body. During this period a person may have flu like sympton. Also during this period is said to be very infectious. 3) The third stage is called symptom free. During this period a person may have no sympton what so ever. This can last any where from 6 months to well over ten years. The medical world is not sure why some people are living sympton free for so long. 4) The final stage is called AIDS. This is the period when TCELL drop to below 200 and the OI"S are present. So, as we see, HIV is a infection that will leads to AIDS.

The body immune system is slowly being attacked until it is destroyed and can't fight off infections. Once this happens a person is said to have AIDS. AIDS is the final stage HIV/AIDS Symptoms and Signs
Many people with HIV do not know they are infected. In the United States, it is likely that 20% of HIVpositive individuals are unaware of their infection. Many people do not develop symptoms after they first get infected with HIV. Others have a history of a flu-like illness within several days to weeks after exposure to the virus. Early HIV symptoms also includefever, headache, tiredness, and enlarged lymph nodes in the neck. These symptoms usually disappear on their own within a few weeks. After that, the person feels normal and has no symptoms. This asymptomatic phase often lasts for years. y The progression of disease varies widely among individuals. This state may last from a few months to more than 10 years. o During this period, the virus continues to multiply actively and infects and kills the cells of the immune system. o The virus destroys the cells that are the primary infection fighters, a type of white blood cell called CD4 cells. o Even though the person has no symptoms, he or she is contagious and can pass HIV to others through the routes listed above. y AIDS is the later stage of HIV infection, when the body begins losing its ability to fight infections. Once the CD4 cell count falls low enough, an infected person is said to have AIDS. Sometimes, the diagnosis of AIDS is made because the person has unusual infections or cancers that show how weak the immune system is. The infections that happen with AIDS are called opportunistic infectionsbecause they take advantage of the opportunity to infect a weakened host. The infections include (but are not limited to) o pneumonia caused by Pneumocystis, which causes wheezing; o brain infection with toxoplasmosis which can cause trouble thinking or symptoms that mimic a stroke; o widespread infection with a bacteria called MAC (mycobacterium avium complex) which can cause fever and weight loss; o yeast infection of the swallowing tube (esophagus) which causes pain with swallowing; o widespread diseases with certain fungi like histoplasmosis, which can cause fever, cough, anemia, and other problems. y A weakened immune system can also lead to other unusual conditions: o lymphoma in (a form of cancer of the lymphoid tissue) in the brain, which can cause fever and trouble thinking; o a cancer of the soft tissues called Kaposi's sarcoma, which causes brown, reddish, or purple spots that develop on the skin or in the mouth. y

HIV/AIDS Diagnosis
HIV infection is commonly diagnosed by blood tests. There are three main types of tests that are commonly used: (1) HIV antibody tests, (2) RNA tests, and (3) a combination test that detects both

antibodies and a piece of the virus called the p24 protein. In addition, a blood test known as a Western blot is used to confirm the diagnosis. No test is perfect. Tests may be falsely positive or falsely negative. For example, it can take some time for the immune system to produce enough antibodies for the antibody test to turn positive. This time period is commonly referred to as the "testing window period" and may last six weeks to three months following infection. Therefore, if the initial antibody test is negative, a repeat test should be performed three months later. Early testing is crucial, because early treatment for HIV helps people avoid or minimize complications. Furthermore, high-risk behaviors can be avoided, thus preventing the spread of the virus to others. Testing for HIV is usually a two-step process. First, an inexpensive screening test is done. If that test is positive, a second test (Western blot) is done to confirm the result. Antibody tests are the most common initial screening test used. There are different types of antibody screening tests available: y y Most commonly, blood is drawn for an enzyme immunoassay (EIA). The test is usually run in a local laboratory, so results can take one to three days to come back. Other tests can detect antibodies in body fluids other than blood such as saliva, urine, and vaginal secretions. Some of these are designed to be rapid tests that produce results in approximately 20 minutes. These tests have accuracy rates similar to traditional blood tests. HIV home-testing kits are available at many local drug stores. Blood is obtained by a finger prick and blotted on a filter strip. Other test kits use saliva or urine. The filter strip is mailed in a protective envelope to a laboratory to be tested. Results are returned by mail in one to two weeks. All positive antibody screening tests must be confirmed with a follow-up blood test called the Western blot to make a positive diagnosis. If the antibody test and the Western blot are both positive, the likelihood of a person being HIV infected is >99%. Sometimes, the Western blot is "indeterminate," meaning that it is neither positive nor negative. In these cases, the tests are usually repeated at a later date. In addition, an RNA test for the virus might be done. Other tests, such as those that look for virus RNA and the combination test, are not commonly used for screening. y ewer agents that keep HIV from entering human cells. Enfuvirtide (Fuzeon/T20) was the first drug in this group. It is given in injectable form like insulin. Another drug called maraviroc (Selzentry) binds to a protein on the surface of the human cell and can be given by mouth. Both drugs are used in combination with other anti-HIV drugs. Integrase inhibitors stop HIV genes from becoming incorporated into the human cell's DNA. This is a newer class of drugs recently approved to help treat those who have developed resistance to the other medications.Raltegravir (Isentress) was the first drug in this class approved by the FDA in 2007. Antiretroviral viral drugs stop viral replication and delay the development of AIDS. However, they also have side effects that can be severe. They include decreased levels of red or white blood cells, inflammation of the pancreas, liver toxicity, rash, gastrointestinal problems, elevated cholesterol level, diabetes, abnormal body-fat distribution, and painful nerve damage. An expert in infectious diseases should be consulted if the patient needs concomitant treatment for diseases such as cancer or hepatitis C.

Pregnant women who are HIV-positive should seek care immediately because HAART therapy reduces the risk of transmitting the virus to the fetus. There are certain drugs, however, that are harmful to the baby. Therefore, seeing a physician to discuss anti-HIV medications is crucial.

Follow-up
People with HIV infection should be under the care of a physician who is experienced in treating the infection. All people with HIV should be counseled about avoiding the spread of the disease. Infected individuals are also educated about the disease process, and attempts are made to improve the quality of their life.

HIV Prevention
Despite significant efforts, there is no effective vaccine against HIV. The only way to prevent infection by the virus is to avoid behaviors that put you at risk, such as sharing needles or having unprotected sex. In this context, unprotected sex means sex without a barrier such as a condom. Because condoms break, even they are not perfect protection. Many people infected with HIV don't have any symptoms. There is no way to know with certainty whether a sexual partner is infected. Here are some prevention strategies: y y y Abstain from sex. This obviously has limited appeal, but it absolutely protects against HIV transmission by this route. Have sex with a single partner who is uninfected. Mutual monogamy between uninfected partners eliminates the risk of sexual transmission of HIV. Use a condom in other situations. Condoms offer some protection if used properly and consistently. Occasionally, they may break or leak. Only condoms made of latex should be used. Only water-based lubricants should be used with latex condoms. Do not share needles or inject illicit drugs. If you work in a health-care field, follow recommended guidelines for protecting yourself against needle sticks and exposure to contaminated fluids. If you have engaged in risky behaviors, get tested to see if you have HIV. The risk of HIV transmission from a pregnant woman to her baby is significantly reduced if the mother takes medications during pregnancy, labor, and delivery and her baby takes medications for the first six weeks of life. Even shorter courses of treatment are effective, though not as optimal. The key is to get tested for HIV as early as possible in pregnancy. In consultation with their physician, many women opt to avoid breastfeeding to minimize the risk of transmission after the baby is born.

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HIV/AIDS Prognosis
There is no cure for HIV infection. Before we had any treatment for the virus, people with AIDS lived only for a couple of years. Fortunately, medications have substantially improved the outlook and survival rates. Prevention efforts have sharply reduced HIV infection in young children and have the potential to sharply limit new infections in other populations. y Medications have extended the average life expectancy, and many people with HIV can expect to live for decades with proper treatment. An increasing number have a normal life expectancy if they adhere carefully to medication regimens.

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Medications help the immune system recover and fight infections and prevent cancers from occurring. Eventually, the virus may become resistant to the available drugs, and the manifestations of AIDS may develop. Drugs used to treat HIV and AIDS do not eliminate the infection. It is important for the person to remember that he or she is still contagious even when receiving effective treatment. Intensive research efforts are being focused on developing new and better treatments. Although currently there is no promising vaccine, work continues on this front.

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AIDS Acquired immune deficiency syndrome Last reviewed: June 9, 2011. AIDS (acquired immune deficiency syndrome) is the final stage of HIV disease, which causes severe damage to the immune system. Causes, incidence, and risk factors Important facts about the spread of AIDS include:
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AIDS is the sixth leading cause of death among people ages 25 - 44 in the United States, down from number one in 1995.

The World Health Organization estimates that more than 25 million people worldwide have died from this infection since the start of the epidemic. In 2008, there were approximately 33.4 million people around the world living with HIV/AIDS, including 2.1 million children under age 15.

Human immunodeficiency virus (HIV) causes AIDS. The virus attacks the immune system and leaves the body vulnerable to a variety of life-threatening infections and cancers. Common bacteria, yeast, parasites, and viruses that usually do not cause serious disease in people with healthy immune systems can cause fatal illnesses in people with AIDS. HIV has been found in saliva, tears, nervous system tissue and spinal fluid, blood, semen (including pre-seminal fluid, which is the liquid that comes out before ejaculation), vaginal fluid, and breast milk. However, only blood, semen, vaginal secretions, and breast milk have been shown to transmit infection to others. The virus can be spread (transmitted):
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Through sexual contact -- including oral, vaginal, and anal sex Through blood -- via blood transfusions (now extremely rare in the U.S.) or needle sharing From mother to child -- a pregnant woman can transmit the virus to her fetus through their shared blood circulation, or a nursing mother can transmit it to her baby in her breast milk

Other methods of spreading the virus are rare and include accidental needle injury, artificial insemination with infected donated semen, and organ transplantation with infected organs. HIV infection is NOT spread by:
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Casual contact such as hugging Mosquitoes Participation in sports Touching items that were touched by a person infected with the virus

AIDS and blood or organ donation:

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AIDS is NOT transmitted to a person who DONATES blood or organs. People who donate organs are never in direct contact with people who receive them. Likewise, a person who donates blood is never in contact with the person receiving it. In all these procedures, sterile needles and instruments are used.

However, HIV can be transmitted to a person RECEIVING blood or organs from an infected donor. To reduce this risk, blood banks and organ donor programs screen donors, blood, and tissues thoroughly.

People at highest risk for getting HIV include:

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Injection drug users who share needles Infants born to mothers with HIV who didn't receive HIV therapy during pregnancy People engaging in unprotected sex, especially with people who have other high-risk behaviors, are HIV-positive, or have AIDS People who received blood transfusions or clotting products between 1977 and 1985 (before screening for the virus became standard practice) Sexual partners of those who participate in high-risk activities (such as injection drug use or anal sex)

Symptoms AIDS begins with HIV infection. People who are infected with HIV may have no symptoms for 10 years or longer, but they can still transmit the infection to others during this symptom-free period. If the infection is not detected and treated, the immune system gradually weakens and AIDS develops. Acute HIV infection progresses over time (usually a few weeks to months) to asymptomatic HIV infection (no symptoms) and then to early symptomatic HIV infection. Later, it progresses to AIDS (advanced HIV infection with CD4 T-cell count below 200 cells/mm3 ). Almost all people infected with HIV, if they are not treated, will develop AIDS. There is a small group of patients who develop AIDS very slowly, or never at all. These patients are called nonprogressors, and many seem to have a genetic difference that prevents the virus from significantly damaging their immune system. The symptoms of AIDS are mainly the result of infections that do not normally develop in people with a healthy immune system. These are called opportunistic infections. People with AIDS have had their immune system damaged by HIV and are very susceptible to these opportunistic infections. Common symptoms are:
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Chills Fever Sweats (particularly at night) Swollen lymph glands Weakness

Weight loss

Note: At first, infection with HIV may produce no symptoms. Some people, however, do experience flu-like symptoms with fever, rash, sore throat, and swollen lymph nodes, usually 2 - 4 weeks after contracting the virus. Some people with HIV infection stay symptom-free for years between the time when they are exposed to the virus and when they develop AIDS. Signs and tests CD4 cells are a type of T cell. T cells are cells of the immune system. They are also called "helper cells." The following is a list of AIDS-related infections and cancers that people with AIDS may get as their CD4 count decreases. In the past, having AIDS was defined as having HIV infection and getting one of these other diseases. Today, according to the Centers for Disease Control and Prevention, a person may also be diagnosed with AIDS if they are HIV-positive and have a CD4 cell count below 200 cells/mm3, even if they don't have an opportunistic infection. AIDS may also be diagnosed if a person develops one of the opportunistic infections and cancers that occur more commonly in people with HIV infection. These infections are unusual in people with a healthy immune system. Many other illnesses and their symptoms may develop, in addition to those listed here. The following illnesses are common with a CD4 count below 350 cells/mm3:
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Herpes simplex virus -- causes ulcers/small blisters in the mouth or genitals, happens more often and usually much more severely in an HIV-infected person than in someone without HIV infection Herpes zoster (shingles) -- ulcers/small blisters over a patch of skin, caused by reactivation of the varicella zoster virus, the same virus that causes chickenpox Kaposi's sarcoma -- cancer of the skin, lungs, and bowel due to a herpes virus (HHV-8). It can happen at any CD4 count, but is more likely to happen at lower CD4 counts, and is more common in men than in women. Non-Hodgkin's lymphoma -- cancer of the lymph nodes Oral or vaginal thrush -- yeast (typically Candida albicans) infection of the mouth or vagina Tuberculosis -- infection by tuberculosis bacteria mostly affects the lungs, but can also affect other organs such as the bowel, lining of the heart or lungs, brain, or lining of the central nervous system (brain and spinal cord)

Common with CD4 count below 200 cells/mm3:

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Bacillary angiomatosis -skin sores caused called Bartonella, which may be caused by cat scratches

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bacteria

Candida esophagitis -- painful yeast infection of the esophagus

Pneumocystis jiroveci pneumonia, "PCP pneumonia," called Pneumocystis cariniipneumonia, caused by a fungus

previously

Common with CD4 count below 100 cells/mm3:

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AIDS dementia -- worsening and slowing of mental function, caused by HIV Cryptococcal meningitis -- fungal infection of the lining of the brain Cryptosporidium diarrhea -- Extreme diarrhea caused by a parasite that affects the gastrointestinal tract Progressive multifocal leukoencephalopathy -- a disease of the brain caused by a virus (called the JC virus) that results in a severe decline in mental and physical functions Toxoplasma encephalitis -- infection of the brain by a parasite, called Toxoplasma gondii, which is often found in cat feces; causes lesions (sores) in the brain Wasting syndrome -- extreme weight loss and loss of appetite, caused by HIV itself

Common with CD4 count below 50/mm3:

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Cytomegalovirus infection -- a viral infection that can affect almost any organ system, especially the large bowel and the eyes Mycobacterium avium -- a blood infection by a bacterium related to tuberculosis

In addition to the CD4 count, a test called HIV RNA level (or viral load) may be used to monitor patients. Basic screening lab tests and regular cervical Pap smears are important to monitor in HIV infection, due to the increased risk of cervical cancer in women with a compromised immune system. Anal Pap smears to detect potential cancers may also be important in both HIV-infected men and women. Treatment There is no cure for AIDS at this time. However, a variety of treatments are available that can help keep symptoms at bay and improve the quality of life for those who have already developed symptoms. Antiretroviral therapy suppresses the replication of the HIV virus in the body. A combination of several antiretroviral drugs, called highly active antiretroviral therapy (HAART), has been very effective in reducing the number of HIV particles in the bloodstream. This is measured by the viral load (how much free virus is found in the blood). Preventing the virus from replicating can improve T-cell counts and help the immune system recover from the HIV infection. HAART is not a cure for HIV, but it has been very effective for the past 12 years. People on HAART with suppressed levels of HIV can still transmit the virus to others through sex or by sharing needles. There is good evidence that if the levels of HIV remain

suppressed and the CD4 count remains high (above 200 cells/mm3), life can be significantly prolonged and improved. However, HIV may become resistant to one combination of HAART, especially in patients who do not take their medications on schedule every day. Genetic tests are now available to determine whether an HIV strain is resistant to a particular drug. This information may be useful in determining the best drug combination for each person, and adjusting the drug regimen if it starts to fail. These tests should be performed any time a treatment strategy begins to fail, and before starting therapy. When HIV becomes resistant to HAART, other drug combinations must be used to try to suppress the resistant strain of HIV. There are a variety of new drugs on the market for treating drug-resistant HIV. Treatment with HAART has complications. HAART is a collection of different medications, each with its own side effects. Some common side effects are:
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Collection of fat on the back ("buffalo hump") and abdomen General sick feeling (malaise) Headache Nausea Weakness

When used for a long time, these medications increase the risk of heart attack, perhaps by increasing the levels of cholesterol and glucose (sugar) in the blood. Any doctor prescribing HAART should carefully watch the patient for possible side effects. In addition, blood tests measuring CD4 counts and HIV viral load should be taken every 3 months. The goal is to get the CD4 count as close to normal as possible, and to suppress the amount of HIV virus in the blood to a level where it cannot be detected. Other antiviral medications are being investigated. In addition, growth factors that stimulate cell growth, such as erthythropoetin (Epogen, Procrit, and Recomon) and filgrastim (G-CSF or Neupogen) are sometimes used to treat AIDSassociated anemia and low white blood cell counts. Medications are also used to prevent opportunistic infections (such as Pneumocystis jiroveci pneumonia) if the CD4 count is low enough. This keeps AIDS patients healthier for longer periods of time. Opportunistic infections are treated when they happen. Support Groups Joining support groups where members share common experiences and problems can often help the emotional stress of devastating illnesses. See AIDS - support group. Expectations (prognosis) Right now, there is no cure for AIDS. It is always fatal without treatment. In the U.S., most patients survive many years after diagnosis because of the availability of HAART. HAART has dramatically increased the amount of time people with HIV remain alive.

Research on drug treatments and vaccine development continues. However, HIV medications are not always available in the developing world, where most of the epidemic is raging. Complications When a person is infected with HIV, the virus slowly begins to destroy that person's immune system. How fast this occurs differs in each individual. Treatment with HAART can help slow or halt the destruction of the immune system. Once the immune system is severely damaged, that person has AIDS, and is now susceptible to infections and cancers that most healthy adults would not get. However, antiretroviral treatment can still be very effective, even at that stage of illness. Calling your health care provider Call for an appointment with your health care provider if you have any of the risk factors for HIV infection, or if you develop symptoms of AIDS. By law, the results of HIV testing must be kept confidential. Your health care provider will review results of your testing with you. Prevention 1. See the article on safe sex to learn how to reduce the chance of catching or spreading HIV, and other sexually transmitted diseases. 2. Do not use illicit drugs and do not share needles or syringes. Many communities now have needle exchange programs, where you can get rid of used syringes and get new, sterile ones. These programs can also provide referrals for addiction treatment. 3. Avoid contact with another person's blood. You may need to wear protective clothing, masks, and goggles when caring for people who are injured. 4. Anyone who tests positive for HIV can pass the disease to others and should not donate blood, plasma, body organs, or sperm. Infected people should tell any sexual partner about their HIV-positive status. They should not exchange body fluids during sexual activity, and should use preventive measures (such as condoms) to reduce the rate of transmission. 5. HIV-positive women who wish to become pregnant should seek counseling about the risk to their unborn child, and methods to help prevent their baby from becoming infected. The use of certain medications dramatically reduces the chances that the baby will become infected during pregnancy. 6. The Public Health Service recommends that HIV-infected women in the United States avoid breast-feeding to prevent transmitting HIV to their infants through breast milk. 7. Safer sex practices, such as latex condoms, are highly effective in preventing HIV transmission. HOWEVER, there is a risk of acquiring the infection even

with the use of condoms. Abstinence is the only sure way to prevent sexual transmission of HIV. The riskiest sexual behavior is receiving unprotected anal intercourse. The least risky sexual behavior is receiving oral sex. There is some risk of HIV transmission when performing oral sex on a man, but this is less risky than unprotected vaginal intercourse. Female-to-male transmission of the virus is much less likely than male-to-female transmission. Performing oral sex on a woman who does not have her period has a low risk of transmission. HIV-positive patients who are taking antiretroviral medications are less likely to transmit the virus. For example, pregnant women who are on effective treatment at the time of delivery, and who have undetectable viral loads, give HIV to their baby less than 1% of the time, compared with 13% to 40% of the time if medications are not used. The U.S. blood supply is among the safest in the world. Nearly all people infected with HIV through blood transfusions received those transfusions before 1985, the year HIV testing began for all donated blood. If you believe you have been exposed to HIV, seek medical attention IMMEDIATELY. There is some evidence that an immediate course of antiviral drugs can reduce the chances that you will be infected. This is called post-exposure prophylaxis (PEP), and it has been used to prevent transmission in health care workers injured by needlesticks. There is less information available about how effective PEP is for people exposed to HIV through sexual activity or injection drug use, but it appears to be effective. If you believe you have been exposed, discuss the possibility with a knowledgeable specialist (check local AIDS organizations for the latest information) as soon as possible. Anyone who has been sexually assaulted should consider the potential risks and benefits of PEP.