There are 3 basic modalities for contact tracing: notification by the index case (patient referral [PaR]), notification by the health care professional (provider referral [PrR]), and conditional notification (conditional-patient referral [CpR]), through which the patient is initially responsible for notification, but if they fail to do so within a specific timeframe, the health care professional takes over. Another additional tool used in some countries is the direct provision of drug to contacts by the index case (patient-delivered partner therapy [PDPT] or expedited partner therapy [EPT]2,3). Fig. 1 illustrates these 4 methods, including their advantages and disadvantages.

Figure 1.

Contact management. PaR: patient referral; PrR: provider referral; CpR: conditional-patient referral; EPT: expedited partner therapy.

Adapted from: Hansman et al.

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PaR can be reinforced by providing the patient with written information about the infection to give to their contacts, as it has been shown that the provision of educational materials increases partner treatment success.4,5 Additionally, the use of new technologies—text messages, emails, mobile apps, automated websites—allows for anonymous communication between the patient and the partner, which can speed up the notification process.4 A systematic review concluded that, although studies found high levels of interest and acceptability for electronic notification, there was little evidence of actual use.6

EPT is a process by which the contact receives treatment without being assessed by a health care professional, either through direct medication administration or by providing medical prescriptions.7 This modality is not currently considered in Spanish legislation; however, it is supported by clinical studies for the treatment of gonorrhea and chlamydia in heterosexual couples and could play a role in trichomoniasis. It is not recommended for syphilis or in men who have sex with men due to the high risk of coexisting STIs.

A Cochrane review failed to identify a single optimal strategy for contact tracing for any particular STI,4 so it should be individualized according to each clinical scenario. According to a systematic review, between 58% and 93% of patients prefer to communicate the infection themselves (PaR). However, only 20% up to 30% of partners ultimately came in for evaluation.8

It is often difficult to pinpoint the exact moment of infection for the index case. Contacts should be traced over time depending on the type of infection, based on the natural history of each STI, the patient's history, and laboratory tests. Table 1 shows the recommended contact tracing periods for each infection.9

Contacts should undergo appropriate testing to detect the infections to which they have been exposed and be treated based on the results. In addition, depending on their history and risk behaviors, the contact should be screened for other STIs (Grade A, Level I).9

Epidemiological management, in which treatment is administered before laboratory confirmation of infection, has a lower level of recommendation (Grade C, Level IV)9 and should generally be avoided except in the case of syphilis.10

The treatment regimen should be the same as that recommended for the index case, except in pregnant patients or known allergies. The use of condoms should be recommended until the treatment is complete and symptoms have disappeared.7

One of the main factors associated with poor control of STIs is the ethical–legal difficulties that arise during contact tracing. In Spain, there is no legislation that specifically addresses the special complexity of STIs. According to the national legal framework, the following questions arise:

• 1.

  Is there a legal obligation to notify? Who is responsible for notifying contacts? Yes. From a legal and ethical standpoint, the primary responsibility for contact tracing lies with the index case (patient referral), who has the legal obligation to inform their contacts of the risk of having contracted a serious disease.11–13 Failure to do so could result in a criminal offense of intentional injury.14

• 2.

  What if the index case refuses to inform? The physician must document this in the health record and warn the patient that if they fail to fulfill their duty to inform, the health care professional may be exempt from the duty of confidentiality due to the serious risk to third parties.11 Contact tracing by the health care professional (provider referral and contract referral) presents significant legal and ethical challenges regarding data confidentiality, professional secrecy, and the duty to assist.12,15–17 To safeguard other important interests, such as the physical integrity of third parties, the ethical and legal framework would allow the health care professional to breach professional secrecy, access confidential personal data, and notify contacts.13,17–20

• 3.

  What if the patient does not know or refuses to provide the contacts’ information? The General Health Act provides for citizens’ duty to cooperate, including abstaining from actions that hinder or prevent public health interventions.21 In such situations, we can only inform the patient of their obligations, the consequences of non-compliance, and document everything in the health record.

Despite all of the above, in doubtful cases or when balancing the rights involved is particularly complex, the Ethics Committee of the relevant hospital or the hospital legal services may always be consulted to provide support in clinical decision-making.

Minors aged 12–16 are considered legally minors in health care. As long as they are considered emotionally and affectively mature and capable of understanding the situation, a patient of this age has the right to be heard, and their opinions should be duly considered based on their age and maturity. For this purpose, they should receive information in comprehensible language, in accessible formats, and adapted to their circumstances. However, their legal guardians or representatives will give consent for decision-making on their behalf.14

The presence of an STI in a minor under 16 years of age should be considered a possible marker of sexual abuse.

In the case of a minor who is emancipated or is 16 years old and has not been legally declared incapacitated nor considered incapable (in the opinion of the health care provider), the minor would be the sole holder of the right to informed consent regarding tests, receiving results, and administering treatments, without the need to inform legal guardians or obtain their consent on the minor's behalf.

However, if the medical decision to be consented to involves a serious risk to the minor's health or life (again, at the discretion of the health care provider), consent will be given by the parents or guardians after hearing and considering the minor's opinion.

In general, any act that violates another person's sexual freedom without their consent is considered a sexual assault. Consent will only be understood to exist when it has been freely expressed through actions that, given the circumstances of the case, clearly indicate the person's will.31

The Criminal Code specifically addresses sexual assaults on minors under 16 years of age, considering not only any sexual act performed with the minor as assault but also sexual acts that the minor performs with a third party or on themselves at the instigation of the perpetrator (Annex 3.3).32

However, it will not be considered sexual assault if there is free consent from the minor under 16 years of age and the perpetrator is close to the minor in age and level of physical and psychological development.

The heads of Health Services and the health care personnel within them are especially obligated to report to judicial authorities any fact they become aware of in the course of their work that may be a crime, especially when it involves minors under 16 years of age.

The medical and forensic evaluation should be performed jointly in a single session, in a location that ensures the safety and privacy of the victim and in the presence of an authorized companion, if desired. The patient must give written consent for the various procedures (Annex 4.2). This will allow the court on duty to be notified for the immediate transfer of the forensic physician and the Judicial Police to facilitate the in situ filing of a complaint. If there is no consent, only a clinical evaluation will be performed, and a medical injury report will be issued.

Without prejudice to any life-threatening injuries that must be treated immediately, once the samples are collected, medical treatment and necessary preventive measures should be implemented:

• -

  Treatment of physical injuries.

• -

  Tetanus prophylaxis: In the presence of lacerated-contused wounds, depending on their characteristics.

• -

  Pregnancy prevention:

• a)

  If the victim was not previously pregnant or is not using an effective contraceptive method, after obtaining consent, pregnancy prophylaxis can be provided by the Gynecology Service.

• b)

  The next menstrual period should be confirmed, or a pregnancy test should be repeated 2–3 weeks later.

• c)

  The victim must be informed that, in the event of pregnancy resulting from the sexual assault, they are legally entitled to an abortion.

• -

  Prevention of STIs1,7,40: post-exposure prophylaxis (PEP) should be offered for HIV, HBV, gonorrhea, Chlamydia, syphilis, and Trichomonas vaginalis (Table 4) along with follow-up serological tests (Table 5).

  Table 4.

  Post-exposure prophylaxis for STIs. GRADE levels of evidence.

  HIV
  Type of exposure	Recommendation	Treatment protocol
  Anal or vaginal intercourse (insertive or receptive) without a condom or improper condom use	PEP is recommended (strong recommendation, low-quality evidence)	Tenofovir/emtricitabine every 24h+raltegravir every 12h, for 28 days (strong recommendation, moderate-quality evidence). Start preferably within the first 24h and always within 72h. Do not start after 72h (strong recommendation, moderate-quality evidence). Discontinue if the source is confirmed to be HIV-negative (strong recommendation, low-quality evidence).
  Orogenital intercourse (insertive or receptive) without a condom or improper condom use, with or without ejaculation	Individualize PEP (weak recommendation, low-quality evidence)
  Exposure of other mucous membranes or non-intact skin to potentially infectious fluids (blood, semen, vaginal secretions, any fluid with traces of blood)
  Exposure to any fluid on intact skin	PEP not recommended (strong recommendation, low-quality evidence)
  Any type of exposure to non-infectious fluids (urine, feces, saliva, sweat, vomit, tears, nasal secretions, as long as they do not contain traces of blood)

  HBV
  Victim's vaccination status	Recommendation
  Unknown or incomplete	Administer 1 dose of HBIG and initiate/complete vaccination within the first 24h (strong recommendation, moderate-quality evidence).
  Complete	Act based on HBs Ag titers, if available within 24h:• HBs Ag≥10mIU/mL: protected. No need for PEP.• HBs Ag<10mIU/mL or not available within 24h: 1 dose of HBIG+vaccination (strong recommendation, moderate-quality evidence).

  Other STI
  Infection	Recommendation and treatment protocol
  Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis	- Single-dose regimen for convenience: IM ceftriaxone 500mg+azithromycin 1g orally+metronidazole 2g orally (strong recommendation, moderate-quality evidence). CDC7: IM ceftriaxone 500mg+doxycycline 100mg orally every 12h for 7 days+metronidazole 500mg orally every 12h for 7 days.
  Syphillis	PEP with penicillin G is ill-advised
  HCV	PEP is ill-advised. Serological follow-up for early treatment (strong recommendation, very low-quality evidence).
  HPV	CDC7: First vaccine dose if the victim is under 26 years old and unvaccinated.

  CDC: Centers for Disease Control; IM: intramuscular; HBIG: hepatitis B immunoglobulin; HBs Ag: hepatitis B surface antigen; PEP: post-exposure prophylaxis; HBV: hepatitis B virus; HCV: hepatitis C virus; HIV: human immunodeficiency virus; HPV: human papillomavirus.

  Adapted from the Expert Group of the National AIDS Plan Secretariat (SPNS), AIDS Study Group (GeSIDA), Spanish Society of Medicine and Occupational Safety (SEMST), et al.40
  Table 5.

  Schedule for repeating diagnostic tests.

  Test	According to Symptoms	2–3 Weeks	4–6 Weeks	12 Weeks	24 Weeks
  HIV					a
  Hepatitis B
  Hepatitis C
  Syphilis
  Other STIs
  Pregnancy test

  a

  If the detection is performed in blood using fourth-generation tests (combined detection of antibodies and antigen p24), a negative result is considered definitive after 6 weeks.

  Adapted from the Expert Group of the National AIDS Plan Secretariat (SPNS) et al.40

The management of a victim of suspected sexual assault requires the completion of various documents, detailed further in Annex 4.4:

• -

  Clinical history and medical report.

• -

  Injury report.

• -

  Standardized form for collected samples and chain of custody.

Before discharge, a follow-up care plan must be established:

• -

  Coordination with other health care resources, such as Primary Care, Dermatology, Gynecology, Internal Medicine, Preventive Medicine, Psychiatry, and Mental Health, depending on the needs of each case.

• -

  Coordination with other regional services for comprehensive victim care: 24-h crisis centers, phone line 016, social services, etc.

The general action plan is outlined in the flowchart in Fig. 2.

Figure 2.

Flowchart for action in case of suspected sexual assault.

Adapted from the basic guidelines of the Spanish National Health System for the management of sexual violence.7.

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