Preventing HIV Infection Among Sexual Assault Survivors
We describe 131 South African sexual assault survivors offered HIV post-exposure prophylaxis (PEP). While the median days completed was 27 (IQR 27, 28), 34% stopped PEP or missed doses. Controlling for baseline symptoms, PEP was not associated with symptoms (OR = 1.30, 95% CI = 0.66, 2.64). Factors associated with unprotected sex included prior unprotected sex (OR = 6.46, 95% CI = 3.04, 13.74), time since the assault (OR = 1.33, 95% CI = 1.12, 1.57) and age (OR = 1.30, 95% CI = 1.08, 1.57). Trauma counseling was protective (OR = 0.18, 95% CI = 0.05, 0.58). Four instances of seroconversion were observed by 6 months (risk = 3.7%, 95% CI = 1.0, 9.1). Proactive follow-up is necessary to increase the likelihood of PEP completion and address the mental health and HIV risk needs of survivors. Adherence interventions and targeted risk reduction counseling should be provided to minimize HIV acquisition.
Antiretroviral therapy reduces HIV transmission risk following needle-stick exposures. Guidelines in many countries, including South Africa, also recommend post-exposure prophylaxis (PEP) following potential sexual exposure to HIV. In reports from North America, Europe and Australia, PEP acceptance, completion and HIV testing rates are generally lower following sexual assault than following consensual sexual exposures. These studies describe Western settings where HIV prevalence is relatively low in the general public but substantially higher among the men-who-have-sex-with-men who have been studied following consensual sexual exposures. Sexual assault survivors may be more motivated to accept and adhere to PEP in higher HIV prevalence areas.
However, rape survivors may be too traumatized when they seek immediate post-rape care to be able to fully understand the risks and benefits of PEP. Even in higher HIV prevalence settings like Kenya and South Africa, PEP adherence is often poor. In Kenya, survivors' willingness to accept and adhere to PEP was affected by the difficulty clinicians have discussing rape and encouraging communication with survivors. South African survivors report that counseling and other forms of emotional and psychological support are important components of PEP provision.
As in many countries, South African health care providers often lack the training to provide quality care for rape survivors, provider attitudes may be negative, there are often no post-rape care protocols, service delivery may be uncoordinated, and there is little trauma counseling and psychosocial referral. A cross-sectional study of 124 doctors and nurses in all nine South African provinces found that one-third did not view rape as a serious medical condition, and less than one-third had ever been trained on caring for rape survivors. Almost 60% reported that their hospital did not have a protocol for post-rape care, and less than half reported that they referred rape survivors for counseling.
In many countries and localities, facilities that initiate PEP after sexual assault may refer clients to specialized local clinics for the remainder of their PEP course and follow-up. There is usually no formal tracking system between or within these clinics and there is no active retention approach. In contrast, when Brazilian sexual assault survivors were followed in a more structured system, PEP completion and follow-up HIV testing rates were marginally higher than generally reported in the literature. And in a more recent study at a rural South African hospital, survivors were three times more likely to complete the entire 28 day course when they received comprehensive care from specially trained nurses than in the pre-intervention period.
Maximizing PEP completion and adherence following sexual assault in South Africa and elsewhere may warrant the development of proactive follow-up systems. Additionally, if some assault survivors are also exposed to HIV through consensual sexual relationships, they may benefit from risk reduction counseling modeled after that provided following consensual exposures. Thus, we designed a proactive, flexible, nurse-driven follow-up system for sexual assault survivors in Cape Town, South Africa. Within the context of such proactive follow-up, we describe PEP adherence and predictors of non-adherence, symptoms associated with PEP use, predictors of HIV risk prior to and following the assault, follow-up HIV testing rates and instances of seroconversion. This information can be used to continue to improve upon PEP service delivery systems for sexual assault survivors in South Africa and elsewhere by identifying survivor characteristics associated with poorer outcomes and developing and testing new strategies to improve follow-up and adherence and reduce subsequent HIV exposures and seroconversion. It also provides critical information about the level of support needed to retain sexual assault survivors for ongoing HIV prevention and testing that can inform public health policy-makers.
Abstract and Introduction
Abstract
We describe 131 South African sexual assault survivors offered HIV post-exposure prophylaxis (PEP). While the median days completed was 27 (IQR 27, 28), 34% stopped PEP or missed doses. Controlling for baseline symptoms, PEP was not associated with symptoms (OR = 1.30, 95% CI = 0.66, 2.64). Factors associated with unprotected sex included prior unprotected sex (OR = 6.46, 95% CI = 3.04, 13.74), time since the assault (OR = 1.33, 95% CI = 1.12, 1.57) and age (OR = 1.30, 95% CI = 1.08, 1.57). Trauma counseling was protective (OR = 0.18, 95% CI = 0.05, 0.58). Four instances of seroconversion were observed by 6 months (risk = 3.7%, 95% CI = 1.0, 9.1). Proactive follow-up is necessary to increase the likelihood of PEP completion and address the mental health and HIV risk needs of survivors. Adherence interventions and targeted risk reduction counseling should be provided to minimize HIV acquisition.
Introduction
Antiretroviral therapy reduces HIV transmission risk following needle-stick exposures. Guidelines in many countries, including South Africa, also recommend post-exposure prophylaxis (PEP) following potential sexual exposure to HIV. In reports from North America, Europe and Australia, PEP acceptance, completion and HIV testing rates are generally lower following sexual assault than following consensual sexual exposures. These studies describe Western settings where HIV prevalence is relatively low in the general public but substantially higher among the men-who-have-sex-with-men who have been studied following consensual sexual exposures. Sexual assault survivors may be more motivated to accept and adhere to PEP in higher HIV prevalence areas.
However, rape survivors may be too traumatized when they seek immediate post-rape care to be able to fully understand the risks and benefits of PEP. Even in higher HIV prevalence settings like Kenya and South Africa, PEP adherence is often poor. In Kenya, survivors' willingness to accept and adhere to PEP was affected by the difficulty clinicians have discussing rape and encouraging communication with survivors. South African survivors report that counseling and other forms of emotional and psychological support are important components of PEP provision.
As in many countries, South African health care providers often lack the training to provide quality care for rape survivors, provider attitudes may be negative, there are often no post-rape care protocols, service delivery may be uncoordinated, and there is little trauma counseling and psychosocial referral. A cross-sectional study of 124 doctors and nurses in all nine South African provinces found that one-third did not view rape as a serious medical condition, and less than one-third had ever been trained on caring for rape survivors. Almost 60% reported that their hospital did not have a protocol for post-rape care, and less than half reported that they referred rape survivors for counseling.
In many countries and localities, facilities that initiate PEP after sexual assault may refer clients to specialized local clinics for the remainder of their PEP course and follow-up. There is usually no formal tracking system between or within these clinics and there is no active retention approach. In contrast, when Brazilian sexual assault survivors were followed in a more structured system, PEP completion and follow-up HIV testing rates were marginally higher than generally reported in the literature. And in a more recent study at a rural South African hospital, survivors were three times more likely to complete the entire 28 day course when they received comprehensive care from specially trained nurses than in the pre-intervention period.
Maximizing PEP completion and adherence following sexual assault in South Africa and elsewhere may warrant the development of proactive follow-up systems. Additionally, if some assault survivors are also exposed to HIV through consensual sexual relationships, they may benefit from risk reduction counseling modeled after that provided following consensual exposures. Thus, we designed a proactive, flexible, nurse-driven follow-up system for sexual assault survivors in Cape Town, South Africa. Within the context of such proactive follow-up, we describe PEP adherence and predictors of non-adherence, symptoms associated with PEP use, predictors of HIV risk prior to and following the assault, follow-up HIV testing rates and instances of seroconversion. This information can be used to continue to improve upon PEP service delivery systems for sexual assault survivors in South Africa and elsewhere by identifying survivor characteristics associated with poorer outcomes and developing and testing new strategies to improve follow-up and adherence and reduce subsequent HIV exposures and seroconversion. It also provides critical information about the level of support needed to retain sexual assault survivors for ongoing HIV prevention and testing that can inform public health policy-makers.
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