When 25-year old Fatuma was raped just a few doors away from her own home in Khayelitsha, South Africa, she knew exactly what to do afterwards.
“I was in shock and I felt as though my life was ruined forever. But something in me must have wanted to survive because I knew I mustn’t wash and that I had to get to a clinic within 72 hours to get medicines to protect me from HIV. I had heard it on the radio and read the leaflets.”
Beacon of hope for survivors of rape
This vital information came from the Khayelitsha Thuthuzela Forensic Centre, a “one-stop shop” for survivors of rape that is a beacon of hope in an area of South Africa that has a very high rate of sexual violence. Thuthuzela is a Xhosa word meaning ‘comfort’.
People are advised to go straight to the centre if they are sexually assaulted, to receive emergency HIV prevention medication - a 28-day course of antiretrovirals, known as “PEP”. Once there, they are also offered advice and support on preventing other sexually transmitted diseases, as well avoiding unwanted pregnancies. They are given psychological support and, if they want it, help to seek justice.
“Because South Africa has such a high prevalence of HIV, survivors of sexual assault are increasingly aware that it is essential to receive HIV prevention medication quickly. When it is taken properly, within 72 hours of a person being exposed to the virus, PEP can reduce the risk of infection by 80%. Not only is that important in itself, but it also acts as a motivator, drawing survivors into the centre where we can provide them with other services as well,” says Dr. Genine Josias, the centre’s medical coordinator.
The challenge of post-exposure prophylaxis (PEP) compliance
The need in South Africa for PEP, which stands for post-exposure prophylaxis, cannot be underestimated. Globally, the country has the largest number of people living with HIV. This, combined with high rates of sexual violence, means sizeable numbers of people are at risk of being infected with the virus.
PEP has been available in South Africa since the 1990s. Understanding of how effective it can be has been growing both amongst health providers and people who may need it. However, as in other countries, compliance with the PEP drug regimen is a challenge. “Recent evidence shows that globally only around 40% of victims of sexual assault who begin PEP complete the course properly,” said Dr Nathan Ford from WHO’s department of HIV/AIDS. “This is partly due to the complexity of prescribing PEP and also to the side effects of some of the drugs used,” he added.
Scaling up use of PEP
In 2013, WHO issued the Consolidated guidelines on the use of antiretroviral drugs for treating and preventing HIV infection: recommendations for a public health approach. An update of these guidelines, which is being released this week, aims to improve uptake and compliance with PEP by simplifying how clinicians prescribe the regimen and by recommending drugs with fewer side effects.
Dr Francois Venter, Deputy Executive Director of Wits Reproductive Health Institute in Johannesburg, believes that South Africa is in a strong position to scale up the use of PEP. “The government here has realized that HIV is a big problem and has adopted a rational approach to the disease. There has been strong interest from government in recent months to update the guidelines on PEP, particularly now that WHO has led the way,” he said.
Dr Venter, who is on the board of the Southern African HIV Clinicians Society, said the country could afford the antiretroviral drugs needed for PEP. “Many of the drugs that are needed are already registered and produced here in South Africa. The drugs are available and affordable,” he added.
Raising awareness in communities
Dr Josias, however, believes that another reason for many survivors of sexual assault not completing their course of PEP is because they underestimate the risk of their being infected with HIV. “Victims often know their attacker and think they also know their HIV status. But they may well be wrong,” Dr Josias explained.
As such, raising awareness in the community is a critical part of the work of the Khayelitsha Thuthuzela Forensic Centre and the other Thuthuzela Centres doing similar work in different parts of the country. “There are always more people who need to be educated, new children growing up. We disseminate information in every way we can, from newspaper adverts through to puppeteering and workshops.”