Health-e, 18 November 2002, Implementing PEP for rape survivors

Despite Cabinet’s April decision to offer free anti-retroviral drugs to survivors of sexual assault, the programme is being undermined by time lags and survivor’s failure to complete the course of drugs.

The programme is been rolled out in Gauteng, the Western Cape, KwaZulu Natal and the Free State, but the AIDS Law Project’s Liesl Gerntholtz says the drugs are not readily available in Mpumalanga, Limpopo and the Northern Cape.

Problem number one is that many people seek help more than 72 hours after being sexually assaulted. By then, it is too late for the anti-retroviral drugs to prevent HIV infection.

"Many rape survivors are in shock. They find it difficult to talk about what has happened, and take time to come to terms with it," says Gauteng Health MEC Dr Gwen Ramakgopa.

"This is why they sometimes only seek help more than 72 hours after being attacked, when it is too late for post-exposure prophylaxis. We need to reach communities and families and explain that the sooner they seek medical attention, the better."

Specialist paediatrician and AIDS expert Dr Neil McKerrow says the time lag particularly affects children who have been sexually assaulted, as it can take a while before their assault is detected by adults.

The US-based Centers for Disease Control recommends that children get the drugs as soon as possible after the assault as the HI virus passes more easily through their immature genital tracts than it does in adults.

The second big problem is that few of those who opt for the drugs actually finish the 28-day course, which is necessary if the drugs are to be effective.

In Gauteng, 16 medico-legal facilities are offering the drugs, while a further 11 sites will stock them by early December.

The drugs are offered for people who seek treatment for sexual assaulted within 72 hours and have tested HIV negative.

"It’s a harrowing experience," says Gerntholz, who is part of a civil society post-exposure prophlaxis (PEP) lobby group. "A woman has to take a decision to have an HIV test while she is highly traumatised."

Between July and the end of September, 1 022 women and children from the 16 Gauteng facilities were eligible for the drugs.

After they had undergone counselling, 858 opted to start the treatment but only 112 completed their treatment.

"It is difficult to say why so many people don’t complete the course, as there could be a number of different reasons," says Mohau Makhosane, deputy director of medico-legal services in the Gauteng health department.

One possible reason is that survivors are only given a week’s supply of drugs at a time, and need to come back three times for more drugs and monitoring.

"We are re-looking at our protocol to see if we can improve on it," says Makhosane. "But it is not just a matter of survivors coming back to collect the drugs.

"It is also important to check if they are taking the medication and if there are any side effects. They need medical follow-up, such as liver function tests and full blood counts."

Anti-retroviral side-effects may include nausea, fatigue, headaches and thirst.

Ramakgopa stresses that follow-up counselling and support are also necessary. "A person cannot take the drugs on an empty stomach, so we need to assess their nutritional and other needs," she says.

The University of Cape Town’s Professor Lynnette Denny, who has treated a number of rape survivors, says that it is hard for women to complete the course as every pill reminds them of their ordeal.

"Most rape survivors want to shut out their experience and go on with their lives," says Denny. "But every day for 28 days while they take the drugs they are reminded of what has happened to them."

Gerntholtz says a third big problem is that many health workers simply do not know about the PEP programme, which means that women who should be offered the drugs are not getting access to them.

"There is a lack of information about what PEP is and which hospitals and clinics are offering it," says Gerntholz. "There is also no clarity about whether doctors at hospitals that are not part of the chosen sites but have anti-retroviral drug supplies for needlestick injuries can offer these to rape survivors."

Ramakgopa said while she did not see a problem with women getting an initial starter-pack from a hospital outside the chosen sites, such a woman needed to be referred to one of the sites so she could be properly monitored.

Gauteng has set aside R5-million from a discretionary budget to pay for the unbudgeted-for drugs.

It offers dual therapy (two drugs, namely 3TC and AZT) taken every eight hours as the standard regimen at a cost of R961,52 per person. Triple therapy is available in cases involving severe injuries or gang rape at a cost of R1 455,44 per person.

"We decided to offer what was already available for healthworkers who get needlestick injuries for now," explains Ramakgopa. "But MinMEC will assess this and decide if we need to change the dug regimen."

At present, anti-retroviral drugs are available at the medico-legal sites at Hillbrow, Natalspruit’s Sinakelwe clinic, Sebokeng, Leratong, Chris Hani Baragwanath’s Nthabiseng clinic, Kopanong, Soshanguve III, Laudium, Mamelodi, Skinner Street in Pretoria, Carletonville, Soweto’s Zamokuhle clinic, Lenasia South, the Teddy Bear clinic in Parktown, Heidelberg and Nigel.

How PEP works in sexual assault

  • For HIV infection to take place, the Human Immuno-deficiency Virus (HIV) needs to penetrate the genital tissue (mucosal membrane) and establish itself in the cells of the lymphatic system (which controls the body’s immune response).
  • Once the virus has penetrated the tissue, it takes about 48 hours to establish itself in the lymph nodes. It takes approximately 72 hours (6 days) before the virus gets into the blood stream.
  • This delay presents an opportunity to prevent the HIV exposure from becoming an HIV infection through anti-retroviral drugs that interrupt the virus’s growth (viral replication).
  • Experiments on monkeys have shown that a course of one anti-retroviral drug administered within 72 hours of HIV exposure delayed, but did not prevent, infection. However, monkeys treated within eight hours of HIV exposure did not become infected.
  • Anti-retroviral drugs are also used to treat health workers with needlestick injuries. A 1995 review of health workers in France, Italy, Britain and the United States who had been given anti-retroviral drugs after being exposed to HIV-infected blood found an 81% decrease in risk for HIV, thus indicating that the drugs can be used as prophylaxis (as a preventative measure after exposure).
  • The use of a single anti-retroviral drug can prevent up to 50% of HIV positive mothers from passing the virus on to their babies, also indicating that the drugs have a prophylactic effect – this time on the foetus.
  • The use of a 28-day course of anti-retroviral drugs as post-exposure prophylaxis (PEP) for survivor of sexual assault is now recommended in a number of countries under controlled circumstances.