Strengthening sexual assault care and HIV pEP in rural south Africa: The Refentse Model

1. Strengthening sexual assault care and HIV pEPin rural south Africa: The Refentse Model Presented by Julie Pulerwitz, ScD Director, Social and Operational Research, HIV/AIDS Scientific Development Workshop Operations Research on GBV/HIV AIDS2014, Melbourne, July 22, 2014

2. Context • Sexual violence is increasingly recognized as an important driver of the HIV epidemic within sub-Saharan Africa. • South Africa remains the country with the largest number of PLHIV in the world - 5,6 million people (UNAIDS,2012). • In addition, South Africa also has the highest incidence of rape reported to police.

3. Problem • International guidelines highlight central role of health sector in clinical care following sexual assault • Number of common challenges to service delivery noted in global North and South • absence of institutional policies or treatment protocols • lack of relevant training for healthcare workers • negative attitudes from service providers • fragmented and sub-standard provision of clinical care • poor collection of forensic evidence • lack of trauma counselling or psychosocial referrals

4. Refentse Project • Implement and evaluate a nurse-driven, comprehensive, post-rape care model integrated into existing HIV/RH services • Including HIV post-exposure prophylaxis (PEP) • Based at 450-bed district hospital in rural South Africa

5. Formative Research • Assessment of sexual assault services at the study hospital. • Key informant interviews conducted with service providers, including doctors, nurses, social workers, pharmacists, and police officers (n = 16). • Questionnaires completed by service providers to document issues related to provision of post-rape care (n = 55). • Review of medical charts documented objective evidence regarding actual post-assault treatments (n >100).

6. Key Findings • Capacity gaps:Few service providers had prior training on post-rape management. • Institutional obstacles:Rape cases were not prioritized, but were directed to wait in the general Out Patients Department (OPD) queue. • Limited PEP delivery:Among those patients who presented <72 hours of the assault (in time to receive PEP), about half were automatically excluded from PEP eligibility because VCT was unavailable at the time.

7. Intervention Model Five components: • Sexual violence advisory committee (SVAC) • Hospital rape management policy • Training workshop for service providers • Centralization and coordination of care through a designated examining room • Community awareness campaigns

8. Evaluation Pre/post intervention design (review of 144 patient charts) to assess potential improvements in: • Quality of general post-rape care (forensic history and exam, provision of EC, STI treatment, referrals) • Provision of PEP (access to VCT, provision of and completion of full 28-day course) • Efficiency and utilization of the service (number of service providers seen on first visit, volume of rape cases presenting to hospital per month)

10. Analysis • Crude risk ratios (RR) of the intervention effect on all of the outcome indicators were calculated along with 95% confidence intervals. • Risk ratios were analyzed using Poison regression models with robust standard errors • Multivariate Poisson regression adjusted for potential confounders including presentations <72 hours after assault, presentation ‘after hospital hours’, age <14 years, sex of attending physician, and patient seen by a senior or junior doctor.

11. Improved Quality of Care Found • Quality of post-rape care improved significantly across all 11 indicators, including quality of clinical history, provision of pregnancy testing/EC, and referrals for counseling. • Provision of VCT increased from 60% to 87%, while syndromic treatment of STIs increased from 88% to 92%. • Significant improvements seen in provision of PEP. • Patients more likely to have received PEP (starter pack or full 28 day course) • Patients more likely to receive the full course on their first visit

12. Ethical considerations • 3 separate IRB reviews (U of Witwatersrand, London School of Hygiene and Tropical Medicines, Population Council). • Data collection informed by international guidelines on conducting research on gender-based violence. • E.g., Face–to-Face interviews conducted in a private room with a female interviewer. • Counseling routinely offered to research staff and subjects. • For patients younger than age 14 years, interviews conducted with parent/guardian. • Careful attention to developing and piloting provider counselling and screening skills.

13. Methodological Challenges • Pre-post design with one facility only (no control facilities). • Medical charts documented evidence regarding treatments undertaken as recorded by provider, as opposed to outside observer.

14. Conclusion • The Refentse Model was the first intervention study from an African setting that evaluated a ‘comprehensive model’ for response to sexual violence. • Results suggest it is possible to improve comprehensive sexual assault services including PEP within a public sector hospital, using existing staff and resources. • With additional training, nurses can play an expanded role in post-rape care.

15. Authors and Institutional Affiliations • Julia C Kim, Ian Askew, Lufuno Muvhango, Ntabo Dwane, Tanya Abramsky, Stephen Jan, EnnicaNtlemo, Jane Chege, Charlotte Watts • Institutional affiliations • Rural AIDS and Development Action Research Programme (RADAR), School of Public Health, U. of Witwatersrand • Gender, Violence and Health Centre, London School of Hygiene and Tropical Medicine • Population Council • The George Institute for International Health

16. Acknowledgements • The study was made possible through the United States Agency for International Development • The Project Advisory Committee • The Department of Health and Social Welfare in Limpopo Province and Mpumalanga Province in South Africa • The Western Cape Provincial Reference Group for Sexual Violence for their technical support in the training workshop and in developing intervention tools