STRENGTHENING SEXUAL ASSAULT CARE AND HIV PEP IN RURAL

SOUTH AFRICA: THE REFENTSE MODEL

Presented by Julie Pulerwitz, ScDDirector, Social and Operational Research, HIV/AIDS

Scientific Development WorkshopOperations Research on GBV/HIV

AIDS2014, Melbourne, July 22, 2014

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.

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

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

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).

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.

Intervention ModelFive components:1. Sexual violence advisory committee (SVAC) 2. Hospital rape management policy 3. Training workshop for service providers 4. Centralization and coordination of care through a

designated examining room 5. Community awareness campaigns

Evaluation Pre/post intervention design (review of 144 patient charts) to assess potential improvements in: 1. Quality of general post-rape care (forensic

history and exam, provision of EC, STI treatment, referrals)

2. Provision of PEP (access to VCT, provision of and completion of full 28-day course)

3. Efficiency and utilization of the service (number of service providers seen on first visit, volume of rape cases presenting to hospital per month)

Quality of care Indicators Pregnancy Prevention Pregnancy test given

EC given STI STI meds given VCT and PEP Any VCT done

VCT on first visit Any PEP given 28d given 1st visit

Referrals Other providers

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.

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

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.

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.

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.

Authors and Institutional Affiliations • Julia C Kim, Ian Askew, Lufuno Muvhango, Ntabo

Dwane, Tanya Abramsky, Stephen Jan, Ennica Ntlemo, 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

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