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Characteristics, treatment, and antiretroviral prophylaxis adherence of South African rape survivors
Global Health Sciences Literature Digest
Published December 11, 2007
Journal Article

Carries S, Muller F, Muller FJ, Morroni C, Wilson D. Characteristics, treatment, and antiretroviral prophylaxis adherence of South African rape survivors. J Acquir Immune Defic Syndr. 2007 Sep 1;46(1):68-71.

Objective

To assess characteristics of rape survivors in South Africa, as well as treatment with antiretroviral post-exposure prophylaxis (PEP), syndromic treatment for sexually transmitted infections (STIs) and emergency contraception (EC), adherence to PEP, and return for follow-up HIV testing.

Study Design

Retrospective observational study using chart review of patients presenting to a rape crisis center between May 2003 and July 2004.

Setting

The Lifeline Rape Crisis Center at Northdale Hospital in Pietermaritzburg, South Africa.

Participants

All 390 persons (389 women and 1 man) who presented to the Northdale Lifeline Rape Crisis Center during the study period.

Intervention

None. Since October 2002, the Northdale Lifeline Rape Crisis Center has provided PEP and counseling to rape survivors. Clients are offered trauma counseling and counseling on prevention of HIV transmission, including PEP and rapid on-site HIV testing (details on laboratory testing methods were not provided in the paper). Antiretroviral prophylaxis with 300mg of zidovudine and 150 mg of lamivudine administered every 12 hours is recommended to all survivors who present to the center within 72 hours of the rape incident and test HIV-negative (consistent with 2002 South African government guidelines). Clients who decline immediate testing are given a three-day antiretroviral starter pack and asked to return for testing within that period. Antiretrovirals are dispensed in seven-day packs; one pack is dispensed initially, and clients are advised to return weekly for a further three weeks to continue prophylaxis for a total of 28 days. All clients are offered a syphilis test, prophylaxis against sexually transmitted infections (STI), emergency contraception (EC), specific medical treatment, and weekly counseling. Survivors who test HIV-positive are offered counseling on safer sexual practices, encouraged to join a support group, and referred for further treatment and care.

Primary Outcomes

Data on age, gender, date of assault, counseling for HIV testing, serology results, and return for repeat antiretroviral prescriptions and follow-up HIV tests was abstracted from clinical records. Adherence to antiretroviral PEP was assessed by recording whether clients kept appointments for repeat weekly prescriptions for a total of four weeks; clients were categorized as being adherent to PEP if all four prescriptions were filled within a four-week period.

Results

Of the 390 clients, 42% were younger than 18 years of age, and the median age was 19.4 years. Ninety-nine percent of clients received HIV pre-test counseling, and 95% accepted HIV testing at presentation. Overall, 139 clients (35.6%) tested HIV-positive. Clients over 18 years of age were more likely to test HIV-positive at presentation than younger clients (p<0.001). Syphilis serology was available on 114 clients, and 5 (4%) tested positive. Only 6.4% reported condom use during the assault. More than 90% received STI prophylaxis, and less than two-thirds were prescribed EC. Of clients younger than 18 years who were eligible for EC, 77% received it, compared to 59% of those over the age of 18 (p=0.001); only 3 of the 17 eligible women over the age of 39 years (17%) received EC. Seventy-three percent of the clients presented to the facility within 72 hours of the assault. Seventy-three percent of HIV-positive women presented before 72 hours, compared with 75% of uninfected women and 50% of women who refused testing (p=0.03). The one man who presented was eligible for PEP, completed the course, and tested HIV-sero-negative at six weeks. Of the 233 clients testing HIV-negative, 198 (85%) received antiretroviral prophylaxis, 57% of whom were assessed as adherent. Of the 35 HIV-uninfected women who did not receive antiretroviral prophylaxis, 32 (91.4%) presented more than 72 hours after the assault and were ineligible, and three (8.6%) were eligible but did not receive prophylaxis. Fifty-five clients (27.1%) returned for HIV testing at six weeks; 15 (7.5%) for the three-month test, and one (0.5%) for the 6-month test. One woman, who filled only the first one-week ARV prescription sero-converted six weeks after the assault. Information on this client's re-exposure to HIV after the assault before the repeat test was not available. Adherence and return for testing was not significantly associated with age.

Conclusions

The authors conclude that post-rape care is an important service provided to South African women, and strategies should be developed to improve adherence to antiretroviral prophylaxis and follow-up testing.

Quality Rating

This study was of adequate quality. Due to the nature of this observational study and the fact that data were abstracted from existing patients' charts, it may have been affected by variety of biases, such as reporting bias and participation bias. Study findings may also have been limited by the low rate of return for re-testing, the crude adherence measure, and the lack of antiretroviral side effect monitoring. Additionally, because this study only included those rape survivors who presented at the crisis center, persons included in the study may not be representative of other rape survivors.

In Context

Sexual violence is common in South Africa and approximately 52,000 episodes of rape or attempted rape are reported to the police annually.(1) Although the efficacy of post-rape antiretroviral prophylaxis has not been determined, zidovudine reduces the transmission of HIV after needlestick injury by 81%,(2) and zidovudine plus lamivudine are effective in reducing the transmission of HIV from mother to fetus during labor.(3) Adherence to antiretroviral prophylaxis after sexual assault has been reported to be poor in a variety of developed-world settings.(4) There are few data on the characteristics of patients presenting for post-rape care and on adherence to post-rape antiretroviral prophylaxis in developing world settings.

Programmatic Implications

Given the high prevalence of HIV and large number of sexual assaults in South Africa, effective PEP for rape survivors is an important means for preventing HIV transmission and warrants further research. The low adherence and follow-up rates in this study are a concern, and highlight the need to improve support for rape survivors. Potential interventions include making post-rape services available in accessible community centers, increasing public awareness of the availability of services, reimbursing travel expenses, and closer monitoring of therapy. Programs should promote the importance of presenting for care as soon as possible after the assault, adhering to antiretroviral therapy, and returning for follow-up HIV testing.

References

  1. Selebi J. Annual report of the National Commissioner of the South African Police Service: 1 April 2002 to 31 March 2003. Accessed Feb 2, 2007.
  2. Cardo DM, Culver DH, Ciesielski CA, Srivastava PU, Marcus R, Abiteboul D, et al. A case-control study of HIV seroconversion in health care workers after percutaneous exposure. Centers for Disease Control and Prevention Needlestick Surveillance Group. N Engl J Med 1997 Nov 20;337(21):1485-90.
  3. Petra Study Team. Efficacy of three short-course regimens of zidovudine and lamivudine in preventing early and late transmission of HIV-1 from mother to child in Tanzania, South Africa, and Uganda (Petra study): a randomised, double-blind, placebo-controlled trial. Lancet 2002 Apr 6;359(9313):1178-86.
  4. Smith DK, Grohskopf LA, Black RJ, Auerbach JD, Veronese F, Struble KA, et al. Antiretroviral postexposure prophylaxis after sexual, injection-drug use, or other nonoccupational exposure to HIV in the United States. MMWR Recomm Rep. 2005; 54(RR02):1-20.