South Africa is often considered to be in the unfortunate position of having some of the world’s best laws and poli-cies to protect women and children but an inability to implement them.
Take the roll-out of post-exposure prophylaxis (PEP) for rape survivors to prevent HIV infection. In April 2002, Cabinet announced that it was making anti-retrovirals available to victims of sexual assault. A protocol for the Gauteng department of health was in place by June 2002 and implementation began at the end of that month. Curently there are 53 treatment sites, 27 community- based referral centres and 26 clinical medico-legal centres that are equipped to perform forensic examinations using a crime kit, administer emergency contraception and prescribe antibitotics against sexually transmitted diseases. Patients are also given an HIV rapid test, which entails both pre- and post-test counselling.
But dissatisfaction with the programme has been widespread and there have been media reports about rape survivors either not knowing that treatment was available, not being treated properly when they tried to access PEP or failing to complete the course of treatment. The Gauteng health department became concerned about the low rates of adherence to PEP, averaging 16% across sites, and last year commissioned the Centre for the Study of Violence and Reconciliation to find out why.
The research was conducted last year over a period of eight months at seven of the 30 treatment sites established in Gauteng at the time of the study.
Researchers found that patients did not understand how to take the drugs, either because health workers did not explain it properly or because they were too traumatised to take in the information.
Some patients stopped taking the medication because of side effects. Some healthcare workers were not familiar with how to administer the medicine. Out of a sample of 37 healthcare workers, only 10 had received training.
This problem was not confined to public hospitals. The study included one private facility and found that staff weren’t necessarily better trained or less judgemental towards patients.
Another issue, which deterred survivors from seeking PEP treatment, was the attitude of health workers. One patient recounted how she was screamed at by a nurse when she went to the centre after being raped: “That’s when she told me that ‘As a 17-year-old girl, what were you thinking? You deserve things like that’.”
Difficulties also arose at sites where treatment is accessed through the casualty department of a hospital, instead of a standalone centre.
“If done properly, the procedure of examination, counselling and testing should take hours. In the meantime, an understaffed casualty department is also expected to deal with other incoming patients, such as car accident victims,” explains Lisa Vetten who, with Sadiyya Haffejee, conducted the research.
“Busy, chaotic casualty departments are a horrible environment for someone who has already been traumatised by sexual assault,” she adds.
Only 56% of the sites provide a 24-hour service, with many of the specialist rape facilities closed at weekends and at night, which is when most rapes occur and patients are treated in casualty.
One patient spent four-and-a-half hours shuttling between two police stations before finally being taken to a health facility. She then waited two-and-half hours before being examined by a doctor and had to wait a further two hours before being taken home by a police officer.
Mohau Makhosane, deputy director general for medico-legal services in the department, says it is precisely this independent perspective that made it vital to have the research conducted by a civil society organisation: “We can’t be both player and referee at the same time.”
The department has moved swiftly to act on recommendations in the report, since October 2004.
Makhosane says the report drove home the importance of not just providing medication but psycho-social support for survivors. He says 132 staff have since been trained on adherence counselling and 33 doctors and nurses will soon begin a five-week course on sexual assault care practice.
Debriefing sessions are being held to help health workers who treat survivors. The department has purchased four colposcopes, which are used for internal physical examinations of survivors, and 16 computers to be used for record keeping purposes at centres.
Vetten says that, while it is the role of civil society to monitor service delivery in government departments, it is also “important to applaud them when they take positive steps to deliver better service to the people. This is one very positive example where they have tried to turn a paper policy into a reality.”
About PEP