/ 17 February 2012

Prophylaxis: A right in name only

Prophylaxis: A Right In Name Only

The Sexual Offences Act of 2007 gives rape survivors the right to receive post-exposure prophylaxis for HIV at the state’s expense, thus raising hopes that rape survivors would in future be better protected against infection. The prophylaxis comprises a 28-day course of antiretrovirals that is prescribed to reduce the risk of HIV transmission.

The treatment is critical for rape survivors: rape bears a higher risk of HIV transmission than consensual sex because of genital or anal injury and, in cases of several perpetrators, multiple exposure to HIV.

Although the right to prophylaxis strengthens rape survivors’ rights in theory, it remains an empty promise if survivors are not aware of their right to the drug or do not receive accurate information on what it is and where to access it.

The need for information on the right to prophylaxis is made more urgent by the limitations of the drug regimen: its effectiveness decreases rapidly over time. Treatment needs to be started as soon as possible, preferably within a few hours after potential exposure to HIV. At the very latest, prophylaxis needs to be initiated within 72 hours of exposure to the virus. Once more than 72 hours have passed, the drugs are not administered because they become ineffective.

In light of these time constraints, it is vital that information on where and how to obtain the prophylaxis is easily accessible.

As part of a body of work monitoring the implementation of the Sexual Offences Act, the University of Cape Town’s gender, health and justice research unit and four non-governmental organisation partners examined the administration of prophylaxis in practice.

The findings from telephone surveys as well as interviews with police officials, health workers and rape survivors suggest that, four years after its introduction, the legal right to the treatment is a right only on paper.

Police officials and health workers need to inform victims about prophylaxis
For those survivors who decide to report the offence, the journey through the criminal justice system starts by reporting to a health facility or a police station. The Sexual Offences Act therefore requires police officials and health workers who receive the report of rape to inform survivors verbally and in writing about the existence of prophylaxis, its time constraints and where to access it.

However, our research indicates that the majority of survivors struggle to obtain information when they report the offence.

To examine the availability of telephonic information on prophylaxis, our researchers called a random sample of public health facilities in four provinces — the Western Cape, Eastern Cape, Free State and Limpopo. We found that telephonic information on the prophylaxis was scarce. Calls to a quarter of the facilities — 11 out of 43 — were never answered, despite numerous attempts to reach them. Two other facilities answered the call but would not provide information. For nine of the remaining facilities, researchers had to make several calls before the telephone was answered. These findings plainly illustrate that telephonic information on the treatment is not readily accessible for rape survivor’s counsellors calling health facilities on their behalf.

The calls to the other health facilities were more fruitful. However, when the field worker finally managed to speak to someone, either a health worker or the switchboard operator, the information provided was often insufficient.

In response to a question about what a woman who was raped should do, every fourth respondent (26%) mentioned the need to get antiretroviral prophylaxis, but only one respondent (3%) underlined the need to go to a health facility as early as possible and within 72 hours. When asked specifically about when to start the treatment, only four respondents (14%) mentioned both the urgency of starting as soon as possible and the 72-hour cut-off time of the drugs.

The failure to alert callers to the urgency of starting as soon as possible and the cut-off time is concerning, because the drugs’ effectiveness decreases rapidly over time and survivors are only eligible for the drugs if they present themselves at the health facility within 72 hours of exposure. Failure to inform survivors about these aspects of the treatment may therefore jeopardise access to it and put survivors at risk of HIV.

The inaccessibility of telephonic information would be less troubling if information was readily available elsewhere — for example, on the websites of the provincial departments of health, and given either verbally or in written form in clinics and police stations. But at the time of the research only two of the four provinces selected — the Eastern Cape and Gauteng — had information on the availability of prophylaxis on their websites and it was limited to listings of health facilities that offer it for rape survivors.

Study reveals few receive info about prophylaxis when reporting offences
Furthermore, only 11% of 122 rape survivors in our study received verbal information on prophylaxis from a police official when they reported the offence, and a mere 3% were given written information by the police — despite the fact that the police have a standardised notice with information on prophylaxis that police officers are meant to hand out.

Another disturbing finding from the survey was that five of the 30 respondents (17%) said, unsolicited, that in rape cases health workers needed to “verify” whether the woman had indeed been raped. They proposed calling the police to check the survivor’s story or examine the woman to find out whether she had really been raped.

The need to “verify” whether the rape was “real” suggests that some of the respondents from the healthcare sector were suspicious of women “crying rape” — a sentiment that was repeatedly echoed by police officers we interviewed.

Questioning rape survivors’ integrity is highly problematic, not only because it may delay access to health services, but also because it further victimises an already traumatised survivor.

It is concerning that information on prophylaxis is still so hard to obtain, four years after the Act was passed. Rape survivors and support organisations need to be able to access information when reporting the offence to the police or a health facility. If the government is serious about “affording victims a right to post-exposure prophylaxis”, as the Act sets out to do, both the provincial departments of health and the police should take practical steps to facilitate the access to the information.

For the health departments this could include disseminating basic information to health workers and switchboard operators and creating a policy on how to respond to telephonic reports of rape and requests for information. Furthermore, information about what prophylaxis is and at which facilities it is offered should be available on the websites of the departments. Police officers, too, must be trained on the Act and their duties relating to the right to prophylaxis. At the same time, police officers who fail to comply with their legal obligations must be held accountable for their actions.

Stefanie Röhrs is a researcher at the gender, health and justice research unit at the University of Cape Town. For the full research report go to: ghjru.uct.ac.za/publications.htm