1. Oral Submission to Portfolio Committee for Justice and Constitutional Development Lynette Denny Department Obstetrics & Gynaecology University of Cape Town/Groote Schuur Hospital

2. Introduction No randomised placebo-controlled trials to demonstrate efficacy of PEP after sexual exposure Neither ethically nor logistically possible Presumed efficacy based on: Reduction in sero-conversion after occupational exposure Reduction in maternal – child transmission Animal studies using SIV Few uncontrolled studies of use of PEP in rape survivors suggest effective

3. Factors Influencing Risk of Transmission of HIV due to Rape Type and frequency of exposure Probability rapist HIV positive Clinical status of HIV positive rapist HIV

4. Estimated Risk of Transmission of HIV * ExposureLikelihood transmission (per 10 000) Needle sharing67 Percutaneous (HCWs)30 Receptive anal intercourse10 - 30 Receptive vaginal intercourse8 - 20 Insertive anal sex3 Insertive vaginal sex3 - 9 *Bamberger J et al. Am J Med 1999;106:323 - 326

5. Probability rapist HIV positive Unknown whether sex offenders have higher rates of HIV infection In USA, HIV prevalence among prisoners 14 x higher than US population High rates of HIV infection reported among SA prisoners Assumption that HIV prevalence higher among rapists based on Nature of their high risk sexual behaviour Higher rates of social dysfunction (substance abuse etc)

6. Clinical status of Rapist if HIV positive Increased risk of transmission AIDS Low CD4 count (<200) P24 antigenaemia Highest in ‘window period’ Late stage disease Concomitant STD Ejaculation during rape

7. Risk factors specific to rape/sexual assault Type and frequency of exposure in SA High levels of accompanying violence Increased risk of micro-trauma to vagina Genital injury common Anal rape Multiple penetrations Multiple perpetrators Ejaculation during rape (  25 - 50%)

8. Recommendations Low risk Single perpetrator Single act of penetration No semen found in vagina No genital or other injuries Vaginal penetration only Zidovudine 300 mg bi-daily for 28 days

9. Recommendations High risk More than one perpetrator Multiple penetrations Semen found in vagina Genital or other injuries Anal penetration Combination Zidovudine 300 mg bi-daily and 3TC 150 mg bi-daily for 28 days

10. Standardised Sexual Assault Examination Medical officers trained in use of protocol Phased implementation at two hospitals in Cape Town Included provision of Zidovudine to all HIV negative women presenting within 72 hours of rape All protocols sent to LD for quality control Data entered into computerised data-base Analysis of 460 cases seen between January 1998 – September 2001

11. Age Distribution

12. Medical and Forensic Examination At time of rape% Pregnant7 Using contraception35 Not using contraception65 Teenagers 40 Prophylaxis given against Pregnancy58 STDs78 PEP for HIV66 Forensic examination performed 80

13. No. of Cases Reported to the Police and Charge of Rape Laid 0100200300400 Charge laid No charge laid Unknown Number of cases

14. Delay between Rape and Medical Examination

15. Place of Rape 0%5%10%15%20%25%30%35%40% Rapist's Home Open Space Victim's Home Motor Car Alley Terminus Public Toilet Beach Work Place

16. Proportion of Women Abducted

17. Number of Perpetrators per Rape

18. Number of Perpetrators in cases more than one Rapist 0% 10% 20% 30% 40% 50% 2345678910 Number of perpetrators

19. Measure of Violence Reported Type of violence% Grabbed36 Hit40 Punched22 Kicked17 Throttled20 Verbally Abused48 Weapons used47

20. Type of Weapon Used

21. Sexual Acts performed by Rapists % Vaginal penetration90 Sodomised8 Fellatio5 Cunnilingus2 Semen found in vagina26

22. Age Distribution of Women Anally Raped 0% 5% 10% 15% 20% 25% 30% 35% 10-1415-1920-2425-2930-3435-39 Age % of cases

23. Clinical Evidence of Trauma % Body injuries30 Neck injuries13 Face and scalp31 Vulval injuries46 Vaginal injuries26 Anal injuries7

24. What have we learned about Rape Survivors presenting to a Health Facility in Cape Town? Commonest age group presenting to health facility with complaint of rape is aged 15 – 19 yrs 75% of women present to health facilities within 24 hours of being raped (NB prevention HIV and pregnancy) High levels of accompanying violence Weapon used in just under 50% of rapes 8 out of 100 women raped are, in addition, raped anally In a quarter of rapes there are multiple perpetrators Physical evidence of injury to body and genital tract documented in large number of cases

25. What have we learned about Rape Survivors presenting to a Health Facility in Cape Town? Survivors are at significant risk of: Serious physical injury Acquisition all STDs, including HIV Pregnancy Rape Trauma Syndrome

26. Conclusions Management of Rape Survivors should be integrated and provided in one-stop rape centres Key elements of management include: Prevention of STIs Prevention Pregnancy Prevention of Rape Trauma Syndrome Treatment of physical, emotional and psychological sequelae of rape Collection of appropriate forensic evidence

27. Conclusions Major obstacles to correct management rape survivors include: Failure to integrate functions of SAPS, Justice, Health and Social Services Inadequate training of health care professionals Underestimation of degree specialisation required to perform adequate forensic examination Lack of understanding of long-term sequelae and costs of incorrect management of rape Lack of true political will

28. Conclusions Rape is one of the most important public health problems of women in South Africa with serious and costly long term sequelae for women and their families Prevention of rape, arrest and conviction of rapists and implementation of efficient, skillful and comprehensive rape management urgently required