1. May 7 th 2013 Carol Odula-Obonyo Senior Medical Officer - Obs/Gyn (UHS) Management of Sexual Violence

3. Definitions

5. Definitions contd….

6. Introduction Sexual assault -any sexual act performed by one (or more) person(s) on another without consent. May include the use or threat of force. In some cases, the person does not give consent to have sex because he or she is unconscious or otherwise incapacitated. A person may be raped by a stranger, an acquaintance or date, or a family member. Rape is a legal term it refers to any penetration of a body orifice (mouth, vagina, or anus) involving force or the threat of force or incapacity (i.e., associated with young or old age, cognitive or physical disability, or drug or alcohol intoxication) without consent.

7. Sexual violence Rape Attempted rape Gang rape Defilement Attempted defilement Indecent act Sexual assault Incest by males and females Deliberate transmission of HIV and any other life threatening sexually transmissible infections Sexual offences relating to positions of authority and persons in positions of trust

8. After sexual assault. Now what ? Why did this happen to me? Could I have prevented this? Will I develop an infection or become pregnant as a result of the assault? Who should I call first? Should I report this to the police? Is this reportable? Since I was drinking, isn't this my fault?

9. The following steps are recommended after sexual assault Find a safe environment away from the assailant Call a close friend or relative – someone who will offer unconditional support Seek medical care; do not change clothes, bathe, douche, or brush your teeth until evidence is collected. A complete medical evaluation includes evidence collection, a physical examination, treatment and/or counseling. You do not have to do any part of this evaluation that you do not want to do.

10. At the clinic History taking Head to toe examination Genito-anal examination Investigations for clinical management of the survivor Investigations carried out for evidence purposes Management of physical injuries Post exposure prophylaxis Pregnancy prevention Prophylaxis of STIs including Hep B

11. The survivor

12. Evidence carried out for investigative purposes

13. Management of physical injuries

14. Prophylaxis for Stis

15. HepB future prevention

18. Counseling or psychotherapy Counseling or psychotherapy can be helpful in dealing with the events of the assault itself as well as the anger, fear, depression, or anxiety that many people feel afterwards. Several types of healthcare providers provide counseling, including social workers, psychologists, nurses, and psychiatrists. Some people prefer to meet one-on-one with a counselor while others prefer to meet in a group setting with other people who have had similar experiences.

19. Post exposure prophylaxis April 17 th 2013

20. PEP

21. Regimes for adults

22. Side effects of PEP

23. Pregnancy prevention

24. Mifepristone and Misoprostol

25. MAY 2 ND 2013 Elimination of parent to child transmission of HIV

27. Steps towards eMTCT Towards the elimination of Mother-to-child transmission of hiv Report of a WHO technical consultation:9-11 November 2010 Geneva, Switzerland

28. Outline Eliminating new HIV infections in children Early diagnosis and treatment of HIV infected children Adolescent Prevention and Treatment Call to Action

29. Key concepts in vertical transmission Transmission can occur during pregnancy, labor & delivery, and postpartum during breast feeding Not all infants born to women living with HIV will acquire HIV infection Estimated risk 25-45% without any intervention TRANSMISSION TIMELINE Source: DeCock et al. JAMA.2000 ; 283:1175-1182.

34. Benefits of preventing mother to child transmission of HIV AIDS related deaths -reversing the gains made in child health and survival in Kenya. Caring for HIV-infected children has major economic and social impacts on families and health systems. Thus at the national level, preventing MTCT has the potential to increase the understanding and acceptance of the HIV/AIDS epidemic and those living with HIV/AIDS. Counseling, testing and community sensitization can contribute to reducing stigma. Reduction of MTCT of HIV: Decreases numbers of HIV infected children Increases child health and survival Decreases the load on the health system Gives an opportunity to improve and expand health services as well as to strengthen the existing health infrastructure

35. PMTCT Global targets and indicators

37. MDGs MDGs are a framework of 8 goals, 18 targets and 48 indicators to measure progress towards the Millennium Development goals - Goal 6: Combat HIV/AIDS, malaria and other diseases Target 6.A: Have halted by 2015 and begun to reverse the spread of HIV/AIDS Target 6.B: Achieve, by 2010, universal access to treatment for HIV/AIDS for all those who need it Target 6.C: Have halted by 2015 and begun to reverse the incidence of malaria and other major diseases

38. Overall Target 1: Reduce the Number of New HIV Infections among children by 90% by 2015 Source: 1. UNAIDS. Together we will end AIDS. 2012 2. HIV/AIDS Response – Epidemic Update and Health Sector Progress Towards Universal Access 2011

39. Overall Target 2: Reduce the Number of HIV- associated maternal deaths to women during pregnancy, delivery and puerperium by 50% by 2015 Source: UNAIDS. Together we will end AIDS. 2012 Goal -2015

40. Global Plan Targets Source: Countdown to zero: Global Plan towards the elimination of new infections among children by 2015 and keeping their mothers alive 2011-2015

41. Comprehensive MNCH Services

42. Prevention and Treatment Interventions for Adolescents DECREASING VULNERABILITYDECREASING RISK 1.Enrollment and retention of girls in School 2.Skill-based health education 3.Decreasing gender-based violence 4.Increasing age of marriage 5.Ensuring that health services respond to the needs of adolescents 6.Social protection 7.Protection, legislation, enforcement 1.Testing 2.Treatment 3.Harm Reduction I.Condoms II.Needle Exchange 4.Male Circumcision 1.For today: Adolescents 2.For the future: Neonatal Interventions that should be supported whether or not there was and HIV epidemic for rights or equity Specific evidence-based interventions that decrease the risk of HIV among young people for HIV, rights and equity Source: UNICEF Making the Case for Adolescents, unpublished data, 2012

43. Call to Action Simplify our programmatic approaches to allow integration of PMTCT/ART in maternal child health services at the lowest levels of care – to optimize treatment access, adherence and retention Introduce innovative approaches to expand provider initiated HIV testing to adolescents, pregnant women and their partners Expand early infant diagnosis and integrate childhood HIV treatment and care at lower level facilities and child survival programs Collaborate with community groups, including people living with HIV, to enhance support to women and their families to maintain good adherence and retention in care and treatment Focus on how to effectively deliver high impact interventions to adolescent to achieve the best prevention and treatment benefits