Presentation on theme: "STRENGTHENING SEXUAL ASSAULT CARE AND HIV PEP IN RURAL SOUTH AFRICA: THE REFENTSE MODEL Presented by Julie Pulerwitz, ScD Director, Social and Operational."— Presentation transcript:
STRENGTHENING SEXUAL ASSAULT CARE AND HIV PEP IN RURAL SOUTH AFRICA: THE REFENTSE MODEL Presented by Julie Pulerwitz, ScD Director, Social and Operational Research, HIV/AIDS Scientific Development Workshop Operations Research on GBV/HIV AIDS2014, Melbourne, July 22, 2014
Context Sexual violence is increasingly recognized as an important driver of the HIV epidemic within sub- Saharan Africa. South Africa remains the country with the largest number of PLHIV in the world - 5,6 million people (UNAIDS,2012). In addition, South Africa also has the highest incidence of rape reported to police.
Problem International guidelines highlight central role of health sector in clinical care following sexual assault Number of common challenges to service delivery noted in global North and South – absence of institutional policies or treatment protocols – lack of relevant training for healthcare workers – negative attitudes from service providers – fragmented and sub-standard provision of clinical care – poor collection of forensic evidence – lack of trauma counselling or psychosocial referrals
Refentse Project Implement and evaluate a nurse-driven, comprehensive, post-rape care model integrated into existing HIV/RH services – Including HIV post-exposure prophylaxis (PEP) – Based at 450-bed district hospital in rural South Africa
Formative Research Assessment of sexual assault services at the study hospital. Key informant interviews conducted with service providers, including doctors, nurses, social workers, pharmacists, and police officers (n = 16). Questionnaires completed by service providers to document issues related to provision of post-rape care (n = 55). Review of medical charts documented objective evidence regarding actual post-assault treatments (n >100).
Key Findings Capacity gaps: Few service providers had prior training on post-rape management. Institutional obstacles: Rape cases were not prioritized, but were directed to wait in the general Out Patients Department (OPD) queue. Limited PEP delivery: Among those patients who presented <72 hours of the assault (in time to receive PEP), about half were automatically excluded from PEP eligibility because VCT was unavailable at the time.
Intervention Model Five components: 1.Sexual violence advisory committee (SVAC) 2.Hospital rape management policy 3.Training workshop for service providers 4.Centralization and coordination of care through a designated examining room 5.Community awareness campaigns
Evaluation Pre/post intervention design (review of 144 patient charts) to assess potential improvements in: 1.Quality of general post-rape care (forensic history and exam, provision of EC, STI treatment, referrals) 2.Provision of PEP (access to VCT, provision of and completion of full 28-day course) 3.Efficiency and utilization of the service (number of service providers seen on first visit, volume of rape cases presenting to hospital per month)
Quality of care Indicators Pregnancy PreventionPregnancy test given EC given STISTI meds given VCT and PEPAny VCT done VCT on first visit Any PEP given 28d given 1 st visit ReferralsOther providers
Analysis Crude risk ratios (RR) of the intervention effect on all of the outcome indicators were calculated along with 95% confidence intervals. – Risk ratios were analyzed using Poison regression models with robust standard errors Multivariate Poisson regression adjusted for potential confounders including presentations <72 hours after assault, presentation ‘after hospital hours’, age <14 years, sex of attending physician, and patient seen by a senior or junior doctor.
Improved Quality of Care Found Quality of post-rape care improved significantly across all 11 indicators, including quality of clinical history, provision of pregnancy testing/EC, and referrals for counseling. Provision of VCT increased from 60% to 87%, while syndromic treatment of STIs increased from 88% to 92%. Significant improvements seen in provision of PEP. – Patients more likely to have received PEP (starter pack or full 28 day course) – Patients more likely to receive the full course on their first visit
Ethical considerations 3 separate IRB reviews (U of Witwatersrand, London School of Hygiene and Tropical Medicines, Population Council). Data collection informed by international guidelines on conducting research on gender-based violence. – E.g., Face–to-Face interviews conducted in a private room with a female interviewer. Counseling routinely offered to research staff and subjects. For patients younger than age 14 years, interviews conducted with parent/guardian. Careful attention to developing and piloting provider counselling and screening skills.
Methodological Challenges Pre-post design with one facility only (no control facilities). Medical charts documented evidence regarding treatments undertaken as recorded by provider, as opposed to outside observer.
Conclusion The Refentse Model was the first intervention study from an African setting that evaluated a ‘comprehensive model’ for response to sexual violence. Results suggest it is possible to improve comprehensive sexual assault services including PEP within a public sector hospital, using existing staff and resources. With additional training, nurses can play an expanded role in post-rape care.
Authors and Institutional Affiliations Julia C Kim, Ian Askew, Lufuno Muvhango, Ntabo Dwane, Tanya Abramsky, Stephen Jan, Ennica Ntlemo, Jane Chege, Charlotte Watts Institutional affiliations Rural AIDS and Development Action Research Programme (RADAR), School of Public Health, U. of Witwatersrand Gender, Violence and Health Centre, London School of Hygiene and Tropical Medicine Population Council The George Institute for International Health
Acknowledgements The study was made possible through the United States Agency for International Development The Project Advisory Committee The Department of Health and Social Welfare in Limpopo Province and Mpumalanga Province in South Africa The Western Cape Provincial Reference Group for Sexual Violence for their technical support in the training workshop and in developing intervention tools