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South African program promotes "resilience" and improves post-rape care.

The prevalence of rape in South Africa presents a daunting public health challenge. According to a June 2009 study by the South African Medical Research Council, as many as a quarter of all men surveyed admitted to raping a woman or girl. In many cases the attacks happen to children under age 13. The health consequences are significant: in addition to the immediate physical injury and psychological trauma, rape survivors often suffer long-term consequences such as depression, post-traumatic stress disorders, and gynecological disorders, and are at risk of unwanted pregnancy and sexually transmitted infections (STIs), including HIV.

A Population Council-supported program known as Refentse--meaning resilience in the face of adversity--demonstrates how a rural hospital can improve post-rape care by training nurses to provide integrated medical-care management for rape survivors. The improvements, which cost little to implement, strengthen and link established services and decentralize care from doctors to nurses. Results of the study were described in a recent issue of the British Medical Journal.

Good care requires quick response

In part because of the violent and invasive nature of sexual assault, health care professionals in both industrialized and developing countries face many challenges in providing timely and comprehensive post-rape services. In addition to immediate medical attention for physical injuries, rape survivors require various therapeutic, social, and legal services, including post-exposure prophylaxis (PEP) for HIV and other STIs, emergency contraception, and trauma counseling. Administration of HIV PEP, which provides the only option for protecting against HIV infection following an assault, is especially challenging: to be most effective, PEP must be started within 72 hours of exposure. Many practitioners lack an adequate understanding of how to administer PEP in the context of sexual assault, and even fewer have well-developed strategies for ensuring adherence to the full 28-day course of treatment. Other important procedures such as emergency contraception to prevent pregnancy and the collection of forensic evidence for legal prosecution are also time-dependent.

Ian Askew, the Population Council's director of reproductive health services and research, and his colleagues from the Rural AIDS and Development Action Research Programme (RADAR), School of Public Health, University of the Witwatersrand in South Africa, initiated the Refentse program in 2003 at a 450-bed district hospital in a rural region in the country's northeast corner. The hospital functions as a referral center for surrounding clinics.

New approach improves services, raises awareness

The team set out to improve the quality of post-rape care with a five-part intervention:

1. A sexual violence advisory committee, comprising hospital staff members, social workers, and local police, contributed to the study's design.

2. The committee drafted a rape management policy for the hospital that defined examination and treatment protocols and included both HIV counseling and testing and an immediate dose of PEP followed by a 28-day course of treatment.

3. A two-day training workshop for health professionals addressed the common myths and attitudes about rape, enhanced doctors' and nurses' clinical skills, and aimed to strengthen the relationships between the health sector and the police and judicial system. After the workshop, police officers decided to prioritize PEP treatment by bringing patients to the hospital immediately.

4. Senior nursing managers designated a room for post-rape care and stocked it with all necessary treatment supplies.

5. A public awareness campaign aimed at the local community disseminated information about sexual violence, its effects on health, and the services available at local clinics, and encouraged survivors of assaults to seek care immediately following an attack.

An expanded role for nurses

After the intervention the hospital's post-rape cases increased from eight to 13 per month, and the proportion of patients who saw six or more service providers on their initial visit decreased from 86 percent to 54 percent. Although these improvements did not result in a decline in the overall time spent at the hospital, patients' impressions of the quality of care improved substantially. On the other hand, patients' confidence in the police and judicial system did not change.

The study showed that nurses could play a key role in post-rape care. Following the intervention, their role was expanded to include documenting the rape, providing acute trauma counseling, and providing an immediate dose of HIV PEP. Nurses proved reluctant to perform the forensic examinations, which are needed to collect evidence, because they were intimidated by the prospect of presenting evidence in court.

"We were successful in introducing many small changes that had a big impact," Askew concluded. "With additional training and linking of existing services, nurses can become the primary providers of this care." The study's findings have helped inform recent international and national policies and guidelines on PEP throughout the region.


Jewkes, Rachel, Yandisa Sikweyiya, Robert Morrell, and Kristin Dunkle. 2009. "Understanding men's health and use of violence: Interface of rape and HIV in South Africa," South African Medical Research Council Policy Brief, June.

Kim, Julia C., Ian Askew, Lufuno Muvhango, Ntabozuko Dwane, Tanya Abramsky, Stephen Jan, Ennica Ntlemo, Jane Chege, and Charlotte Watts. 2009. "Comprehensive care and HIV prophylaxis after sexual assault in rural South Africa: The Refentse intervention study," British Medical Journal 338 (b515): 1559-1562.


US Agency for International Development, US President's Emergency Plan for AIDS Relief (PEPFAR)
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Publication:Population Briefs
Geographic Code:6SOUT
Date:Dec 1, 2009
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