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Deadly Delay: South Africa's Efforts to Prevent HIV in Survivors of Sexual Violence

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Deadly Delay: South Africa's Efforts to Prevent HIV in Survivors of Sexual Violence Human Rights Watch March 2004, Vol. 16, No. 3 (A) Deadly Delay: South Africa's Efforts to Prevent HIV in Survivors of Sexual Violence I. Summary ..................................................................................................................................... 1 II. Recommendations ................................................................................................................... 3 To the Government of South Africa..................................................................................... 3 Institutional and Programmatic Measures ........................................................................ 3 Legal and Policy Measures .................................................................................................. 5 To Donors and Regional and International Organizations ........................................... 7 III. Methods................................................................................................................................... 7 IV. Background: HIV/AIDS and Sexual Violence in South Africa...................................... 8 HIV/AIDS in South Africa .................................................................................................... 8 Sexual Violence Against Women and Girls in South Africa.............................................. 9 The Role of Gender-Specific Violence in HIV Transmission.........................................11 Preventing HIV After Sexual Violence Through HIV Post-Exposure Prophylaxis....13 Antiretroviral Drug Therapy and HIV/AIDS....................................................................16 Health and Social Service Provision.....................................................................................25 V. PEP Implementation: Human Rights Watch Findings..................................................28 Lack of Information about PEP...........................................................................................29 Provincial Efforts to Disseminate Information about PEP ........................................30 Lack of Information about PEP among Service Providers .........................................32 Lack of Information among Sexual Violence Survivors...............................................34 Lack of Information about PEP in Rural Areas............................................................35 Government Opposition to Antiretroviral Drugs as an Obstacle to PEP Services.....35 Lack of Guidance Regarding PEP for Children Under Fourteen...................................38 Consent to HIV Testing and to Medical Treatment for Children Under Fourteen.....38 Procedures to Bypass Consent .........................................................................................39 Parental/Guardian Refusal to Provide Consent............................................................40 Unaccompanied Children..................................................................................................40 Recommendations to Facilitate Obtaining Consent .....................................................41 Police Interference with Access to PEP and Related Services ........................................43 Arbitrary Denial of PEP Services.........................................................................................47 Sexual Violence Against Boys and Men ..............................................................................51 Stigma and Discrimination Interfering with PEP Services ..............................................52 Services for Low-Income Survivors and Rural Dwellers..................................................54 Additional Challenges to PEP Implementation.................................................................55 Problems with Ensuring Completion of PEP Regimen...............................................55 Problems with Coordination Among Service Providers ..............................................56 VI. Law and Policy Efforts to Improve Services for Rape Survivors.................................58 Prosecution of Sexual Offence Cases..................................................................................58 Law Reform.............................................................................................................................59 VII. South Africa’s Obligations Under International and National Law ...........................61 International Law....................................................................................................................61 The Right to the Highest Attainable Standard of Health.............................................62 The Right to Information..................................................................................................64 The Right to Life ................................................................................................................65 The Right to Measures of Protection ..............................................................................65 National Law ...........................................................................................................................67 VIII. Conclusion .........................................................................................................................70 Acknowledgments.......................................................................................................................73 I. Summary Sexual violence against women and girls is a problem of epidemic proportions in South Africa, including a virtually unprecedented epidemic of child rape. Because South Africa is also in the grips of an explosive HIV/AIDS epidemic, sexual violence is a potential death sentence. The most vulnerable members of society are thus doubly victimized— first suffering the trauma of sexual violence and then its potentially fatal long-term consequences. Prompt medical attention can reduce the likelihood of HIV infection for rape survivors. The South African government has adopted a policy to provide this service, but its implementation has been rocky. In April 2002, the South African government took the important step of pledging to provide the short and affordable course of antiretroviral drugs known as post-exposure prophylaxis (PEP) to survivors of sexual violence throughout the country. Prompt PEP administration reduces the risk of HIV transmission following exposure to HIV. First developed for occupational exposures to HIV (such as when health workers are accidentally pierced by an infected syringe), PEP has been the standard of care for occupational exposures and for rape survivors in industrialized countries for several years, and for occupational exposures in South Africa since 1999. South Africa’s commitment to provide PEP to rape survivors represents a crucial step in its efforts to protect them from the consequences of sexual violence. But there remain significant obstacles to rape survivors’ ability to obtain PEP. Human Rights Watch found that government failure to provide adequate information or training about PEP or clear messages in support of PEP significantly undermined access to this lifesaving service. Police, health professionals, and counselors working with rape survivors often lacked basic information about PEP, as did rape survivors themselves. As a result, many rape survivors did not get PEP simply because the various agencies charged with providing these services did not know that they existed. The national government’s opposition to providing antiretroviral drugs in the public health system, including the health ministry’s highly publicized resistance to providing antiretroviral drugs for prevention of mother-to-child HIV transmission, continued even after the government said it would provide PEP. In part due to this opposition, frontline service providers who should have been offering PEP services may not have done so, even when they had information about PEP. 1 Human Rights Watch, Vol. 16, No. 3 (A) South African law and policy provide a framework to facilitate the prompt and integrated provision of health and other services to children and other rape survivors. Human Rights Watch found that the failure of key service providers to follow these rules undermined rape survivors’ access to PEP, at the potential cost of their lives. Police failure to provide prompt assistance to rape survivors in obtaining medical treatment, and therefore PEP, completely barred some rape survivors, including children, from obtaining PEP. Medical staff refusal to treat rape survivors without police intervention also impeded access to PEP. Children faced particular obstacles in obtaining PEP services. HIV testing is a government prerequisite for PEP, but, under South African law, children under fourteen cannot consent on their own to HIV testing or to medical procedures. This posed problems for children who attempted to get PEP unaccompanied by a parent or guardian and for children whose caretakers refused to consent to HIV testing and PEP, perhaps against the child’s best interests. At the time of this writing, national government guidelines for the administration of PEP to rape survivors do not cover children under fourteen, which leaves some health care providers with insufficient guidance regarding treatment of children. PEP was generally unavailable outside major urban centers, effectively barring PEP access for many poor, rural rape survivors. Stigma associated with both HIV/AIDS and rape also kept many rape survivors from seeking rape support
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