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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.

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 services.

Because HIV/AIDS is a fatal disease that as yet has no cure, government failure to provide information about PEP and ensure effective implementation of PEP services threatens the right to life. The obligation to ensure the right to the highest attainable standard of health and to protect women and children from violence and its consequences require that South Africa address obstacles to PEP access and implement its PEP program on an urgent basis.

PEP services for rape survivors are provided in Botswana and on a very limited basis in a few other southern African countries but across most of the continent have not even been considered at the policy level. This report seeks both to highlight obstacles to effective PEP provision in South Africa and their solutions and to illustrate lessons of the South African experience that may be useful for countries that are beginning to discuss or develop PEP services.

In late 2003, the South African cabinet approved a plan to provide antiretroviral (ARV) drugs as part of a revitalized national AIDS program. The plan confirmed the government’s commitment to providing PEP and promised investment of substantial resources into upgrading the national health system, including training for health professionals on use of antiretroviral drugs. The government also committed itself to an extensive education campaign, including information about ARVs, as part of the plan. These are laudable commitments. But lessons from the PEP experience—which involves some of the same challenges as the bigger ARV roll-out, such as public education, combating stigma, a scientifically sound and constructive presentation of ARVs—must be learned and addressed. If not, the PEP experience will not bode well for the larger treatment program.

In pledging to provide PEP to rape survivors, South Africa has shown an important commitment to protecting survivors of sexual violence from HIV/AIDS. But commitment to PEP services at the policy level will continue to be compromised without measures to ensure their availability and accessibility to all sexual violence survivors, including children, on an equal basis. The government’s renewed commitment to provide PEP as part of its comprehensive HIV/AIDS program presents an opportunity to strengthen support and treatment services for survivors of sexual violence. It must meet this opportunity by allocating significant resources to the task, including adequate funding to train police, health care providers and others likely to come into contact with rape survivors. To undo the damage done by their past denigration of ARVs, the president and health minister should also speak out strongly in support of PEP as a means of HIV prevention. Otherwise, the dual epidemics of rape and HIV/AIDS will continue to claim the lives of too many South Africans.

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March 2004