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II. Recommendations

To ensure government provision of HIV post-exposure prophylaxis as part of a comprehensive package of care for sexual violence survivors, we urge that the South African government, donors, and regional and international organizations undertake the following actions:

To the Government of South Africa

Institutional and Programmatic Measures

  • Launch an information campaign to educate the public about PEP and its provision as part of a comprehensive package of services for sexual violence survivors. The president, health minister and all other Cabinet ministers should take a leadership role in this campaign and provide clear messages supporting PEP services and the use of antiretroviral drugs to prevent HIV after sexual violence. In addition, to support the implementation of the national HIV/AIDS treatment and care plan, the president, health minister and other leaders should make clear statements about the value of antiretroviral drugs for the treatment of HIV/AIDS more broadly. This is essential to overcome the confusion and lack of confidence in antiretroviral drugs caused by misinformation about them. National and provincial governments should work with the media and nongovernmental organizations to distribute materials in local languages and in a manner that is accessible to people with limited literacy skills.

  • Provide PEP at all government health facilities used by the general population, including primary health care clinics. If the PEP drugs are not available at the facility where a sexual violence survivor presents, require staff at the facility to assist the survivor in obtaining them, including by steering the survivor to the nearest facility where PEP is available.

  • In urban and rural areas, continue to establish and fund multidisciplinary rape service centers that provide comprehensive support and treatment, including PEP services, voluntary and confidential HIV testing, testing and treatment for other sexually transmitted diseases (STDs), legal assistance, and other appropriate counseling for survivors of sexual violence. Ensure that personnel in facilities providing these services are trained to address the particular needs of children and young adults who survive sexual violence.

  • Provide training on PEP and on sexual and gender-based violence to all key service providers, including police, teachers, health care providers, and social workers handling cases of sexual and domestic violence. Ensure as a matter of priority resources to enable training to reach all frontline service providers and not be limited to high-ranking individuals. This training should include information about applicable law and policy and their implementation and include a particular focus on children. Ensure that all police officers (frontline officers, as well as station commanders and police charged with investigating cases of sexual violence) receive training on investigation of sexual violence cases.

  • Staff police stations with social workers who can offer support services (including counseling and transportation to PEP services and other necessary medical treatment) to children and other sexual violence survivors.

  • Ensure that PEP is covered in all public and private health insurance plans.

Legal and Policy Measures

  • In accordance with current proposals to amend the Child Care Act (the Children’s Bill), permit consent to HIV testing and medical treatment for children too young to consent on their own to be given by the parent, caregiver, a designated child protection organization, the head of a hospital, or a child and family court. This legislation must be passed urgently to ensure that all children have access to PEP.

  • In the interim, where consent to HIV testing and medical treatment cannot be obtained due to parental absence, unreasonable refusal or incompetence, put procedures in place to obtain consent promptly from another authority.

  • Enact provisions in the Criminal Procedure (Sexual Offences) Amendment Bill requiring the state to provide prophylactic treatment for HIV and sexually transmitted infections, as well as other appropriate medical and psychological treatment to survivors of sexual violence; to amend the definition of rape to make it gender-neutral and to include situations in which a perpetrator coerces another to have sex by the use or threat of force or harm to that person or to his or her property, and to criminalize oral and anal rape; to place the decision to discontinue prosecution with the National Department of Public Prosecutions rather than with the police; to abolish evidentiary rules that devalue the testimony of sexual violence survivors and children (such as corroboration and cautionary rules); and to provide protection for vulnerable witnesses.

  • Clarify the responsibilities of the different departments that provide services for child survivors of sexual violence. Develop a binding mechanism to ensure effective coordination among all such departments, including implementation of sexual assault management policies, planning, monitoring and evaluation of services.

The Department of Health should:

  • Draft a national protocol on PEP provision for child sexual violence survivors under fourteen and distribute this protocol to all relevant provincial departments.

  • Issue policy guidance that makes clear that provision of PEP in the context of sexual violence should be regarded as an emergency and that the medical superintendent should be permitted to consent to HIV testing and PEP on behalf of children under fourteen.

  • Amend national policy guidance for PEP provision for sexual violence survivors to eliminate the requirement that an HIV test be necessary to receive PEP and to ensure that in seeking consent for an HIV test, the health facility must advise the survivor of this fact and otherwise inform the survivor why the test is being offered.

  • Monitor the progress made by provinces regarding implementation of PEP and provide guidance to them regarding improvements. Ensure that evaluation and monitoring of problems and progress is an integral part of national and provincial PEP programs.

  • Ensure that accredited health care practitioners and other medical officers charged with forensic examination of sexual violence survivors have a reliable supply of drugs for PEP in cases of sexual violence and are trained regarding their proper use.

  • Ensure that health care providers are trained on the use of antiretroviral drugs. Institutionalize this training as part of state medical school courses.

  • Develop and implement binding protocols for medical practitioners and health care professionals regarding appropriate steps to be taken when sexual violence survivors present themselves for treatment. Implementation should include training on the protocols. The protocols should provide that all sexual violence survivors be examined by a health care professional immediately after reporting the incident to the police or presenting at a health care facility for care, be informed of the risk of HIV infection as a result of sexual violence and where indicated, about the availability of PEP to reduce the risk of HIV infection.

  • Establish a national standard that requires that sexual violence survivors receive treatment by the same facility collecting forensic evidence and not be referred to another facility.

The Department of Safety and Security should:

  • Take steps to ensure that police are trained regarding PEP and the importance of prompt access to medical care so that rape and sexual violence survivors are referred to a facility where PEP can be administered promptly.

  • Together with the Department of Health, release and disseminate a clear policy statement that filing a police report is not a prerequisite to seeking PEP and other medical services following rape and sexual violence.

  • Amend police instructions regarding management of sexual offences cases (SAPS National Instruction 22/1998: Sexual Offences: Support to Victims and Crucial Aspects of the Investigation) to mandate that police have no discretion regarding whether to accept a charge of rape or sexual violence and that sexual offence cases be immediately allocated to specially trained investigating officers who are responsible for ensuring that sexual violence survivors receive adequate medical treatment (including PEP, where indicated) and that forensic examination is completed when appropriate.

To Donors and Regional and International Organizations

  • Provide financial and technical assistance to civil society organizations offering PEP and other medical and legal services to rape and sexual violence survivors, including children, and contribute to training law enforcement, judicial and health care personnel.

  • Provide financial and technical assistance to strategies that facilitate rapid implementation of the government’s commitment to provide PEP and related services to children and other rape and sexual violence survivors, and monitoring and evaluation of progress toward implementation.

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March 2004