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VIII. Conclusion

South Africa should be commended for making a commitment to provide HIV post-exposure prophylaxis for sexual violence survivors through its public health system. But for PEP services to succeed, South Africa must strive to ensure that all sexual violence survivors who need the drugs can get them—promptly and with sufficient guidance and support to ensure that they will complete the course of treatment that could save their lives.

Particular attention needs to be placed on children and young women and poor and rural sexual violence survivors. The government must immediately provide clear guidance regarding PEP provision for children under fourteen, including expanded provisions for consent to PEP. With respect to poor and rural women and children, it should make a serious resource commitment to rural leadership, including rural women and NGOs who work with survivors of domestic and sexual violence, whose experience and knowledge of local conditions can facilitate the implementation of PEP services in underserved areas.

The silence around HIV/AIDS “is as serious a killer as the virus itself,” as former South African president Nelson Mandela has warned. South Africa’s political leadership must break the silence around HIV/AIDS and address the deep stigma attached to the disease if rape survivors are to be able to come forward and seek PEP services in a prompt manner. Sexual violence survivors must surmount the double stigma of being HIV-positive (presumed or in reality) and being survivors of sexual violence. The deep shame associated with child rape compounds these obstacles, leaving many child sexual violence survivors to suffer in silence. As a result, government must work especially hard to reach them. Government leaders also must make serious efforts to build public confidence in the efficacy and safety of antiretroviral therapy.

South Africa’s efforts to implement PEP services illustrate the importance of integrating work around sexual violence and HIV/AIDS. To implement PEP successfully, including for children, South Africa must strengthen the skills and coordination of all those likely to be important contact points for sexual violence survivors, including health care providers, police, social workers and teachers. It must also disseminate information about PEP services—including what they are, why they are important and where to get them—to all of these contact points as well as in the general community.

South Africa has considerable financial resources, well-trained, capable service providers, and an active civil society supporting PEP provision and other services for sexual violence survivors. This would suggest that South Africa would represent a model for implementation of PEP services for other countries in the region. However, South Africa must overcome practical and political obstacles to implementation. It still struggles to address serious problems in health and social service provision rooted in apartheid-era inequalities, where services in former homelands and in townships in urban areas were practically nonexistent prior to 1994. And its history of political opposition to providing antiretroviral drugs at the highest level of government—including engaging AIDS denialists as high-level AIDS advisors—has impeded effective access to PEP. Learning from the South African experience highlights the challenges that other countries may face, and illustrates that even in countries that lack South Africa’s resources, a critical determinant of successful PEP service provision will be the depth and scope of political commitment to the provision of those services.

Other countries should assist South Africa by working to promote and establish fairer terms for South Africa to acquire and produce PEP drugs that are affordable, so that they may be available on a more equitable basis to all sexual violence survivors who need them. And all of these things need to be done right away.

By beginning programs to provide PEP services to sexual violence survivors, South Africa has made the crucial leap in thinking and policy to link sexual violence and HIV/AIDS. But only when lifesaving services like PEP are available for all who need them will South Africa truly shatter the silence that the onslaught of HIV/AIDS and sexual violence have caused in combination. South Africa will then have taken a major step towards becoming the sign of hope and progress in public health that it is for many with regard to its victory over apartheid.

As Stephen Lewis, U.N. special envoy for HIV/AIDS in Africa, once passionately observed:

[W]hen people are dying. . . [s]peed and action become the sine qua non. And when the action finally happens, there will be an outpouring of relief and exhilaration throughout Africa, akin, for many, to the emotional catharsis which accompanied the end of apartheid. South Africa is one of the leaders on this continent. If there is a breakthrough here, every country will feel similarly encouraged. And . . . I genuinely believe that resources will flow to sustain whatever South Africa undertakes. The world, overwhelmingly, wants South Africa to defeat the pandemic.

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March 2004