"When the physician told me that my health problems were related to what was happening in my house, I started to understand what was going on with me. It was as if a screen was lifted from my eyes, and I started to think that I did not deserve this."
— Survivor of intimate partner violence, the Dominican Republic
Key Points
Reproductive health care providers may be able to offer counseling, medical, and referral services.
Addressing nonconsensual sex and other forms of violence against women within reproductive health services can improve quality of care.
Effective services require clear policies and procedures, positive provider attitudes toward victims, institutional support, and referral networks.
Research is needed to determine the impact of provider interventions.
This woman's experience illustrates how, by defining violence as a health threat, medical professionals can encourage victims of sexual coercion or of physical or psychological abuse by intimate partners to consider making positive changes in their lives.1
Reproductive health care providers are often particularly well placed to detect sexual coercion and to care for its predominantly female victims since many women routinely attend family planning or primary health care clinics. Reproductive health care providers also often see the effects of sexual coercion on their clients' health, such as recurrent sexually transmitted infections and unintended pregnancies.2
But providers in family planning clinics and other health facilities rarely have the knowledge, skills, resources, and support necessary to identify cases of sexual coercion; offer medical, counseling, and referral services to those who experience it; or document evidence of sexual assault.
"Sexual and reproductive health programs are largely premised on consensual sex," notes Dr. Shireen Jejeebhoy, a senior program associate in the Population Council's office in New Delhi, India, in a recent review of the nonconsensual sexual experiences of young people in developing countries.3 "At the same time, programs that deal explicitly with nonconsensual sex are often narrowly focused on improving the management of the few rape cases reported to the police."
Addressing sexual coercion more comprehensively within reproductive health and women's health care services poses challenges but also offers opportunities to improve quality of care. Providers who understand how sexual coercion can affect clients' health are more likely than others to provide relevant family planning and sexual risk-reduction counseling, and they are less likely to misdiagnose chronic complaints resulting from abuse. Strengthening services for victims of violence can also benefit clients because staff members are more aware of the need to protect clients' privacy and maintain the confidentiality of medical records.4
Challenges for providers
Providers are often reluctant to address sexual coercion or other forms of violence experienced by their clients. Perceived barriers to helping victims include an inability to spend enough time with clients, limited training and skills, lack of referral services or effective interventions, concern about legal consequences, and fear of offending clients.5
Many providers simply do not know how to help clients who have experienced sexual coercion. In South Africa, only about a quarter of 354 providers interviewed at hospitals and primary care centers had received any training in sexual assault services, and training that had occurred focused largely on medical and forensic issues, with little attention to psychosocial aspects or provider attitudes.6
Training should address providers' attitudes because it may be difficult for providers to offer nonjudgmental, sensitive counseling and care to victims if they share common misconceptions about violence and have negative attitudes toward victims.7 In a survey of reproductive health care providers in the Dominican Republic, Peru, and Venezuela, for example, more than half of 79 respondents thought that some women's behavior was "inappropriate" and thus provoked their husbands' aggression.8
Some providers' own experience as victims or perpetrators of sexual coercion may affect their attitudes toward clients. In a study among South African public health nurses, 11 of 36 female nurses reported sexual abuse by an intimate partner, and six of eight male nurses admitted abusing a partner. Both male and female nurses thought violence against women was sometimes justified.9
Many providers are concerned about the effects of sexual coercion and other forms of violence. But they often report frustration that they cannot "fix" the problem and that some clients ignore their advice.10 Trainers can help providers understand the difficulties abused clients face and the value of offering emotional support.11
Transforming systems
Lack of institutional support, community resources, referral networks, and evidence of effective interventions compromises providers' ability to help victims of sexual coercion or other forms of violence against women.12 Providers are often expected to implement such services on their own after attending a single training session or workshop on sexual violence.
Many experts emphasize that effective service provision requires that policies and procedures for managing cases of sexual violence against women become standard practice throughout an entire health care system.13 This "systems approach" requires attention to details of clinical infrastructure, such as ensuring that a facility has a cabinet with a lock for storing clients' records and a room where clients can be asked about violence without being overheard by partners, relatives, or other clients.14 It also involves supporting staff through ongoing training and supervision and, perhaps, by designating a staff violence specialist or holding monthly meetings to discuss difficult cases and help providers cope with emotional stress.15
In one example of such a systems approach, the International Planned Parenthood Federation/Western Hemisphere Region (IPPF/WHR) and its member associations in the Dominican Republic, Peru, and Venezuela reviewed all aspects of their health programs before beginning to screen clients for experience with sexual coercion, sexual abuse in childhood, and violence within their families. Aspects that were evaluated included patient flow, clinic infrastructure, staff training, treatment protocols, clinical history forms, data systems, and agreements with referral organizations. The member associations even changed their hiring procedures to ask job candidates about their views on violence against women, seeking out people who shared the organizations' commitment to assist victims.16
Evidence needed
photo credit: Gabriel Amadeus Cooney
During routine counseling sessions, providers at clinics associated with the International Planned Parenthood Federation in the Dominican Republic, Peru, and Venezuela are expected to screen all clients for experience with physical or sexual violence.
IPPF/WHR and its member associations in the Dominican Republic, Peru, and Venezuela were able to both identify cases of sexual, physical, or psychological abuse of women and offer comprehensive services in their clinics or through referrals. 17 Meanwhile, a growing number of other organizations are taking on the challenges of detecting, treating, and preventing sexual coercion and other forms of violence against women.
In Brazil, the number of public hospitals providing comprehensive care to women who experience sexual violence rose from just three in 1996 to 63 in 2001 through the advocacy and training efforts of obstetrical and gynecological societies. Screening clients for violence and then offering victims counseling and referrals is being tested in primary health care centers in São Paulo.18 Another initiative by the USAID-funded PRIME II project raised awareness about physical, sexual, psychological, and economic abuse of women and the need for legal protection against such abuse. It also established screening, counseling, and referral services for abused clients in a busy reproductive health clinic in the Armenian capital of Yerevan.19 In South Africa, an alliance of individuals and organizations is working with the government to change policies, raise community awareness, and improve health sector responses to sexual violence.20 Program implementation there has lagged behind policy reform,21 but guidelines for clinical management of victims of sexual assault have been developed, and the government plans to train service providers to use them.
Similar pilot programs are also under way in countries such as Bangladesh, Costa Rica, India, Nicaragua, the Philippines, and Venezuela.22 Few efforts have been evaluated, however, and most evaluations that have been conducted have been limited to measuring detection rates or changes in provider attitudes or practices. Measuring the impact of provider intervention is difficult because of the need to rely on self-reported experiences of violence and ethical concerns about withholding services from members of study comparison groups.
Because limited evidence is available on how screening and other provider interventions affect clients' health or exposure to further violence (see Advisability of Screening for Violence Debated), experts have called for more rigorous evaluation of such interventions. This includes, in a variety of health care settings, randomized controlled trials and qualitative research among women who have experienced physical or sexual abuse to analyze which interventions they think are effective, and why.23
— Kathleen Henry Shears
References
Bott S, Guedes A, Guezmes A. The health service response to sexual coercion/violence: lessons from IPPF/WHR members associations in Latin America. Non-consensual Sexual Experiences of Young People in Developing Countries: A Consultative Meeting. New Delhi, India, September 22-25, 2003.
Stevens L. A Practical Approach to Gender-based Violence: A Programme Guide for Health Care Providers and Managers. New York, NY: United Nations Population Fund, 2001; Watts C, Mayhew S. Reproductive health services and intimate partner violence: shaping a pragmatic response in sub-Saharan Africa. Int Fam Plann Perspect 2004;30(4):207-13.
Jejeebhoy S, Bott S. Non-consensual Sexual Experiences of Young People: A Review of the Evidence from Developing Countries. New Delhi, India: Population Council, 2003.
Bott S, Guedes A, Claramunt MC, et al. Improving the Health Sector Response to Gender-based Violence: A Resource Manual for Health Care Professionals in Developing Countries. New York, NY: International Planned Parenthood Federation, Western Hemisphere Region, 2004.
García-Moreno C. Dilemmas and opportunities for an appropriate health-service response to violence against women. Lancet 2002;359(9316):1509-14; Waalen J, Goodwin MM, Spitz AM, et al. Screening for intimate partner violence by health care providers: a review of barriers and interventions. Am J Prev Med 2000;19(4):230-37; Guedes A, Stevens L, Helzner J. Addressing gender-based violence in a reproductive and sexual health program in Venezuela. In Haberland N, Measham D, eds. Responding to Cairo: Case Studies of Changing Practice in Reproductive Health and Family Planning. New York, NY: Population Council, 2002.
Christofides N, Webster N, Jewkes R, et al. The State of Sexual Assault Services: Findings from a Situation Analysis of Services in South Africa. Pretoria, South Africa: South African Gender-based Violence and Health Initiative, 2003.
García-Moreno; Jejeebhoy.
Guedes A, Bott S, Cuca Y. Integrating systematic screening for gender-based violence into sexual and reproductive health services: results of a baseline study by the International Planned Parenthood Federation, Western Hemisphere Region. Int J Gynaecol Obstet 2002;78(Suppl 1):57-63.
Kim J, Motsei M. "Women enjoy punishment": attitudes and experiences of gender-based violence among PHC nurses in rural South Africa. Soc Sci Med 2002;54(8):1243-54.
García-Moreno; Guedes, Stevens, Helzner.
Bott, Guedes, Claramunt.
García-Moreno.
Heise L, Ellsberg M, Gottemoeller M. Ending violence against women. Popul Rep 1999;27(4):36.
García-Moreno; Stevens.
Stevens; Parsons L, Goodwin MM, Petersen R. Violence against women and reproductive health: toward defining a role for reproductive health care services. Matern Child Health J 2000;4(2):135-40; Llorens M, Medina S. Support groups for providers. Basta! March 2002. Available online (PDF, 172K).
Bott, Guedes, Guezmes.
Bott, Guedes, Guezmes.
Faúndes A, Andalft J. Sexual violence against women. The role of gynecology and obstetrics societies in Brazil. Int J Gynaecol Obstet 2002;78(Suppl 1):67-73; Schraiber LB, d'Oliveira AF. Violence against women and Brazilian health care policies: a proposal for integrated care in primary care services. Int J Gynaecol Obstet 2002;78(Suppl 1):21-25.
Newman C, Sargsyan I, Kohler R, et al. Improving Primary Providers' Response to Violence Against Women in Reproductive Health Services in Armenia. Yerevan, Armenia: PRIME II Armenia, 2004.
Christofides.
Guedes A. Addressing Gender-based Violence from the Reproductive Health/HIV Sector: A Literature Review and Analysis. Washington, DC: Poptech, 2004.
Haque YA, Clarke JM. The Woman Friendly Hospital Initiative in Bangladesh setting: standards for the care of women subject to violence. Int J Gynaecol Obstet 2002;78(Suppl 1):45-49; Stevens.
García-Moreno; Nelson HD, Nygren P, McInerney Y, et al. Screening women and elderly adults for family and intimate partner violence: A review of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2004;140(5):387-96; Gazmararian JA, Petersen R, Spitz AM, et al. Violence and reproductive health: current knowledge and future research directions. Matern Child Health J 2000;4(2):79-84.
Advisability of Screening for Violence Debated
Fearing disbelief, blame, or retribution, many victims of forced sex tell no one about their experiences — unless they are asked.1 Routine screening for physical and sexual abuse by intimate partners is recommended by several professional associations in the United States and the United Kingdom,2 and a growing number of organizations in developing countries are training providers to ask all clients3 or all clients with certain symptoms4 about such abuse. Some experts question, however, whether such screening is advisable or even ethical in most resource-poor settings.
Proponents of screening say that failing to inquire about sexual coercion or other forms of violence compromises quality of care and misses opportunities to save women from potentially life-threatening situations. Others insist that screening should not take place unless the necessary support, policies, procedures, and referral networks are in place to ensure clients' safety.
At the heart of the debate is the question of what is an effective intervention: Is providing emotional support to women who have disclosed sexual coercion or other forms of violence beneficial in itself, or is screening effective only when it prevents further abuse?
The evidence to date suggests that screening efforts can improve detection of sexual coercion and other abuse.5 In most surveys among women who have experienced violence, the majority of women support screening, and many express relief and gratitude for the chance to talk about their abuse, often for the first time.6 But whether disclosure has a positive effect on women's health and safety is still in question.7
Researchers at the State University of New York in Albany, New York, USA, and Johns Hopkins University in Baltimore, Maryland, USA, are conducting a randomized controlled trial to assess whether screening and intervention for partner violence among women receiving primary care services reduces their exposure to future violence. The trial, which is sponsored by the U.S. Centers for Disease Control and Prevention (CDC), will also measure the impact of provider intervention on the women's quality of life and mental and physical health. Results are expected in 2005. Additional studies are needed to determine when and how to screen for violence in different settings, particularly in developing countries.8
In the meantime, based on the experience of family planning associations in the Dominican Republic, Peru, and Venezuela, the International Planned Parenthood Federation's Western Hemisphere Region office recommends that health facilities establish routine screening only when they can ensure clients' privacy, safety, and confidentiality. Managers should also help ensure that providers have positive attitudes toward victims of violence and can offer clients who disclose violence some assistance on-site or through referrals.
Even when screening policies and protocols are not in place, some clients will seek care for the effects of abuse or disclose their experiences to a provider. Therefore, providers need to be prepared to respond sensitively to victims of violence and to care for women in crisis.9
— Kathleen Henry Shears
References
García-Moreno C. Sexual violence. IPPF Med Bull 2003;37(6):1-2; Jejeebhoy S, Bott S. Non-consensual Sexual Experiences of Young People: A Review of the Evidence from Developing Countries. New Delhi, India: Population Council, 2003.
García-Moreno C. Dilemmas and opportunities for an appropriate health-service response to violence against women. Lancet 2002;359(9316):1509-14.
Bott S, Guedes A, Guezmes A. The health service response to sexual coercion/violence: lessons from IPPF/WHR members associations in Latin America. Non-consensual Sexual Experiences of Young People in Developing Countries: A Consultative Meeting, New Delhi, India, September 22-25, 2003.
Schraiber LB, d'Oliveira AF. Violence against women and Brazilian health care policies: a proposal for integrated care in primary care services. Int J Gynaecol Obstet 2002;78(Suppl 1):21-25.
Bott; Velzeboer M, Ellsberg M, Clavel Arcas C, et al. Violence Against Women: The Health Sector Responds. Washington, DC: Pan American Health Organization, 2003; Waalen J, Goodwin MM, Spitz AM, et al. Screening for intimate partner violence by health care providers: a review of barriers and interventions. Am J Prev Med 2000;19(4):230-37.
Bott S, Guedes A, Claramunt MC, et al. Improving the Health Sector Response to Gender-based Violence: A Resource Manual for Health Care Professionals in Developing Countries. New York, NY: International Planned Parenthood Federation, Western Hemisphere Region, 2004; Parsons L, Goodwin MM, Petersen R. Violence against women and reproductive health: toward defining a role for reproductive health care services. Matern Child Health J 2000;4(2):135-40.
Nelson HD, Nygren P, McInerney Y, et al. Screening women and elderly adults for family and intimate partner violence: a review of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med 2004;140(5):387-96; Family Violence Prevention Fund Research Committee. Review of the U.S. Preventive Services Task Force draft recommendation and rationale statement on screening for family violence. San Francisco, CA: Family Violence Prevention Fund, 2003. Available online (PDF, 269K); Ramsay J, Richardson J, Carter YH, et al. Should health professionals screen women for domestic violence? Systematic review. BMJ 2002;325(7359):314-18.
García-Moreno, 2002.
Bott, Guedes, Claramunt.
How Providers Can Help
Providers can help clients cope with the effects of sexual coercion and prevent further abuse in many ways. They can:
Recognize warning signs. Warning signs — such as recurrent sexually transmitted infections (STIs), unplanned pregnancy, depression, self-destructive behavior, or a history of chronic, unexplained physical symptoms — can alert providers that a client may have experienced sexual assault or other types of nonconsensual sex.1
Assess safety. A provider can help a woman who discloses abuse determine whether she may be in immediate danger of further abuse and, if so, help her find a safe place to stay.
Provide sensitive, nonjudgmental counseling. Clients interviewed after visiting clinics in three Latin American countries where providers routinely screened for sexual, physical, and psychological abuse appreciated providers' nonjudgmental attitudes, respect for confidentiality, belief in their accounts, and emotional support.2 Providers should assure clients who have experienced forced sex that the abuse was not their fault.3
Confront myths. Analyzing personal beliefs and prevailing myths about nonconsensual sex can help providers become more effective counselors. It is important to understand, for example, that sexual violence is driven by anger and a need to control victims rather than by sexual desire, and that rape can occur within marriage.4
Counsel clients on contraception and STI prevention. Women who experience any kind of sexual coercion need special counseling about how to protect themselves from HIV, other STIs, and unintended pregnancy. A client may need a clandestine form of contraception if a coercive partner does not want her to use family planning. Negotiating condom use is rarely an option for a woman in an abusive relationship.5
Offer emergency contraception. Clients who have had forced sexual intercourse within the past five days should be offered emergency contraception; a woman who has waited more than five days to seek help should be advised to return for pregnancy testing if she misses her next period.6 Emergency contraception can help prevent pregnancy for up to five days but is most effective within 72 hours of intercourse.7
Provide timely, appropriate STI testing and treatment. Local protocols should guide decisions about which STI tests to offer a victim of sexual violence and whether to offer postexposure prophylaxis for STIs. If postexposure prophylaxis for HIV infection is available, a thorough discussion of its risks and benefits can help a client make an informed decision (see Research on Postexposure Prophylaxis for HIV).8
Know the legal requirements. To avoid compromising future investigations or court hearings, providers should have a thorough understanding of local regulations governing sexual abuse. In cases of rape, for example, forensic services should be performed by someone the courts recognize as qualified to document evidence of rape.9
Build and maintain a referral network. Few health facilities can offer victims of sexual coercion all the medical, psychological, legal, and social services they need. Providers should know what referral services are available and should develop cooperative relationships with referral agencies.10
Redefine nonconsensual sex as a health problem. By raising awareness of the serious health consequences of forced sex, health care providers can help change societal attitudes that condone or even encourage it. They can ensure that their own institutions do not tolerate coercion. Also, they can educate clients and help influence policies that guide medical, legal, and social responses to nonconsensual sex.
The appropriate level of services to offer in a given setting depends on the resources available. Some hospitals may be able to provide comprehensive services, while providers at primary health centers focus on education, detection, basic medical care, and referrals. The United Nations Population Fund (UNFPA) helps program managers establish one of the following three levels of services for victims of sexual violence: displaying information in clinics, screening all clients and referring them for care and support, or screening clients and providing care and support on-site.11
— Kathleen Henry Shears
References
Heise L, Ellsberg M, Gottemoeller M. Ending violence against women. Popul Rep 1999;27(4):22-23; Stevens L. A Practical Approach to Gender-based Violence: A Programme Guide for Health Care Providers and Managers. (New York, NY: United Nations Population Fund, 2001)12-13.
Bott S, Guedes A, Guezmes A. The health service response to sexual coercion/violence: lessons from IPPF/WHR members associations in Latin America. Non-consensual Sexual Experiences of Young People in Developing Countries: A Consultative Meeting, New Delhi, India, September 22-25, 2003.
Stevens.
World Health Organization (WHO). Guidelines for Medico-legal Care for Victims of Sexual Violence. Geneva, Switzerland: WHO, 2003.
Stevens.
WHO.
International Consortium for Emergency Contraception. Regimen Update, June 2003. Available online(PDF, 200K).
WHO.
Jejeebhoy S, Bott S. Non-consensual Sexual Experiences of Young People: A Review of the Evidence from Developing Countries. New Delhi, India: Population Council, 2003.
WHO.
Stevens.
Research on Postexposure Prophylaxis for HIV
Antiretroviral treatment of rape victims definitely or probably exposed to HIV during their assaults can be cost-effective in countries with high HIV prevalence. It also may be affordable in a middle-income country like South Africa, a recent modeling study conducted there shows.1
Such treatment, called postexposure prophylaxis (PEP), has been available through the South African public health system since 2002. "In one year between April 2002 and March 2003, nearly 53,000 rapes and attempted rapes were reported in South Africa, although the actual rate may be up to nine times greater," says Nicola Christofides, the study's principal author and a senior scientist with the Medical Research Council of South Africa. With 14 percent to 28 percent of rapists in South Africa estimated to be HIV-infected, their victims face considerable infection risks. Providing all rape victims with PEP may be substantially less costly than later treating only those who become infected. In South Africa, the difference could be as great as U.S. $2,000 per person.
In the modeling exercise, researchers made several assumptions. First, they assumed that the use of PEP after rape would be at least 80 percent effective. This reflects results from a retrospective case-control study indicating that the odds of HIV infection were reduced by about 81 percent among health care workers who took PEP after exposure to HIV via needlestick injuries.2 A substantial body of other research also supports the effectiveness of PEP after occupational exposures to HIV in health care settings. PEP has become the standard of care in such settings, and the United States has national guidelines for occupational PEP. Nevertheless, the efficacy of occupational PEP has not been proven, and failure of PEP to prevent HIV infection has been reported.3
Limited data exist about PEP's effectiveness when given after sexual exposure to HIV. A small Brazilian study among homosexual men exposed to HIV found that PEP reduced seroconversion by 83 percent.4 Otherwise, efficacy has been largely assumed on the basis of animal and human data including occupational, perinatal, and nonoccupational exposures to HIV. Several European nations, Australia, and some U.S. states — New York, Rhode Island, Massachusetts, and California — have issued guidelines for the use of PEP after sexual or other forms of nonoccupational exposure to HIV.5 The U.S. Centers for Disease Control and Prevention (CDC) had not recommended for or against the use of PEP after nonoccupational exposure to HIV because it lacked information on PEP's effectiveness at curbing infection.6 But in January 2005, after considering recent animal and lab studies, the CDC began recommending a 28-day course of antiretroviral therapy for persons seeking care within 72 hours after nonoccupational exposure to blood, genital secretions, or other potentially infectious body fluids of a person known to be HIV-infected, when that exposure represents a substantial risk of infection.7
Nevertheless, the question of how to determine whether the risks of HIV infection justify use of PEP remains. Most exposures to HIV will not result in infection. In the case of sexual assault, considerations include the infectiousness of the rapist (e.g., viral loads are higher in recently seroconverted individuals) and the risk of infection based on the victim's age. For biological reasons, younger women are more susceptible. (Notably, the South African researchers estimated that women under age 18 years had twice the risk of infection than did adult women.) Also to be considered is the degree of vaginal trauma and abrasions caused by rape. Risk of HIV infection after unforced vaginal intercourse with an infected man has been estimated to be 0.1 percent to 0.2 percent per act,8 but traumatic, forced sex could quadruple that risk, the South African researchers estimated. This heightened risk approximates that associated with occupational needlestick exposure, which may be as high as 0.36 percent.9
Even when HIV risk is clearly high and thus use of PEP seems most appropriate, type of treatment and compliance to treatment regimens need to be considered.
PEP involves taking a brief course (usually 28 days) of antiretroviral medications as soon as possible after exposure, preferably beginning within 36 hours. Usually, a regimen of two nucleoside reverse transcriptase inhibitors — ideally, zidovudine and lamivudine (otherwise, lamivudine and stavudine, or stavudine and didanosine) — is recommended. This approach is especially advised if the source is of unknown HIV status but presumed to be at low risk of infection. A regimen that includes a third drug — usually a protease inhibitor such as indinavir or nelfinavir — may be warranted for exposures that pose an especially high risk of HIV transmission (for example, when the source is definitely HIV-positive or at very high risk of infection).10
The potential benefits of PEP must be carefully weighed against its potential dangers. All approved antiretroviral drugs have substantial drug interactions and adverse side effects that are occasionally serious; thus, PEP is not justified for exposures posing a negligible risk for HIV infection.11 (Regardless of HIV risk, nevirapine is not recommended for PEP for safety reasons.12) The health risks associated with PEP are of particular concern when treatment is considered for adolescents or children, and great care must be taken in its administration.13
Among the factors that the South African researchers considered in their PEP cost-effectiveness model was that of treatment compliance, which can be poor. Analysis of a registry of some 450 U.S. health care workers who received PEP (often consisting of at least three antiretroviral drugs) after exposure to HIV found that nearly half of the workers discontinued all drugs and another 13 percent modified their drug regimen, commonly in response to adverse side effects.14 Even with support and counseling of patients, discontinuation of PEP can be high.15
In the South African cost-effectiveness study, a two-drug regimen of zidovudine and lamivudine was modeled. Whether to use a two- or three-drug regimen is debated.16 Because a two-drug regimen is likely to be less costly, less toxic, have fewer side effects, and be better tolerated than a three-drug regimen, it may be less frequently discontinued and may actually result in lower HIV transmission rates.17 In a study of PEP that primarily involved two reverse transcriptase inhibitors, 78 percent of some 400 individuals treated for four weeks completed treatment.18
A multidisciplinary team approach to PEP provision for rape victims may increase adherence even to the three-drug regimen, a small study in London suggests.19 Although evidence-based guidelines are needed, essential services suggested for rape victims receiving PEP include HIV testing for at least six months after exposure; counseling about the importance of completing the drug regimen, possible drug interactions and side effects, and how to minimize side effects and recognize serious side effects; and medical evaluation for toxicity at baseline and again two weeks after starting PEP.
In middle- and low-income countries, particularly those with generalized HIV epidemics, research is urgently needed on how PEP can be included in patient care.20 But, in South Africa, the researchers who found PEP for rape victims to be cost-effective have conducted additional research to explore how women themselves want PEP to be delivered.21 Interviews with 292 women, 159 of whom had accessed sexual assault services, revealed that they preferred PEP to be offered with other related sexual assault services. Such services included provision of HIV testing before PEP begins, increased availability of counseling, easily remembered information about side effects, and medications to alleviate the common side effect of nausea. Finally, the interviewed women preferred delivery of all PEP drugs at an initial visit. Although not current practice, this approach appears to increase compliance, which was only 44 percent, says study coauthor Christofides.
— Kim Best
References
Christofides N. Postexposure prophylaxis after rape. XV International AIDS Conference, Bangkok, Thailand, July 11-16, 2004.
Cardo DM, Culver DH, Ciesielski CA, et al. A case-control study of HIV seroconversion in health care workers after percutaneous exposure. Centers for Disease Control and Prevention Needlestick Surveillance Group. N Engl J Med 1997;337(21):1485-90.
U.S. Centers for Disease Control and Prevention (CDC). Updated U.S. Public Health Service guidelines for the management of occupational exposures to HBV, HCV, and HIV and recommendations for postexposure prophylaxis. MMWR 2001;50(RR-11):1-42; Fournier S, Maillard A, Molina J-M. Failure of postexposure prophylaxis after sexual exposure to HIV. AIDS 2001;15(3):430.
Schechter M, Lago RF, Ismerio R, et al. Acceptability, behavioral impact, and possible efficacy of post-sexual exposure chemoprophylaxis (PEP) for HIV. 9th Conference on Retroviruses and Opportunistic Infections, Seattle, WA, February 24-28, 2002.
New York State Department of Health AIDS Institute. HIV Prophylaxis Following Non-occupational Exposure Including Sexual Assault. New York State Department of Health AIDS Institute, 2004. Available online; Mayer KH, Merchant RC, Browning CA. Nonoccupational Human Immunodeficiency Virus Postexposure Prophylaxis Guidelines for Rhode Island Healthcare Practitioners. Brown University AIDS Program and the Rhode Island Department of Health, 2004. Available online (PDF, 129K); Massachusetts Department of Public Health. HIV Prophylaxis Following Non-Occupational Exposures Recommended Protocol Components. Massachusetts Department of Public Health, 2002. Available online; Myles JE, Bamberger J. Offering HIV Prophylaxis Following Sexual Assault: Recommendations for the State of California. San Francisco Department of Public Health, California HIV PEP after Sexual Assault Task Force, California State Office of AIDS, 2001. Available online(PDF, 221K); Stephenson J. PEP talk: treating nonoccupational HIV exposure. JAMA 2003;289(3):287-88.
U.S. Centers for Disease Control and Prevention (CDC). Management of possible sexual, injecting-drug-use, or other nonoccupational exposure to HIV, including considerations related to antiretroviral therapy. MMWR 1998;47(RR-17):1-14.
U.S. Centers for Disease Control and Prevention (CDC). Antiretroviral postexposure prophylaxis after sexual, injection-drug use, or other nonoccupational exposure to HIV in the United States. MMWR 2005;54(RR-02):1-20; Health officials hail government's decision to extend emergency AIDS treatment to rape victims, drug users. Associated Press, January 21, 2005.
Mastro TD, de Vincenzi I. Probabilities of sexual HIV-1 transmission. AIDS 1996;10(Suppl A):75-82.
Tokars JI, Marcus R, Culver DH, et al. Surveillance of HIV infection and zidovudine use among health care workers after occupational exposure to HIV-infected blood. Ann Intern Med 1993;118(12):913-19.
CDC, 2001; Olshen E, Samples CL. Postexposure prophylaxis: an intervention to prevent human immunodeficiency virus infection in adolescents. Curr Opin Pediatr 2003;15(4):379-84; Sarrazin U, Brodt R, Sarrazin C, et al. Postexposure prophylaxis after occupational exposure to HBV, MCV and HIV. Radiologe 2004;44(2):181-94; Alvarado-Ramy F, Beltrami E. New guidelines for occupational exposure to blood-borne viruses. Cleveland Clin J Med 2003;70(5):457-65. Available online(PDF, 361K).
CDC, 2001.
Patel SM, Johnson S, Belknap SM, et al. Serious adverse cutaneous and hepatic toxicities associated with nevirapine use by non-HIV-infected individuals. J Acquir Immune Defic Syndr 2004;35(2):120-25.
Havens PL, American Academy of Pediatrics Committee on Pediatric AIDS. Postexposure prophylaxis in children and adolescents for nonoccupational exposure to human immunodeficiency virus. Pediatrics 2003;111(6 Pt 1):1475-87.
Wang SA, Panlilio AL, Doi PA, et al. Experience of healthcare workers taking postexposure prophylaxis after occupational HIV exposures: findings of the HIV Postexposure Prophylaxis Registry. Infect Control Hosp Epidemiol 2000;21(12):780-85.
Rabaud C, Bevilacqua S, Beguinot I, et al. Tolerability of postexposure prophylaxis with zidovudine, lamivudine, and nelfinavir for human immunodeficiency virus infection. Clin Infect Dis 2001;32(10):1494-95.
Kim JC, Martin LJ, Denny L. Rape and HIV post-exposure prophylaxis: addressing the dual epidemics in South Africa. Reprod Health Matters 2003;11(22):101-12.
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