Significant role of sexual violence in HIV infection and depression

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ViolenceFocusSexual violence plays a significant role in HIV infection and depression, according to ground-breaking research with women living in Rustenburg. Conducted by humanitarian organisation Médecins Sans Frontières, the study involved a sample of 800 women, of which one in four had been raped, as had been a third of women seeking abortions.

Health-e News reports that the research, conducted by humanitarian organisation Médecins Sans Frontières (MSF), involved a sample of 800 women. One in four of these women had been raped. MSF estimates that around 6,765 female HIV infections and 5,022 depressions in Rustenburg have their roots in sexual violence. In addition, about one-third of women seeking abortions – about 1,296 – did so because they had fallen pregnant after being raped.

The report says these startling findings are being presented at the Conference on Retroviruses and Opportunistic Infections 2017 in Seattle.

“Opportunities are missed each day to prevent HIV infection, psychological trauma, and unwanted pregnancy for victims of sexual violence in on the platinum mining belt, because there are too few health facilities with the capacity to provide essential care,” according to MSF epidemiologist Sarah-Jane Steele.

As South Africa finalises its next five-year National Strategic Plan (NSP) on HIV, TB and STIs (2017-2022), MSF is calling for the inclusion of “ambitious targets for increasing sexual violence survivors’ access to medical, psycho-social and legal services at primary health facilities” to be included in South Africa’s new five-year National Strategic Plan on HIV, TB and STIs, which is currently being finalised.

Key interventions include providing ARVs as post-exposure prophylaxis to prevent HIV, trauma counselling, emergency contraception, first aid and the option of forensic examination.

“It is not unrealistic to expect, at a minimum, that every sub-district in the country has a health centre that can provide an essential package of care to mitigate the consequences of rape and other sexual violence,” Steele says.

Alongside increased access to services there is also a need for health promotion within communities, as half of the women MSF surveyed in 2015 did not know that HIV can be prevented after rape if PEP is received within 72 hours.

The report says while the extent of sexual violence varies from place to place, MSF believes that its Rustenburg survey has national implications. “The MSF research findings are undoubtedly of national significance because two major contributing factors – namely a high prevalence of sexual violence and poor access to essential care for survivors of sexual violence – are issues with which communities across South Africa grapple on a daily basis,” says Junaid Khan, MSF project co-ordinator in Rustenburg.

“In order to prevent or mitigate death and illness stemming from sexual violence a national, multi-sectoral approach is required. In Rustenburg, efforts are being made to bring together different stakeholders to define an effective model for providing essential medical, psycho-social and legal services to survivors of sexual violence. The hope is that this model could be replicated in other parts of the country.”

MSF report executive summary
This brief provides a snapshot of the findings of a survey conducted by Doctors Without Borders/Médecins Sans Frontières (MSF) in November-December 2015, among women in Rustenburg Local Municipality, in the heart of the platinum mining belt in North West Province. The survey found that one in four women living in Rustenburg has been raped in her lifetime, and approximately half have been subject to some form of sexual violence or intimate partner violence—shocking but not uncommon statistics in South Africa. In line with the South African Constitution, MSF works to ensure that all survivors of sexual violence have access to emergency medical care and psychosocial support. Services for survivors should be of high-quality, and accessible at the primary health care level.
Yet, survey findings suggest that survivors do not report incidents of sexual violence to health facilities. Women’s responses also suggest low levels of treatment literacy about how a basic package of care can prevent HIV and mitigate other potential health consequences of rape.
Survivors of sexual violence face numerous other barriers to seeking care–stigma within communities is high, and options are few for accessing well-resourced, dedicated sexual violence health services. There is urgent need to improve access to medical services for sexual violence survivors, and provide a more patient-centred response to sexual violence—both in Rustenburg, and across South Africa.
Shifting from widespread stigma and untreated violence to the practice of seeking and providing care will prevent unnecessary infections of HIV and other sexually transmitted diseases, and limit unwanted pregnancies. At the same time, improved access to services will provide psychosocial support and facilitate the process of seeking legal recourse for those who choose to do so.
As South Africa finalizes a new five-year National Strategic Plan for HIV, TB and STIs, government departments must ensure they adequately support survivors to receive prevention and treatment services, and manage other detrimental impacts of sexual violence on individual and national health and wellbeing.

CROI 2017 abstract
Physical and sexual intimate partner violence (IPV) and forced-sex or sexual acts by non-partners (NP-rape) are common in South Africa. Access to effective medical services for survivors, such as post exposure prophylaxis (PEP) for HIV prevention and sexually transmitted infections (STIs), counseling and social services is often severely limited by individual (e.g. awareness) and service-level factors (e.g. location), leaving health consequences of rape and IPV largely unaddressed. Rustenburg Municipality (RM) is South Africa’s platinum mining capital and one of Africa’s fastest growing cities, with a population of 301,795 men and 247,780 women living in informal settlements near the mines. We quantified the prevalence of IPV and NP-rape in this setting, and estimated the associated disease burden. By considering this alongside levels of access to services, we describe the extent to which opportunities to address this disease burden are realized.
Cluster-randomized household survey of women 18-49 years living in RM conducted (Nov– Dec, 2015) to determine the prevalence of IPV and NP-rape. We used WHO estimates of disease risk to determine population attributable fractions (PAF) and applied the PAFs to the population distribution (2011 Statistics SA Census) and local disease prevalence estimates obtained through literature review to determine burden of disease.
Eighty-five percent (n=882) of eligible women participated. Lifetime prevalence of IPV was 45% – >82000 women. Lifetime prevalence of NP-rape was 18% – >28000 women and girls. Very few sought care – 5% told a health care professional about their experiences, 4% a counselor, and 3% a social worker. Of the estimated 35,680 women in RM living with HIV, 6765 cases can be attributed to IPV (19%; Table 1). The burden of IPV on induced abortion is 1296. IPV resulted in 5022 major depression disorder (MDD) cases and 2 suicides. An additional 2012 MDD cases are attributed to NP-rape.
IPV and NP-rape were extremely common among women and girls living in RM, contributing to a large disease burden, including 1/5 of HIV prevalence and more than 1/3 of major depressive disorders. Much of this disease burden could be prevented, through improved access to quality medical services including PEP for HIV and STI prevention, counseling and social services. Current low levels of access mean that this is not achieved, leaving major opportunities for improved health of this very vulnerable population unrealized.

Meiwen Zhang, Sarah Jane Steele, Amir Shroufi, Gilles van Cutsem, Junaid Khan, Garret Barnwell, Julia Hill, Kristal Duncan

Health-e News report
MSF study
CROI 2017 abstract

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