A SA Medical Research Council study – with important legal implications – has shown that female rape survivors are 60% more likely to contract HIV within a year or two after their rape than women who have not been raped, writes Mia Malan for Bhekisisa.
The results of the study, which followed female rape survivors for up to three years, have finally given courts empirical evidence to use to prove that convicted rapists can – at least partly – be held responsible when women contract HIV for up to three years after their rape.
The Rape Impact Cohort Evaluation (RICE) study found that female rape survivors between the ages of 16 and 40 were 60% more likely to contract HIV within a year or two after their rape than women who had not been raped, regardless of the HIV status of their rapist.
Reported rapes have consistently increased in South Africa between 2016-17 and 2019-20, police statistics show. In the 2019-20 year, 42,289 rapes were reported at police stations, but the actual number of incidents is almost certainly much higher – a 2012 community-based survey in Gauteng revealed that only one in 25 women who were raped reported it to the police.
Rape survivorsʼ chances of getting their perpetrators convicted is extremely low. A 2013 South African Medical Research Council (SAMRC) study found that fewer than one in 10 rape cases opened by the police resulted in a guilty conviction. In fact, only 18.5% of such cases made it to trial and about half the time prosecutors would not prosecute a rape case referred to them if they believed it would not result in a conviction.
Trauma of rape makes it harder to negotiate safe sex
One of the recommendations of the RICE study, conducted by the SAMRC gender and health research unit, is that the long-term HIV-related “health burden associated with a rape experience” should be used “effectively in the justice processes” as aggravating evidence for sentencing.
“Our study has shown that rape causes long-term health problems, such as an increased risk to acquire HIV for years after the rape,” says lead study author Naeemah Abrahams. “The immediate risk of infection after a rape, if the rapist was HIV-positive, is by no means the only HIV-related risk and prosecutors should be able to use the new evidence about the long-term infection risk to argue for heavier sentences for convicted rapists.”
Numerous studies have found that rape-related trauma, such as post-traumatic stress disorder, anxiety, depression and self-blame can all massively compromise a survivor’s ability to negotiate safer sex.
If this type of trauma is left untreated, it can also lead to self-medication such as heavy drinking or drug use, which in turn, increases the chances of risky sexual behaviour.
A 2007 study in the Journal of American College Health has, for instance, found that the less help an abused woman receives, the higher the likelihood that she will turn to alcohol to cope with her trauma and suffer further abuse.
The new evidence can help prosecutors argue for heavier sentences
Now there is new evidence about the impact of rape on womenʼs long-term health, that could help prosecutors to argue for more severe sentences for convicted rapists.
The National Prosecuting Authority sexual offence and community affairs unit has agreed to include the results of the RICE study in their advance training of prosecutors “to enhance their knowledge regarding the utilisation of this research in court for aggravating circumstances”, says the acting special director of public prosecutions, Pierre Smith.
“One of the benefits of the findings of the RICE study is that it can be used to assist the court to arrive at a just sentence for a rape perpetrator,” he says. “It could, for instance, be used by the prosecution as an aggravating factor to argue that the court should impose the maximum sentence for a particular rape.”
But such evidence, says Smith, would need to be presented to the court by an expert – as opposed to a prosecutor – as it is based on research analysis.
“That expert would need to be informed about the merits of the particular case in order to place the merits of the case in context with the findings of the study. This is essential to exclude misinterpretation or incorrect analysis findings of this particular research.”
The RICE researchers followed just over 1,000 women from Durban – about half of them rape survivors and the other half not – for between one and three years between October 2014 and March 2020.
The peer reviewed study, which will be published in the journal AIDS in December/January, is the first to track such a large number of rape survivors for a long period – from within 20 days after their rape – and then compare their HIV status with that of a control group.
Abrahams explains: “Not many other countries can do this type of study, because they do not have the large numbers of both rape and HIV that we have in South Africa. That horrible situation – ironically – made this study possible.”
How the researchers found trial participants
The average age of participants in the RICE study was 23 years. This age group falls within the group of people in South Africa – teenage girls and young women between the ages of 15 and 24 – that is contracting HIV at the fastest rate by far.
In some areas of the country, the HIV prevalence among adolescent girls and young women is up to six times higher than that of their male peers, according to UNAids.
The RICE study researchers visited rape crisis centres to recruit rape survivor trial participants and primary healthcare clinics to enrol control group volunteers. All participants were tested for HIV at the start and then at every return visit, which was every three months in the first year and then every six months thereafter.
The difference in HIV incidence (the rate of new infections), between the control and the rape survivor group started to show from the sixth month after enrolment; in other words, more or less six months after a rape had occurred.
Why the HIV prevention pill should be available
To decrease a rape survivorʼs immediate chances of getting infected with HIV if the rapist was HIV-positive, South Africa started to provide postexposure prophylaxis, or PEP, to rape survivors for free in the public sector in 2002. If people who have been raped take this 28-day long course of antiretroviral drugs within 72 hours of having been raped, the medicine dramatically reduces their likelihood of being infected.
But the RICE study has shown that PEP is not enough.
Because we now know there is a long-term risk of HIV infection, survivors also need to be prioritised for pre-exposure prophylaxis, or PrEP, the researchers argue. Studies have shown that PrEP, in the form of a daily pill, can reduce an HIV-negative personʼs chances of getting infected with HIV by more than 90%, if taken correctly.
Currently, South Africaʼs PrEP guidelines do not include rape survivors as a priority risk group to which the HIV prevention pill should be provided – but adolescent girls and young women in general are.
The RICE study data show that the HIV incidence for both the control and rape survivor group is alarmingly high. So high that all participants, by World Health Organisation (WHO) standards, qualify as populations at substantial risk of HIV infection that should be prioritised for PrEP. WHO guidelines recommend that PrEP should be a priority for populations with an HIV incidence of three per 100 person-years or higher.
The HIV incidence of the RICE studyʼs survivor group was 6.6 per 100 person-years and for the control group it was 4.7 per 100 person-years.
PrEP should therefore be a priority for all adolescent girls and young women in South Africa, says HIV researcher and clinical epidemiology professor at Columbia University, Quarraisha Abdool Karim.
“The findings of the RICE study confirm the intertwining of the HIV and gender-based violence epidemics. Young women, especially those between 15 and 24, have a high chance of getting infected with HIV, but even more so if they had been raped.”
COVID-19 resulted in PrEP targets falling behind
The health department, with help from the US governmentʼs Presidentʼs Emergency Fund for Aids Relief, PEPFAR, provides PrEP for free at 218 sites in South Africa, including at 39 schools, 13 universities and 11 technical and vocational education and training (TVET) colleges and 1,135 public health facilities.
Although the department exceeded its targets for PrEP distribution among adolescent girls and young women for 2019-20, it fell behind with its goals this year (2020-21) because of the COVID-19 pandemic. By the end of August, only 17,748 out of the target of 41,105 girls and young women had been reached with the HIV prevention pill.
“COVID-19 lockdowns limited movement and resulted in fewer people visiting public health facilities and other venues where PrEP is provided and that impacted heavily on how many people we could reach,” explains health department Director of HIV Prevention, Thato Chidarikire.
“But weʼre picking up speed again – remember, this is a phased in approach, weʼre only in the beginning stages of making PrEP more widely available in the public sector.”
Chidarikire says, based on the RICE study results, rape survivors will likely be added to the department PrEP guidelines as a risk group that should be prioritised for PrEP and the department will look into making the medication available at rape crisis centres.
“It makes sense to invest resources into preventing HIV acquisition, because good prevention is better than treating HIV.”
We need long-acting forms of PrEP for teenage girls and young women
The HIV prevention pill needs to be taken once a day at more or less the same time to produce the best results. So, adherence to PrEP has often proven to be a problem to young women in studies. Researchers are therefore looking into forms of PrEP that can be taken less often.
In November, the results of the HPTN084 study, that tested whether a PrEP injection every eight weeks could prevent HIV infection in cisgender women, showed that the shot is even more effective than a daily pill.
But the jab, which contains the antiretroviral drug cabotegravir, is more expensive than a daily pill and has not yet been registered for use.
The Centre for the Aids Programme of Research in South Africa, Caprisa, where Abdool Karim is the associate scientific director, is also researching a long-acting form of PrEP for teenage girls in the form of a match-sized implant that could potentially be inserted in the upper arm once a year, but the study is still in its infancy.
Ultimately, Abdool Karim says, we need to address the cause of HIV and rape: gender inequity.“Gender-based violence and HIV are not two independent epidemics, they are intertwined. Both are fuelled by gender inequity, which puts particularly young women on a very different trajectory from young men. Whether we look at gender-based violence or HIV, women are bearing the brunt.”
Rape survivors need comprehensive, long-term health care and support to prevent HIV: Evidence from the Rape Impact Cohort Evaluation (RICE) study
Published by the South African Medical Research Council on 1 December 2020.
Naeemah Abrahams, Shibe Mhlongo, Kristin Dunkle, Esnat Chirwa, Leane Ramsoomar, Carl Lombard, Soraya Seedat, Andre Pascal Kengne, Bronwyn Myers, Nasheeta Peer, Claudia Garcia-Moreno and Rachel Jewkes
This is a shortened version of the study content.
The research question
Our aim was to understand the long-term health impact of rape on women and to discover whether women who have been raped have a greater risk for acquiring HIV in the longer term
How we conducted the research
The Rape Impact Cohort Evaluation (RICE) was a longitudinal study conducted in Durban, South Africa. Our study enrolled two groups of women aged 16 to 40 years: a group of women who reported a rape to post-rape care services (Thuthuzela Care Centres and a hospital based Crisis Clinic) were interviewed within 20 days of the rape, and a second group of women recruited from Primary Health Care services, who reported they had never been raped. We included women from the rape services irrespective of their sexual orientation and who perpetrated the rape (e.g. intimate partners and non-partners).
The study started in Oct 2014 and ended in March 2020. We conducted repeated interviews for between 12 months and 36 months. We tested all women for HIV and interviewed them about their sexual and reproductive health, mental health, and their HIV risk behaviour at every visit. These were held every three months in the first year and every six months thereafter.
The RICE study staff received extensive training to ensure the research was conducted ethically and sensitively. We created a supportive and caring environment, with our trauma counsellor providing immediate counselling if needed, and all staff were trained to facilitate access to services, care and support.
Assessing HIV status was key in understanding the role of rape in HIV acquisition over time. We therefore compared HIV sero-conversion between HIV negative women in the two study groups in the follow-up period.
Among the women recruited, 1,019 were HIV negative at baseline (441 among the women who reported a recent rape and 578 among the women who have not reported a rape). They were on average 23 years old.
We found that the women who had been raped had a 60% increased likelihood of HIV infection over the next 1-2 years compared to women who had not been raped.
The difference in the rate of HIV new infections among women who had been raped compared to those who had not was notable from the 6th month onwards (see diagram above). Preventing HIV transmission from the rape event is important and post-exposure prophylaxis (PEP) programming focuses on this, but we have found that rape is also associated with a long-term increase in the risk of HIV infection.
Programme and policy recommendations
- The study provides empirical evidence of the role of rape in HIV acquisition. Addressing these twin epidemics is critical.
Effective long-term psychosocial support for rape survivors is vitally important. Post-rape care policies and guidelines should enable the rape survivors to access quality long-term care and support .
- Post-exposure prophylaxis (PEP) remains vital in the immediate period post rape to prevent HIV acquisition from the rape.
- Pre-exposure prophylaxis (PrEP) should be included in the package of care for prevention of HIV in the long-term. Understanding how this will be done for rape survivors require further investigation.
- The evidence of the long-term health consequences following rape should be used to attain justice for rape survivors. The evidence of the impact on survivors’ health must be used in the prosecuting process to argue for lengthier sentences.
- Rape, intimate partner violence and HIV share root causes in gender inequalities and poverty. This risk is exacerbated by individual and social factors including low levels of education, other trauma exposure and harmful use of alcohol. Evidence-based prevention interventions to stem the tide of these dual epidemics are critical.
Bhekisisa story – How rape survivorsʼ long-term risk of HIV infection can lead to heavier sentences for rapists
SAMRC research – Rape survivors need comprehensive, long-term health care and support to prevent HIV: Evidence from the Rape Impact Cohort Evaluation (RICE) study