Presentation to The Joint Monitoring Committee on the Improvement of Quality of Life and Status of Women

Prepared by Lynette Denny, on behalf of Groote Schuur Hospital, Cape Town

How best can South Africa address the impact of HIV/AIDS on women and girls?

Introduction
We have been asked to address this question from the perspective of Groote Schuur Hospital, a large tertiary institution which also serves as a teaching hospital for undergraduate and postgraduate students of the Faculty of Health Sciences of the University of Cape Town. This presentation will address the question from a gynaecological perspective, particularly in relation to women who use the facilities of the Department of Obstetrics & Gynaecology, Groote Schuur Hospital, and will therefore not address all or the wider issues pertaining to the impact of HIV/AIDS on women and girls. We also acknowledge and agree with many of the previous submissions to this committee from the AIDS Legal Network, Treatment Action Campaign, UNAIDS, Speak Out and CASE, all of whom have contextualised the impact of HIV/AIDS on women and girls in the wider gender and socio-economic context. This part of the submission will therefore have a relatively narrow focus on the issue, specifically, from the perspective of a tertiary health institution. My colleague, Dr Besser, will address the question from the perspective of maternal and child health. It should be noted that the request for this submission was received on Friday morning, September 21, 2001.

1. Details on our work with HIV/AIDS
Clinical Perspective
HIV/AIDS has dramatically changed the face of clinical practice. Not only do we see a whole range of new and often devastating diseases in HIV infected women, but women present with more advanced disease, often desperately ill, requiring expensive and often invasive intervention, with long hospital stays. Management of these women in the context of competing health needs and shrinking budgets for tertiary institutions has often been extremely challenging and ethically complex.

Infection
The majority of HIV infected women treated for gynaecological disease at GSH are not on anti-retroviral therapy. The diagnosis of HIV/AIDS is frequently made during the first admission to hospital. The commonest serious gynaecological diseases are related to infection, either sexually transmitted or post-pregnancy. It has become common place to perform hysterectomies in young HIV positive women for overwhelming post-partum (i.e. after delivery of a baby) or post-abortion sepsis. In addition, a significant number of women present with severe sexually transmitted pelvic infection, which frequently requires surgical intervention. Often these women present at an advanced stage of their disease due to either poor prior access to or utility of health care or the manner in which HIV/AIDS may mask the severity of disease.

These women frequently require multi-disciplinary teams of highly trained specialists in all disciplines to treat them effectively. This includes access to our often over-loaded intensive care units. With the pressure on access to intensive care units, sick women with advanced AIDS may not be ‘triaged’ to receive intensive care treatment and this often raises complex ethical issues.

While we whole-heartedly support the emphasis on the development of an effective and strong primary health care system in South Africa, from the perspective of HIV positive women, it is clearly essential to maintain the resources and expertise of the tertiary institutions, particularly in a context in which very few women receive anti-retroviral therapy. From experience in countries where women are treated with anti-retroviral therapy, severe illness as experienced in South Africa is much less commonly observed.

Cancer
In addition to infectious diseases, we anticipate a significant increase in the incidence of cervical cancer in HIV infected women. Cervical cancer is considered a largely preventable disease through the implementation of organised screening programmes that are designed to detect precancerous lesions. Once precancerous lesions of the cervix have been detected and treated, progression to cervical cancer will be prevented in the vast majority of women. While South Africa adopted a national policy for cervical screening of women in December 2000, implementation of this policy has not yet taken place on a significant scale. The policy aims to provide all women over the age of 30, with three free Pap smears in lifetime, at 10 yearly intervals.

While we support this policy, it is apparent that HIV infected women develop cervical cancer and precancerous lesions at an earlier age than non-HIV infected women and it may be necessary to consider a different approach to screening of HIV positive women in order to prevent cervical cancer in this group. There is also evidence that the management of precancerous conditions of the cervix is less effective in HIV positive immune-compromised women compared to non-HIV infected women. Further, treating immune-compromised HIV infected women with anti-cancer therapies, such as radiation and chemotherapy is associated with more severe complications than in non-HIV infected women.

Facilities for the treatment of women with cancer have been down-sized at Groote Schuur Hospital and currently there is a 6 week delay for women with cancer (of any kind) to receive radiation or chemo-therapy, which many would consider unacceptable. With the anticipated increase in the incidence of cervical cancer (and it should be noted that we have already have one of the highest incidences of cervical cancer in the world), the resources to treat all women with this potentially curable cancer needs to be urgently addressed. It is our experience that non immune- compromised HIV positive women with cervical cancer respond as well as non-HIV infected women to radiation, chemotherapy or surgical therapy. It is imperative that these women be offered effective therapy and that alternative, less radical therapies be developed for immune-compromised women.

While it is our policy to treat HIV infected women with cancer in the same manner as non-HIV infected women, the fact that we are treating their cancer but not their HIV status is contradictory. Women being offered radical therapy for cancer, should all ideally receive effective anti-retroviral therapy.

The provision of expensive tertiary level treatments for women should be considered complimentary, not in opposition, to the policy of emphasising primary health care. The management of cancer is a tertiary health care function and it is critical to maintain the resources and expertise at this level.

Violence Against Women
Rape
I would like to refer the committee to the submissions by Speak Out and the AIDS Legal Network for a wider discussion of the incidence and impact of rape on women and girls in SA.

The Department of Obstetrics & Gynaecology at Groote Schuur Hospital in collaboration with the Department of Forensic Medicine at University of Cape Town, the Department of Justice and the Maternal and Child Health Directorate of the Provincial Administration of the Western Cape have developed a comprehensive clinical and forensic protocol for the management of women and men who have been raped. Data from 500 cases who presented to either Groote Schuur Hospital or G F Jooste Hospital have now been computerised and are currently being analysed.

A preliminary analysis of this data shows us the following:
Many women do not report rape to the police, largely due to fears of being further victimised, either by the perpetrator/s or the system
Only 50% of women present to a medical facility within 24 hours of rape.
Over 40% of women are raped by more than one perpetrator.
Approximately 30% of women reported being raped on the way to or from their work place
More than 60% of women have evidence of general bodily injuries and/or injury to the genital tract, suggesting high levels of accompanying violence in most rapes.
15% of women are sodomised at the time of rape.
Approximately 1 in 10 000 raped women are murdered at the time of the rape.

When one considers the high prevalence of HIV among the South African population, the high-risk nature of the sexual activity of rapists and the high levels of violence committed against raped women, we consider the risk of acquiring HIV after rape to be significantly high. In our opinion, it is essential to provide raped women with post-exposure anti-retroviral prophylaxis (PEP), despite the absence of good scientific evidence of its efficacy in preventing HIV transmission. The premise that PEP will work in this situation is based on the biological plausibility and the evidence from other exposure situations (occupational and maternal to child) where we do have evidence that anti-retrovirals prevent transmission of the virus. We have been providing PEP to raped women at Groote Schuur Hospital and G F Jooste for the past 2 and half years. Unfortunately we have very poor follow up data, with only approximately 25% of women returning for follow up. While we cannot comment on the true impact of PEP on HIV sero-conversion, we have not to date, documented any sero-conversions in women who received PEP.

To address this particular question, we are starting a large observational study to track women for 3 – 6 months post rape and hopefully this study will provide some valuable information on the impact of PEP on HIV seroconversion.

For the interest of the committee, a copy of the Sexual Assault Examination form and the protocol for the management of rape, which has been adopted by the Provincial Administration of the Western Cape as formal policy, is attached to this document. The Provincial Rape Task Team is currently involved in conducting two-day training sessions for doctors, nurses and social workers throughout the province. The first training of 40 health personnel took place in July in George, and the second will take place in Worcester later this week. It is our intention to train health personnel in all regions of the Western Cape. In addition, extensive training of health personnel is ongoing in the Cape Metropole region.

The training includes input on understanding rape, the Rape Trauma Syndrome and appropriate counselling provided by Rape Crisis Cape Town, the legal aspects of rape are covered by an advocate from the Department of Justice and the clinical and forensic management of rape is provided by specialists from the Departments of Obstetrics & Gynaecology and Forensic Medicine at Groote Schuur Hospital.

We have developed a training manual to ensure a standardised and holistic approach to training. We believe that we have developed a useful model for the care of raped women (and men), which could be adopted nationally.

Proposed Strategies in Terms of Prevention and Treatment
This document has only touched on some of the aspects of the impact of HIV/AIDS on women, due to time constraints we would like to make the following recommendations

Women with HIV/AIDS are offered anti-retroviral therapy.
The tertiary institutions be adequately resourced and the expertise maintained to enable us to respond effectively to women who present with the complications of HIV/AIDS. Women with HIV/AIDS, as should all ill people, should be offered the highest quality of health care available and affordable in South Africa.
Cervical cancer screening be prioritised and the national policy for the prevention of cervical cancer be implemented urgently.
The State should adopt a national, standardised, women-centred policy for the management of raped women, which should include routine PEP where appropriate.
The incidence of rape exceeds that of Tuberculosis and is probably one of the most serious public health pro blems of women in this country. This requires a national, multi-disciplinary response from all sectors of our society, led by and prioritised by government. Key role-players should include, Health, Justice, Safety and Security, Social and Prison services. The prevention and management of rape should be declared a national emergency. There needs to be a co-ordinated and powerful response from government to end this scourge in our society, which is causing so much suffering to so many women.
Many of the health problems experienced by women are amenable to prevention strategies. These include:
Prevention of unwanted pregnancy through access to contraceptive health services, abortion services and most importantly, by empowering women to control their own reproductive health.
Prevention of sexually transmitted infection (STIs), including HIV, by informing men and women about how to prevent and to treat STIs. Women need to be empowered to negotiate safe sex with their partners, without fear of violence or rejection. Male and female condoms should be widely available, however, while relations between men and women are dominated by patriarchy and the status of women is considered inferior to men, ‘safe sex’ is unlikely to have the desired impact on the prevention of STIs.
Serious illness and its consequences and HIV transmission, can be prevented in HIV infected women by early and rigorous treatment of STIs. This requires providing well-developed, effective, accessible and patient-centred primary health care services for all South Africans, and in particular, HIV infected women. The health care service should be augmented by an extensive campaign in schools, the work-place and the general population about the manner in which STIs are acquired, how they can be prevented and the necessity for early treatment once acquired.
Prevention of cervical cancer by implementing the national policy for cervical cancer screening. The likely impact of HIV on the screening programme needs to be researched and it may be necessary to lower the initial age of screening in order to prevent cervical cancer in HIV infected women.

7. Finally, one of the most important functions of the tertiary institutions should be to conduct well-designed research that impacts on the quality of life of women. Research should include primary health care structures and should be contextualised to the needs of the people served by the institutions. Good clinical practice is enhanced by evidenced-based research and this approach should be encouraged and rigorously promoted.

Addendum A

All patients aged 14 years or older, who present to a health facility, with a complaint of rape or sexual assault must be assessed as soon as possible using the attached management guidelines.

For children younger than 14 years refer to the Child Abuse policy and management guidelines in Circular H102/2000 (dated 21 September 2000).

NOTE: This document constitutes the confidential medical record of the patient. It may however be subpoened as a court document if the court deems it necessary. It is essential to record all information and findings accurately, legibily and to remember that the original document could become part of a court record.

Remember to label each page with the patient’s name and folder number.

A J88 form must be filled in for all cases. The J88 form will be used for the court record in the first instance.

If you are subpoened to give medical evidence in a rape case, you are strongly advised to consult with the prosecutor or other medico-legal experts before giving testimony in court.

Under no circumstances should any patient be turned away to seek help from another facility.

All rape survivors are to be interviewed by the appropriate health worker in a private room. It is advisable that a trusted friend, relative or nurse supports him/her during the interview, according to the patient’s wishes.

Establish whether the patient has reported the matter to the police. Explain to her/him the advantages and disadvantages of reporting the incident.

If the survivor declines to report the rape to the police or to undergo the forensic examination, this choice should be respected and no undue pressure exerted upon her/ him.

If (s)he choses to report the case to the police, phone the police station in the area in which the rape or assault occurred and ask for a police officer to come to the health facility to take a statement from the patient.

It is important to note that in terms of the National Police Instructions on Sexual Offences (NI022/1998) that a medical examination must take place as soon as possible. It is not necessary for an in-depth statement to be taken from the survivor should (s)he have reported the matter to the police, before the examination is done. The in-depth statement should only be taken from the survivor as soon as (s)he has recuperated sufficiently, ideally within 24 – 36 hours.

All forensic specimens are to be locked away in a designated cupboard, in which a register must be kept. The register must record the name of the patient and the health worker, and the date and time of collection. The Sexual Assault Examination form attached must be delivered by hand to the health worker-in-charge of the health facility. The form must be placed in a special envelope marked "Private and Confidential".

Complete the J 88 form.

NOTE: Routine clerking notes of the patient should be kept in the patient’s folder.

Rape survivors should be given the option of going for counseling to:

Social worker

Trained counselor (regional specific)

Private therapist, e.g. psychologist

Rape Crisis or other local services

The survivor and family should be given an updated list of local resources.

[PMG Ed. Note: Actual Report Form not included]