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rape survivors in South Africa may not go to the police because they lack
confidence in the criminal justice system and believe that perpetrators will not
be punished for their acts.

These concerns appear justified: a government study found that only 7. In many
cases, rape survivors gave statements to officers untrained to deal with rape or
sexual offence cases in environments that were not private. Investigating
officers were not always available, and women and children rape survivors often
waited hours before meeting an investigating officer.

Sexual violence may increase the risk of HIV for all survivors, male and female.
Women and girls are physiologically more vulnerable than men and boys to HIV
infection during unprotected heterosexual vaginal sex.

Forced oral sex may cause tears in the skin, also increasing the risk of HIV
transmission. In cases of gang rape, exposure to multiple assailants increases
the risk of transmission. The presence of other sexually transmitted diseases
also heightens HIV transmission risk. Women and girls in abusive relationships
may have limited capacity to negotiate the terms and conditions of sex,
including when and whether sex takes place and whether condoms are used.
HIV-positive women who disclose their status are often at risk of violence from
their intimate partners, family members, or the community, which may range from
emotional abuse to coerced sex and even to homicide.

Girls and young women face particular risks of contracting HIV through sexual
violence. The administration of a short and affordable course of antiretroviral
drugs following a potential HIV exposure-post-exposure prophylaxis or PEP-can
greatly reduce the risk that a survivor of sexual violence will contract HIV
from an HIV-positive attacker. The provision of PEP, which was first developed
for occupational exposures to HIV such as when health workers are accidentally
pierced by an infected syringe , has been the standard of care for high-risk
occupational exposures, including in South Africa, for some years [27] and is
emerging as the international standard of care for survivors of sexual violence.

In April , the South African Cabinet pledged to provide PEP to survivors of
sexual violence in all of the country's nine provinces. The government's April
announcement marked an important shift in policy. Before then, PEP was generally
unavailable through the public health system, although some service providers in
the public and private sectors had offered it to survivors of sexual violence as
early as Under the national policy guidelines issued in May , PEP should be
offered to all male and female sexual violence survivors fourteen years and
older who present to a health facility within seventy-two hours of being raped
and who test negative for HIV.

PEP services are centered on the provision of antiretroviral drugs, which have
been the object of an extraordinary political battle in South Africa. In South
Africa developed a national drug policy, intended to address problems with the
affordability and availability of essential medicines to all citizens who needed
them.

The policy recommended a number of strategies to meet these objectives,
including legal and regulatory mechanisms encouraging generic substitution of
medicines not under patent, parallel importation of medicines and purchasing of
generic medicines on the international market. Although the Medicines Act of was
passed, it did not come into force. In February , the South African
Pharmaceutical Manufacturers Association and forty-one multinational drug
companies filed an action in the Pretoria High Court to prevent the government
from bringing into operation certain sections of the Act that would allow the
government to produce or import drugs at lower cost.

In the Treatment Action Campaign TAC , a nongovernmental organization with a
nationwide base, coordinated an aggressive international campaign in response
urging the pharmaceutical industry to lower the prices of patented drugs and
calling for the United States government to halt its efforts to roll back the
Medicines Act. In September , following intense activist pressure in both South
Africa and the U.

In April the Pharmaceutical Manufacturers Associationwithdrew its case seeking
to strike down legislative provisions that would allow the government to produce
or import antiretroviral drugs at low cost. In , nongovernmental organizations
began lobbying the Department of Health to develop a program to prevent
mother-to-child transmission of HIV, including by providing AZT an
antiretroviral drug that that reduces the risk of perinatal transmission when
administered to pregnant women.

In a speech, President Thabo Mbeki questioned the safety of AZT, warning that
"the toxicity of this drug is such that it is in fact a danger to health. By
early , Mbeki had begun to solicit the opinions of AIDS "denialists" or
"dissidents," a small group of scientists and activists who believe that AIDS in
Africa is not caused by HIV, but by poverty, poverty-related conditions and
illnesses such as malnutrition and tuberculosis , and drugs used to treat HIV.

In August , a committee of the national Minister of Health and the nine
provincial cabinet health ministers the Minister and the Members of the
Executive Council, or MinMEC took the decision to provide the antiretroviral
drug nevirapine at a small number of pilot sites throughout the country once it
was registered with the Medicines Control Council. In August , following the
withdrawal of the Pharmaceutical Manufacturers Association's case challenging
the Medicines Act, a coalition including TAC sued the government to require it
to provide antiretroviral drugs in the public sector to all HIV-positive women
to prevent mother-to-child HIV transmission.

In December , after the Pretoria High Court ruled that the government's refusal
to provide antiretroviral drugs to HIV-positive pregnant women violated the
constitution and ordered it to provide these medications, Tshabalala-Msimang
announced that she would seek leave to appeal this decision directly to the
Constitutional Court. Provincial governments share responsibility with the
national government for health policy and provision and are responsible for
implementing national health policy.


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The eastern province of Mpumalanga is a case in point. Thys von Mollendorff, who
had been unable to secure a budget or staff to improve his hospital's existing
internal services for rape survivors. In October provincial health minister
Sibongile Manana criticized GRIP for providing antiretroviral drugs to rape
survivors, reportedly accusing GRIP and von Mollendorff of trying to poison
black people and undermining national government policy by doing so. Manana
eventually withdrew these charges, but in November , she suspended von
Mollendorff, charging him with gross insubordination for allowing GRIP to
dispense drugs in a manner the provincial Department of Health considered a
violation of national and provincial policy forbidding the use of antiretroviral
drugs in public hospitals.

Mpumalanga's conflicts with GRIP contributed to misinformation about
antiretroviral drugs. As members of the ANC, we cannot defy our government and
its policies. In Northern Cape province, a doctor in Kimberley in November
provided PEP to a nine-month-old rape survivor, apparently pursuant to a
provincial policy that the doctor's discretion should be used regarding the
administration of PEP in rape cases. The official also demanded to know whether
the practice had been widespread.

The government was still engaged in a court battle contesting High Court orders
requiring the government to provide the antiretroviral drug nevirapine to
prevent mother-to-child transmission.

Exploring Queer Identity With South Africa's Born-Free Generation And LGBTQI
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In August the South African government stated that HIV causes AIDS and that
antiretroviral drugs can mitigate the impact of the disease, and directed the
Department of Health "as a matter of urgency" to develop a detailed operational
plan for a nationwide antiretroviral treatment program. The plan confirmed the
government's prior commitment to providing PEP and committed it to investing
substantial resources to upgrade the national health system, including by
implementing a training program for health professionals regarding use of
antiretroviral drugs.

It also committed itself to an extensive education campaign as part of the plan.
Meanwhile, just as Mbeki's Cabinet declared itself ready to authorize the use of
antiretroviral drugs in government health services, other parts of the
government were taking steps to make it more difficult to get such drugs.


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Guy looking for a female friend with benefits. Doctors, in turn, often refused
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Allison, administrator at a crisis center in Pinetown, KwaZulu-Natal, explained
that if a rape survivor came to the crisis center where she worked black escort
Thohoyandou South Africa gay having seen the police, "we take them to the police
because for them to get examined by a doctor, they need to go to the police and
get a J88 form. Rape crisis counselors in Black escort Thohoyandou South Africa
gay Elizabeth, Eastern Cape also reported that doctors had refused to examine
sexual violence survivors without case numbers. Mayor Matibe honoured by
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seventy-two hours of rape, this lack of information may have been deadly for
many sexual violence survivors. In mid, an experienced physician who had
provided PEP to hundreds of rape survivors in Western Cape expressed his
confusion to Roland about the utility of antiretroviral drugs to treat HIV, in
light of past government statements that these drugs were toxic and of no
probable value to treat HIV.

On the eve of the Cabinet's August announcement, the South African Medicines
Control Council questioned the use of nevirapine, threatening to revoke its
approval unless its manufacturer provided new evidence of the drug's safety
within ninety days. Resource constraints compound barriers posed by government
failure to provide clear messages in support of PEP.

A lack of sufficient financial and human resources poses considerable obstacles
to health and social service provision in South Africa, particularly in areas
historically disadvantaged under apartheid, such as former "homeland" areas and
townships and shanty towns-known as squatter camps-in urban areas. Unequal
resource allocation, scarcity of clinics to cover rural areas, and difficulty in
retaining medical staff within the public health sector and within South Africa
all contribute to these problems.

Health services, social services and specialized police services that provide
the structures and personnel for making PEP provision work are severely
understaffed and underfunded in many parts of South Africa. Police officers who
are meant to transport sexual violence survivors to health facilities may find
themselves without enough working vehicles to provide this important service.

Many have caseloads so high that they lack time to conduct proper
investigations. Many health care practitioners lack sufficient training and
expertise regarding the examination and treatment of rape survivors. Until
recently, district surgeons-medical doctors appointed by government to perform
clinical medico-legal examinations-or physicians in private practice performed
forensic examinations on sexual violence victims.

Many sexual violence survivors' first contact with the health system is with the
casualty accident and emergency department at a hospital, where treating
physicians and nurses are often overworked, inexperienced, and untrained to do
clinical forensic exams or manage rape cases. Notwithstanding these resource
problems, South Africa has the capacity to provide PEP in more areas than it is
doing so.

And PEP can-and should-be integrated into existing health care services that the
government has promised. Many of the services required as part of prevention of
mother-to-child HIV transmission programs which the health ministry has been
establishing since , as well as for the treatment plan to which the government
committed itself in November , overlap with those required for PEP provision.
These currently exist at some level throughout the country.


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Outside of Western Cape, PEP was not generally provided to rape survivors by the
public health system prior to April Government failure to provide adequate
information or training about PEP left rape survivors and key service providers
with little or no knowledge about PEP. Government failure to provide clear
messages in support of ARVs compounded this problem. In the face of its history
of pronouncements against ARV drugs, even those who had information about PEP
were confused about whether it was government policy to provide it. Inadequate
police response to sexual violence complaints coupled with arbitrary
requirements imposed by health professionals has also posed barriers to PEP.

Problems obtaining consent to PEP services and lack of guidance for providers
regarding PEP administration were additional concerns for children under
fourteen. Other barriers to PEP services include stigma and discrimination of
rape survivors and people with HIV, unequal access to poor and rural dwellers,
inattention to social factors that inhibit completion of medications, and
inadequate coordination among service providers.

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The national government announced its intention to roll out PEP services in
April as part of a "comprehensive package of support" for sexual violence
survivors without launching an information campaign to educate the general
public and relevant service providers about PEP or providing training on its
administration.

Provincial governments, for the most part, neglected this task as well. As a
result, rape survivors often did not know about the health risks of rape or
about PEP and other treatment and services available to them. Some of the
agencies charged with providing services to rape survivors likewise did not know
that the government has committed itself to providing PEP, nor what it is, where
to get it, or how to administer it.

Human Rights Watch's investigation suggests that they failed to meet this
obligation. Many rape survivors had not received PEP services simply because
neither they nor the various agencies charged with providing services to them
had any idea that they existed. Health care providers, police, rape crisis
center staff, and others who interact with sexual violence survivors were
inadequately informed about this service.

Since PEP must be administered within seventy-two hours of rape, this lack of
information may have been deadly for many sexual violence survivors. Gauteng
started its PEP program in June , two months after the national policy was
announced. According to Mohau Mokhasane, deputy director of medico-legal
services in the Gauteng Health Department: "We entered into the program
cautiously because we didn't want to get everyone to come into clinics without
having the correct information out there.

In KwaZulu-Natal, provincial health authorities informed hospital directors by
electronic mail and follow-up fax that the protocol for the management of rape
survivors had been amended to include PEP at end-September and relied on
hospital directors to inform relevant health care workers of these changes.
There were few efforts to train clinicians regarding administration of the
drugs; monitoring or evaluation procedures were not put in place to see that the
programs were properly implemented. Kas Kasongo, a physician who had conducted
PEP training for health care providers in Eastern Cape on behalf of the
provincial health department noted similar problems.

People who attended the trainings on PEP services for rape survivors were
hospital superintendents and matrons, [] not frontline health care workers who
received rape survivors and dealt with their issues on a daily basis.




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