The South African health department has issued guidance on the provision of antiretrovirals as post-exposure prophlaxis (PEP) to rape survivors. The move has been expected since the South African cabinet’s announcement on HIV on 17 April, which has been seen as a major reversal of policy on the provision of anti-HIV drugs.
Rape survivors will be offered PEP including two antiretrovirals, 3TC and AZT, the same therapy as offered to public health workers after a needle stick injury.
“Antiretrovirals are prescribed after rape on the basis that they have been shown to reduce infection among healthcare workers who sustain needle-stick injuries,” said health minister Dr Manto Tshabalala-Msimang. She added “however we lack research that shows conclusively the effectiveness of antiretrovirals in preventing the HIV transmission as a result of sexual assault because of this we felt that the prophylactic use of antiretrovirals in the case of rape survivors should be modelled as closely as possible on the protocols that we follow for occupational needlestick injuries.”
Rape survivors will also be offered counselling to ensure that they understand that even with PEP they may still become HIV-positive and that the drugs have potential side-effects.
However, the regimen being offered by the South African government may be suboptimal. In the UK healthcare workers who experience blood splashes from a person known to be HIV-positive or at high-risk of HIV, are offered a three drug combination including a protease inhibitor or non-nucleoside reverse transcriptase inhibitor, particularly if injury was severe or exposure was prolonged. In other cases the same combination as is being offered to South African rape survivors – 3TC and AZT – is provided. In all cases it is recommended that PEP be offered within 24-36 hours of potential exposure, but preferably sooner, as treatment is most likely to work if offered within an hour of exposure to HIV.
It is not routine practice in the UK to offer PEP to people after a possible sexual or IV drug use exposure to HIV and practice varies between clinics with decisions made on a case-by-case basis. However there are concerns about side-effects, adherence and attendance for repeat HIV-testing. In addition, PEP treatment (especially with a two drug regimen) could lead to drug resistance emerging, particularly if a person requesting PEP is already HIV-positive but believes him or her self to be negative.
South Africa’s provincial governments will now have to make arrangements for the provision of treatments and counselling to rape survivors.
The 3TC-AZT combination has been used by Dr Adrienne Wulfsohn of Sunninghill Hospital in Johannesburg with hundreds of raped women and children, none of whom have subsequently tested HIV-positive, provided treatment was started within 72 hours of the assault.