- All women and men, aged 14 years and older, presenting to a health facility after being raped should be counselled by the examining health worker about the potential risks of HIV transmission post-rape. If the survivor presents within 72 hours of being raped, ARV therapy should be offered to prevent HIV transmission.
The following points should be covered during counselling: The risk of HIV transmission is not known, but it exists. That it is important to know the survivor’s own HIV status prior to using any anti-retrovirals, as using AZT and 3TC in a known HIV positive patient is not adequate therapy and may lead to resistance.That it is the survivor’s choice to have immediate HIV testing. If she/he refuses, no ARV prophylaxis will be given. The efficacy of AZT and 3TC in preventing HIV sero-conversion in cases of sexual assault is not known. The survivor should be made aware that the efficacy of AZT and 3TC prophylaxis is still under study and that the drug itself is not yet licensed for use in post-rape prophylaxis. The common side effects of the drug should be explained, with particular reference to feelings of tiredness, nausea, and flu-like symptoms.
All women who choose to use AZT and 3TC should undergo pregnancy testing to ensure that pregnant women have been booked and are undergoing appropriate antenatal care. The use of AZT and 3TC in the first trimester of pregnancy has not been shown to be teratogenic. It is not possible, however, to guarantee the safety of the drug regarding the foetus in the first trimester of pregnancy. Women who are less than 12 weeks pregnant should be informed of this and be allowed to make a choice as to whether they are prepared to use the drug or not.
The possibility of HIV transmission to their unborn babies should they sero-convert should be discussed, and the women be advised on the option of termination of pregnancy as per the Termination of Pregnancy Act if they so choose.
Taking other medication such as those for pregnancy prevention and antibiotics may also compound the side effects of AZT and 3TC.
The importance of compliance should be emphasised.
- Survivors presenting after 72 hours should be counselled about the possible risk of transmission. For those who request AZT and 3TC, it should be explained that there is good evidence that the use of AZT and 3TC so long after the rape will have NO impact on preventing HIV sero-conversion. This patient will therefore not be given ARVs.
- Voluntary rapid HIV testing should be made available and should be done on all opting for PEP. The rape survivor should sign a consent form for both testing and ARV prophylaxis. Further blood tests that will be done should also include full blood count (FBC), urea & electrolytes for renal function test (UNE) and other liver function tests (LFTs). For those refusing an HIV test, no ARV prophylaxis will be provided.
- Blood should be taken at 6 weeks, 3 months and 6 months and repeat all the above blood tests.
- The dose for AZT is 200mg 8 hourly for 28 days.
- The dose of 3TC is 150mg 12 hourly for 28 days
- The following should be taken into consideration:
Survivors should be given one-week supply of AZT and 3TC and a date to return for reassessment in one week. For those who cannot return for a one-week assessment due to logistical or economic reasons, a one-month supply should be given and once again the issue of compliance be emphasised.- All survivors who have been supplied with AZT and 3TC should be seen one-week post rape for further evaluation. The remainder of the AZT and 3TC should be given at this visit.
- The next visit should be at 6 weeks, then 3 months, and 6 months after the rape. HIV testing should be performed at both the 6-week, 3-month and 6-month visits.
- Survivors who are either known to be HIV positive or found to be HIV positive should not be offered AZT and 3TC. They should be appropriately counselled and referred an appropriate health facility for long-term management of their HIV status.
- Relative contra-indications to the use of AZT and 3TC include significant renal or liver impairment. Where in doubt about the use of AZT and 3TC in individual patients, contact your local physician or referral centre for advice.
- It is strongly suggested that AZT and 3TC be administered only in the context of using the comprehensive National Policy and Standardised Management Guidelines for Rape Survivors. This should encompass the following:
- STI prophylaxis: Presumptive prophylaxis should be given in the form of azithromycin (dose 1g STAT)
- Ovral 28 should be given to prevent unintentional pregnancy
- Counselling of the rape survivor, identification of support needs, and necessary referrals should be done
- In cases where rape survivors have severe bleeding, the issue of proper nutrition with regard to foods that are high in iron, folate, riboflavin, vitamin A and vitamin B12 to avoid the possibility of developing anaemia should be emphasised
- For those that sero-convert, the importance of good nutrition to avoid rapid progression to AIDS should be discussed as in the South African National Guidelines for People Living with TB, HIV/AIDS and Other Chronic Debilitating Conditions, and they should be referred for further HIV management
- In subsequent visits, issues relating to stress management should be discussed as part of the support programme. The survivor should be made aware of the indicators that point to stress such as general irritability, trembling, pain in neck and/or lower back, changes in appetite or sleep pattern etc., as stress may eventually cause exhaustion and illness, either physical or psychological
- Medico-legal assessment of injuries
- Completion of appropriate registers
