Each year World Aids Day falls at the halfway point of the 16 Days of Activism against Gender-Based Violence. While it is not entirely clear if the timing of these campaigns is coincidental, the relationship between gender-based violence and HIV is not.
Gender-based violence — and sexual violence specifically— has been shown to be a primary driver of HIV transmission. Research published in 2010 in The Lancet medical journal found that women in areas with high HIV prevalence rates who are exposed to intimate partner violence are 50% more likely than their peers to become HIV positive.
According to the Human Sciences Research Council’s national HIV household survey, South Africa’s rate of new HIV infections is among the highest in the world. The country also has one of the highest rates of sexual violence globally, according to crime statistics collected by the United Nations Office on Drugs and Crime.
One would expect then that in a country like South Africa, the relationship between sexual violence and HIV would be understood and accounted for in the responses to HIV and sexual violence.
The reality is it’s not. Government’s response to both these issues remains largely uncoordinated and under-resourced.
Sexual violence receives little attention in government’s current HIV plan, the National Strategic Plan for HIV/Aids, TB and STIs.
This NSP recognises the importance of addressing sexual violence as part of curbing new HIV infections. But the plan’s only measurable target related to sexual violence is the provision of post-exposure prophylaxis (PEP). As part of PEP, antiretrovirals are given to HIV-negative rape survivors within 72 hours to prevent infection.
We know that PEP is highly effective at preventing but it can only prevent HIV if it’s accessible. The current NSP says little about programmes aimed at enabling survivors to access PEP or care, while avoiding repeat violence or secondary victimisation in healthcare systems that do not offer sufficient privacy, psychosocial support or follow-up care.
The NSP’s silence on sexual violence is symptomatic of the health system’s broader failures.
The health department is the primary provider of both medical and psychological care to survivors of sexual violence. This department, which is arguably best placed to take the lead in a co-ordinated response to sexual and gender-based violence, has yet to finalise its National Sexual Assault Policy that has been in draft form since 2011.
If ever finalised, the draft policy would provide the basis for a more effective response than what is currently available. Not only does it outline the treatment guidelines for survivors of sexual violence, it also provides a framework for how departments can work together to holistically respond to violence.
In the meantime, survivors of sexual violence can expect to receive a bare minimum of care. PEP is available in the public health system only at designated, specialised facilities.
There is no obvious reason for why it should not be made available at every facility that currently offers antiretroviral therapy.
Even where PEP is available, health care workers are often not trained to deliver services beyond clinical care. Survivors often do not receive appropriate psychosocial support and are seldom referred for this service.
These gaps in the health system’s response should be filled by the 56 Thuthuzela Care Centres (TCC) located at health facilities across the country. TCCs are meant to act as one-stop facilities where survivors can expect to receive medical care, forensic services, psychosocial counselling and assistance with case reporting and court preparation.
A recent USAID report, however, suggests that these facilities tend to be “chronically” under-resourced and often inaccessible when services are needed most.
While the TCC model is sound, it too suffers from a lack of policy direction and institutional support.
The centres fall under the remit of the National Prosecuting Authority, which funds operational costs and staff responsible for case management.
Resources for medical, forensic and psychosocial support services are the responsibility of the health and social development departments. Neither department plans or budgets specifically for services offered at the centres, and so their involvement in service delivery at the centres is patchy at best. The net result is that the centres tend to prioritise prosecution over the medical and psychosocial care of survivors.
But there is a small window of opportunity to fundamentally shift how sexual violence is treated, at least within the health system.
South Africa’s next national HIV plan is currently being developed. While the NSP is unlikely to be the primary vehicle for coordinating the response to sexual violence, it does have a vital role to play in spurring the government into action.
The implementation of the NSP is likely to remain a government priority for the foreseeable future. The plan provides an opportunity to establish sexual violence as a priority within the fight against HIV and this cannot be confined to just the provision of PEP. Addressing the needs of survivors means prioritising other critical resources like medical and forensic services and psychosocial support.
Measuring the success of programme implementation can hold the government to account for better ensuring sexual violence is addressed as a driver of HIV infections and not merely coincidental to it.
Daygan Eagar is an independent budget and health systems analyst working on health rights and social justice projects
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