Management of Sexual Violence

May 7 th 2013 Carol Odula-Obonyo Senior Medical Officer - Obs/Gyn (UHS)

Definitions

Definitions

Definitions contd….

Introduction

 Sexual assault -any sexual act performed by one (or more) person(s) on another without consent.  May include the use or threat of force. In some cases, the person does not give consent to have sex because he or she is unconscious or otherwise incapacitated.  A person may be raped by a stranger, an acquaintance or date, or a family member.  Rape is a legal term it refers to any penetration of a body orifice (mouth, vagina, or anus) involving force or the threat of force or incapacity (i.e., associated with young or old age, cognitive or physical disability, or drug or alcohol intoxication) without consent.

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Sexual violence

Rape Attempted rape Gang rape Defilement Attempted defilement Indecent act Sexual assault Incest by males and females Deliberate transmission of HIV and any other life threatening sexually transmissible infections Sexual offences relating to positions of authority and persons in positions of trust

After sexual assault. Now what ?

 Why did this happen to me?

 Could I have prevented this?

 Will I develop an infection or become pregnant as a result of the assault?

 Who should I call first?

 Should I report this to the police?

 Is this reportable?

 Since I was drinking, isn't this my fault?

The following steps are recommended after sexual assault

 Find a safe environment away from the assailant  Call a close friend or relative – someone who will offer unconditional support  Seek medical care; do not change clothes, bathe, douche, or brush your teeth until evidence is collected. A complete medical evaluation includes evidence collection, a physical examination, treatment and/or counseling. You do not have to do any part of this evaluation that you do not want to do.

At the clinic

 History taking  Head to toe examination  Genito-anal examination  Investigations for clinical management of the survivor  Investigations carried out for evidence purposes  Management of physical injuries  Post exposure prophylaxis  Pregnancy prevention  Prophylaxis of STI’s including Hep B

The survivor

Evidence carried out for investigative purposes

Management of physical injuries

Prophylaxis for Sti’s

HepB future prevention

Counseling or psychotherapy

 Counseling or psychotherapy can be helpful in dealing with the events of the assault itself as well as the anger, fear, depression, or anxiety that many people feel afterwards.

 Several types of healthcare providers provide counseling, including social workers, psychologists, nurses, and psychiatrists. Some people prefer to meet one-on-one with a counselor while others prefer to meet in a group setting with other people who have had similar experiences.

Post exposure prophylaxis

April 17 th 2013

PEP

Regimes for adults

Side effects of PEP

Pregnancy prevention

Mifepristone and Misoprostol

Elimination of parent to child transmission of HIV

M A Y 2 N D 2 0 1 3

Steps towards eMTCT

   Towards the elimination of Mother-to-child transmission of hiv Report of a WHO technical consultation:9-11 November 2010 Geneva, Switzerland

Outline

 Eliminating new HIV infections in children  Early diagnosis and treatment of HIV infected children  Adolescent Prevention and Treatment  Call to Action

Key concepts in vertical transmission

TRANSMISSION TIMELINE

 Transmission can occur during pregnancy, labor & delivery, and postpartum during breast feeding  Not all infants born to women living with HIV will acquire HIV infection  Estimated risk 25-45% without any intervention

Source: DeCock et al. JAMA.2000

; 283:1175-1182.

Benefits of preventing mother to child transmission of HIV

 AIDS related deaths -reversing the gains made in child health and survival in Kenya.   Caring for HIV-infected children has major economic and social impacts on families and health systems. Thus at the national level, preventing MTCT has the potential to increase the understanding and acceptance of the HIV/AIDS epidemic and those living with HIV/AIDS. Counseling, testing and community sensitization can contribute to reducing stigma. Reduction of MTCT of HIV:  Decreases numbers of HIV infected children   Increases child health and survival Decreases the load on the health system  Gives an opportunity to improve and expand health services as well as to strengthen the existing health infrastructure

PMTCT Global targets and indicators

Overall Targets

1. REDUCE THE NUMBER OF NEW HIV INFECTIONS AMONG CHILDREN BY 90%. 2. REDUCE THE NUMBER OF HIV-ASSOCIATED DEATHS AMONG WOMEN DURING PREGNANCY, DELIVERY AND PUERPERIUM BY 50%. Reduce under 5 deaths due to HIV by > 50% Provide antiretroviral therapy for all HIV– infected children. Prong 1 – Primary prevention of HIV infection among women of childbearing age

Target

Reduce HIV incidence in women 15-49 by 50%. Prong 2 – Preventing unintended pregnancies among women living with HIV

Target

Reduce unmet need for family planning among women to zero (MDG goal). Prong 3 – Preventing HIV transmission from pregnant women living with HIV to their infants

Target

Reduce mother-to-child transmission of HIV to 5%. 90% of mothers receive perinatal antiretroviral therapy or prophylaxis. 90% of breastfeeding infant mother pairs receive antiretroviral therapy or prophylaxis. Prong 4 – Providing appropriate treatment, care and support to mothers living with HIV and their children and families

Target

Provide 90% of pregnant women in need of antiretroviral therapy for their own health with life-long antiretroviral therapy.

MDG’s

 MDGs are a framework of 8 goals, 18 targets and 48 indicators to measure progress towards the Millennium Development goals  

Goal 6: Combat HIV/AIDS, malaria and other diseases

    Target 6.A

:

HIV/AIDS Have halted by 2015 and begun to reverse the spread of Target 6.B: Achieve, by 2010, universal access to treatment for HIV/AIDS for all those who need it Target 6.C: Have halted by 2015 and begun to reverse the incidence of malaria and other major diseases

450 000 Overall Target 1: Reduce the Number of New HIV Infections among children by 90% by 2015 430,000 Estimated new Pediatric Infections in Low and Middle Income Countries (LMICs) 390,000 400 000 350 000 300 000 250 000 200 000 150 000 100 000 50 000 0 330,000 43,000 New Infections 2009 New Infections 2010 New Infections 2011 New Infections 2015 (Goal)

Source: 1. UNAIDS. Together we will end AIDS. 2012 2 . HIV/AIDS Response – Epidemic Update and Health Sector Progress Towards Universal Access 2011

45 000 40 000 35 000 30 000 25 000 20 000 15 000 10 000 5 000 0

Overall Target 2: Reduce the Number of HIV associated maternal deaths to women during pregnancy, delivery and

puerperium

by 50% by 2015 Women dying from AIDS-related causes during pregnancy or within 42 days of the end of pregnancy in the 22 priority countries

42,000 33,000

Source: UNAIDS. Together we will end AIDS. 2012

2005 2005 2010 2010 21,000

Global Plan Targets

Source: Countdown to zero: Global Plan towards the elimination of new infections among children by 2015 and keeping their mothers alive 2011-2015

Comprehensive MNCH Services

Prevention and Treatment Interventions for Adolescents

DECREASING VULNERABILITY DECREASING RISK 1. Enrollment and retention of girls in School 2. Skill-based health education 3. Decreasing gender-based violence 4. Increasing age of marriage 5. Ensuring that health services respond to the needs of adolescents 6. Social protection 7. Protection, legislation, enforcement 1. Testing 2. Treatment 3. Harm Reduction I. Condoms II. Needle Exchange 4. Male Circumcision 1. For today: Adolescents 2. For the future: Neonatal Interventions that should be supported whether or not there was and HIV epidemic for rights or equity Specific evidence-based interventions that decrease the risk of HIV among young people for HIV, rights and equity

Source: UNICEF Making the Case for Adolescents, unpublished data , 2012

Call to Action

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Simplify our programmatic approaches to allow integration of PMTCT/ART in maternal child health services at the lowest levels of care – to optimize treatment access, adherence and retention

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Introduce innovative approaches to expand provider initiated HIV testing to adolescents, pregnant women and their partners

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Expand early infant diagnosis and integrate childhood HIV treatment and care at lower level facilities and child survival programs

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Collaborate with community groups, including people living with HIV, to enhance support to women and their families to maintain good adherence and retention in care and treatment

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Focus on how to effectively deliver high impact interventions to adolescent to achieve the best prevention and treatment benefits