Management of sexual violence
May 7th 2013
Carol Odula-Obonyo
S.M.O.-Ob/Gyn
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.
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-HIV, VDRL, HeB, urinalysis, PDT
 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
May 7th 2013
PEP
Side effects of PEP
Pregnancy prevention
Elimination of parent to child
transmission of HIV
M A Y 7 TH 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
Kenya HIV/AIDS Estimates for adults and children-2011
People living with HIV
Adults
Children
1.6 million
1.4 million
200,000
New infections
104,000
Adults
Children
91,000
13,000
Deaths
Adults
Children
62,000
50,000
12,000
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.
HIV Incidence and Prevalence, KAIS 2007
Coast
Incidence*
Prevalence
1.7%
8.1%
Rift Valley 1.4%
6.3%
Nyanza
1.3%
14.9%
Nairobi
0.8%
8.8%
* Based on assay for recent infection
Percent New Infections by Mode of Transmission
(Kenya Modes of Transmission Study, 2008)
Heterosexual sex with union/regular partnership
44.1%
Casual heterosexual sex
20.3%
Men who have sex with men/prison populations
15.2%
Sex workers and their clients
14.1%
Injecting drug users
3.8%
Health facility—related infections
2.5%
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%.
Prong 1 – Primary
prevention of HIV
infection among women
of childbearing age
Prong 2 – Preventing
unintended pregnancies
among women living
with HIV
Reduce under 5
deaths
due to HIV by > 50%
Provide antiretroviral
therapy for all HIV–
infected children.
Prong 3 – Preventing
HIV transmission from
pregnant women living
with HIV to their infants
Target
Target
Target
Reduce HIV incidence in
women 15-49 by 50%.
Reduce unmet need for
family planning among
women to zero (MDG
goal).
Reduce mother-to-child
transmission of HIV to
5%. 90% of mothers
receive perinatal
antiretroviral therapy or
prophylaxis. 90% of
breastfeeding infantmother 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.
Prevention of Mother-to-Child Transmission
The Four-pronged Strategy
Primary prevention of HIV
 Prevention of unwanted
pregnancies
 Prevention of transmission from
HIV-infected mother to infant
 Appropriate treatment and care

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: Have halted by 2015 and begun to reverse the spread of
HIV/AIDS
 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
Overall Target 1: Reduce the Number of New HIV
Infections among children by 90% by 2015
450,000
430,000
Estimated new Pediatric Infections in Low and Middle Income Countries
(LMICs)
390,000
400,000
350,000
330,000
300,000
250,000
200,000
150,000
100,000
43,000
50,000
0
New Infections 2009
New Infections 2010
New Infections 2011
Source: 1. UNAIDS. Together we will end AIDS. 2012
2 . HIV/AIDS Response – Epidemic Update and Health Sector Progress Towards Universal Access 2011
New Infections 2015 (Goal)
Overall Target 2: Reduce the Number of HIVassociated 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
45,000
42,000
40,000
35,000
33,000
30,000
25,000
21,000
20,000
15,000
10,000
5,000
Source: UNAIDS. Together we will end AIDS. 2012
0
2005
2005
2010 2010
Goal
-2015
2015
(Goal)
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
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
Interventions that should be supported
whether or not there was and HIV
epidemic for rights or equity
Source: UNICEF Making the Case for Adolescents, unpublished data , 2012
DECREASING RISK
1. Testing
2. Treatment
3. Harm Reduction
I. Condoms
II. Needle Exchange
4. Male Circumcision
1. For today: Adolescents
2. For the future: Neonatal
Specific evidence-based interventions
that decrease the risk of HIV among
young people for HIV, rights and equity
Call to Action
 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
Introduce innovative approaches to expand provider initiated HIV
testing to adolescents, pregnant women and their partners
Expand early infant diagnosis and integrate childhood HIV treatment
and care at lower level facilities and child survival programs
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
Focus on how to effectively deliver high impact interventions to
adolescent to achieve the best prevention and treatment benefits