INTEGRATED ACTIVITY FLAG:

Research Triangle Institute (RTI) implements related activities described in the Basic Health Care and Support (#7541) program area. RTI will work closely with the Population Council (#7611) which is also providing care and support for rape victims (but in different communities).

SUMMARY:

This goal of this project is to improve care provided to victims of rape, through the establishment of seven new Thuthuzela Care Centers (TCCs). These multi-disciplinary centers provide comprehensive care services to women and children rape survivors, including post-exposure prophylaxis (PEP), HIV and AIDS counseling and testing, and referral to HIV care and treatment services. These centers will also assist men and boys, who are increasingly becoming victims of rape. The major emphasis area will be on training with minor emphasis on commodity procurement. Target population will include infants, girls, boys, men, women, doctors, nurses and pharmacist. Commodities to be procured include rape kits, medical equipment, comfort kits, and PEP medication.

BACKGROUND:

This project is a continuation of work supported through PEPFAR funds in FY 2006 in which the standards of existing TCCs were made consistent with the National Department of Health's (NDOH) National Management Guidelines for the Care of Rape Victims. In FY 2007, this project will focus on establishing seven new TCCs in provinces where they do not currently exist and in other locations where need is identified. Ten TCCs currently exist. This activity is linked to the USAID Democracy and Governance office's longstanding program to support the Sexual Offenses and Community Affairs (SOCA) Unit of the National Prosecuting Authority of South Africa in its endeavor to eradicate all forms of gender-based violence against women and children, especially the crime of rape. The SOCA Unit has responded to the ongoing problem of sexual offences and specifically rape in the country in several ways. One way was to establish 54 sexual offenses courts country-wide. The other has been to establish the Thuthuzela ("to comfort" in isiXhosa) Care Centers. The TCCs are a bold approach to rape care management. When the anticipated Women's Justice and Empowerment Presidential Initiative (WJEI) starts, there will be an important linkage established between the objectives of the SOCA Unit and those of the WJEI to increase women's legal rights. Very aptly SOCA's slogan is "Putting the rights of women and children first."

For victims of rape, the benefit of being assisted through a TCC is that the rape survivor can obtain comprehensive, integrated rape services at a single location, including receiving medical assistance, reporting the case to the law enforcement authorities (the police and prosecutors), and accessing counselors and emergency support services on a 24-hour basis. To allow for easy access to health services, the TCCs are located within hospitals and health care facilities. The TCCs are an initiative of the SOCA Unit of the National Prosecuting Authority and are in compliance with the standards of the NDOH.

The past few years have witnessed a growing recognition of the links between violence against women and HIV and AIDS. The risk of HIV infection is a very real possibility with rape. Perpetrators seldom use condoms, placing the vast majority of women and children who are victims of this crime immediately at risk. For example, of every 100 survivors that report rape at the Manenberg (Cape Town) TCC, an average of five are HIV-infected. This means that 95% of survivors are HIV-negative at the time of rape at this particular TCC and can benefit from PEP and ongoing counseling. On average, 80% of rape victims in South Africa are HIV-negative at the time of rape.

According to the TCC model, when rape victims arrive at the police station to report a rape, they are removed from the crowds to a quiet room to take a statement. They are then transported to the nearest TCC where they are welcomed by a site coordinator. Once the nurse or doctor is summoned to conduct the forensic medical exam, the Victim Assistance Officer (VAO) and the doctor or nurse explains to the victim what procedures need to be performed and help her understand why she must sign consent forms. The police detective on call to the center is summoned and assigned to the case. Case

managers are responsible for coordinating sexual offenses cases and assist the victim in understanding what information the police investigator needs to investigate the crime. If the victim decides to pursue charges, the case manager opens a file where copies of all the relevant documents will be kept and the status of the victim's case will be tracked.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: Scale-up of TCCs

With FY 2007 PEPFAR funds, RTI will support SOCA's efforts to establish seven TCCs in provinces where they do not currently exist. Part of this funding will go towards the training of the medical officers (doctors, nurses and pharmacists) on how to provide PEP as well as to site coordinators and VAOs on how to educate victims on compliance with PEP. Site coordinators manage the multidisciplinary team and administer each TCC. When the victim arrives, she is comforted by a VAO, who is also responsible for building a relationship with the victim until she has been able to report the rape, receive a medical examination, and obtain voluntary counseling and testing (VCT). In addition, the victim is linked to any other critical service that she may require such as a place of safety and follow up medical assistance. Promotion and education activities will also be conducted to educate communities in which TCCs are located about the services they provide.

At the TCCs, each rape victim is encouraged to test for HIV. If the rape is reported within 72 hours, the rape survivors who test negative are immediately provided with PEP. They are placed on PEP for 28 days and are tested again for sero-conversion at 3 months and again at 6 months. In these 28 days, the survivor is intensively supported to ensure compliance with medication as well her overall well-being. Rape victims who test positive for HIV will be given appropriate counseling and will be referred to the nearest government treatment site for further counseling, care and Antiretroviral Treatment (ART) when necessary.

U.S. legislative interests being addressed by this project include increasing gender equity in HIV and AIDS programs and women's legal rights. This activity is also closely linked to USAID's programs in Democracy and Governance. The National Prosecuting Authority is committed to addressing rape and the resulting problems such as HIV and AIDS, especially the support and development of TCCs. The National Prosecuting Authority is particularly committed to empowering women, protecting children and ensuring that the crime of rape is reduced throughout South Africa. As such, this project will be sustainable beyond the provision of PEPFAR funds, as the government will continue to support it.

This project will assist PEPFAR meet its goal of averting 7 million new infections by playing a critical role in increasing access to and improving quality of vital post-rape services, including the provision of PEP.

INTEGRATED ACTIVITY FLAG:

This activity relates to Research Triangle Institute (RTI) activities in Condoms and Other Prevention (#7539). RTI will work closely with the Population Council (#7611) which is also providing care and support for rape victims (but in different communities). This partner may benefit from the Partnership for Supply Chain Management ARV Drugs activity (#7935), which will explore current pain and symptom management practices, drug availability and cost, and provide recommendations.

SUMMARY:

The first RTI component includes support to strengthen the HIV-related clinical, psychological and social care services for the Thuthuzela Care Centers (TCCs) for rape victims in all provinces with the exception of Limpopo, Free State and Mpumalanga. The second component encompasses strengthening the Department of Provincial and Local Government (DPLG) HIV and AIDS care program in workplace programs in 4 districts and 15 local municipalities located in Gauteng, Mpumalanga, Western Cape, and Limpopo provinces. The third component includes training of community health care workers in the same municipality catchment areas on quality HIV palliative care. Populations served are adults and children, PLHIV, health care workers and caregivers. The major emphasis area is training with minor emphasis areas in IEC, commodity procurement, network/linkages/referral; linkages with other sectors and initiatives and local organization capacity development.

BACKGROUND:

This is the second year of support to the TCCs and DPLG. The community care component is a new activity in FY 2007. Thuthuzela means "to comfort" in isiXhosa; TCCs are multi-disciplinary centers that provide comprehensive care for rape survivors with an emphasis on women and children. Funding to the DPLG in FY 2007 provides for the ongoing implementation of HIV and AIDS workplace activities initiated in FY 2006 with an emphasis on integrating elements of the preventive care package, psychosocial support and stigma reduction strategies for PLHIV. Caregiver training in DPLG catchment areas varies; as a result quality of care for PLHIV suffers. Select municipalities and districts will partner with the provincial Departments of Health and Social Development for standardized national HBC training.

ACTIVITIES AND EXPECTED RESULTS:

ACTIVITY 1: Strengthening HIV care in the TCCs

PEPFAR funding will enable the TCCs to improve the quality of basic HIV-related clinical, psychological and social care services offered by the TCCs for rape victims with an emphasis on women and children rape victims (key legislative area). The TCCs offer a place of refuge and comfort for raped women and children, with an aim to reduce secondary victimization suffered by rape victims by ensuring that the reporting process, medical examination, initial counseling, quality of HIV-related care services are all done in one place on a 24-hour basis. Care services that will be provided include counseling and testing, disclosure support, PEP, gender-based violence screening, quality and supportive medical examination, psychological care and counseling by trained providers, personal hygiene, screening for pain and symptoms and HIV-related conditions such as opportunistic infections and provision of shelter and comfort measures. Qualified health care workers will also provide messaging on HIV prevention and counsel and refer for the provision of CD4 testing, ART, OI prevention and treatment (including cotrimoxazole prophylaxis, TB care), nutritional care and appropriate child survival and child care interventions (growth monitoring, child-specific nutritional care, immunizations). The program will provide legal counseling, program linkages for the legal protection of women and children and follow-up legal advice. A particular program emphasis is ensuring that women's legal rights and child protection is promoted and protected.

ACTIVITY 2: Strengthening HIV Care in Municipality Workplace Settings

This component assists 4 districts and 15 local municipalities located in Gauteng,

Mpumalanga, Western Cape, and Limpopo provinces to initiate and/or strengthen care delivery via HIV and AIDS workplace programs. Activities will be developed and strengthened that encourage employees to obtain access to HIV prevention and care services including emphasis on integrating elements of the preventive care package, psychosocial support and stigma reduction strategies for PLHIV. This includes counseling and referring for HIV testing services, disclosure support, basic screening for pain and symptoms and HIV-related conditions such as opportunistic infections, HIV prevention messaging and access to condoms, referrals for the clinical monitoring and care that includes ART, OI prevention and treatment (including cotrimoxazole prophylaxis, TB care), nutritional care and appropriate child survival and child care interventions. On-site psychosocial care will be provided. Mandatory employee participation in HIV and AIDS education programs is a key element of the program. Strategies to reduce stigma directed towards PLHIV will be integrated in partnership with municipality leaders and participation with labor unions is included. Outcomes include improved access to HIV and AIDS care, stigma reduction and strategies to prevent the further spread of the disease

ACTIVITY 3: Expanding the Community Response to HIV and AIDS in Municipality Catchment Areas

All the targeted 4 districts and 15 local municipalities (mentioned in Activity 2) have CBOs who carry out HIV-related community and home-based care activities for PLHIV and OVC in their vicinity. It has been noted that community providers who receive the 59-day South African Government accredited home-based care training from the NDOH provide exemplary services. However, many CBOs do not have access to the standardized training program. This activity will expand NDOH standardized training in the targeted municipalities depending on the unique needs and ongoing training programs supported by the provincial Departments of Health and Social Development. The training will include but not be limited to the following topics: elements of the preventive care package for adults and children; basic HIV terminology and facts; psychosocial aspects of HIV and AIDS; basic pain and symptom management; bereavement care and communication skills; legal issues; care considerations for OVC; infection control; health education; culturally appropriate care; end of life care; ART adherence; how to provide referrals; supportive supervision; program design; and project management. Community caregivers working in drop-in centers (catering to orphans and vulnerable children) will be trained in ways to mitigate the burden of women and girls in their care of family members who are ill and of young children who have lost their parents to HIV and AIDS. Sites will be selected in partnership with municipalities and the provincial Departments of Health and Social Development. Follow up from the training and technical support will be provided to the community organizations by the designated training support team. Training provided through this activity serves to build and sustain linkages between the district municipalities, the provincial Departments of Health and Social Development, and community-based organizations (CBOs) and non-governmental organizations (NGOs) thereby reinforcing the coordination role of the DPLG.

These activities will contribute to PEPFAR goals of providing palliative care to 10 million HIV-infected individuals and their families, including OVC.