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Wangamati CK, Sundby J, Izugbara C, Nyambedha EO, Prince RJ. Challenges in Supporting Survivors of Child Sexual Abuse in Kenya: A Qualitative Study of Government and Non-governmental Organizations. JOURNAL OF INTERPERSONAL VIOLENCE 2021; 36:NP8773-NP8799. [PMID: 31046529 DOI: 10.1177/0886260519846864] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Child sexual abuse (CSA) is a global, social, and health challenge. Existing literature on post-sexual assault care has focused largely on health providers' skills and capacity to offer quality clinical, medicolegal, and psychosocial care. Services other than medical and psychosocial care provided to survivors of CSA remain poorly studied, particularly in the global south. The study aimed to explore challenges facing service providers supporting children who have experienced sexual abuse and make suitable recommendations. We triangulated different qualitative methods: in-depth interviews with 61 key informants, three focus group discussions with community leaders, and unstructured observations for data collection. Findings indicate that service providers supporting children who had experienced sexual abuse play a vital role in ensuring that survivors receive clinical and medicolegal care, psychosocial support, have access to justice, and are protected from further victimization. However, these service providers face several challenges, including poor infrastructure, the lack of effective coordination and linkage among the service providers in the continuum of care, corruption among officials, and harmful patriarchal norms that hinder reporting of abuse. To effectively support and care for survivors, we recommend government commitment to, and investments in, safe spaces, supervision, and professional development of providers. Working with community leaders and gatekeepers of all genders is critical to address harmful practices that perpetuate CSA and make it difficult to care for and obtain justice for CSA survivors.
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Shubber Z, Ford N. Adherence to HIV post-exposure prophylaxis for children/adolescents who have been sexually assaulted: A systematic review of barriers, enablers, and interventions. CHILD ABUSE & NEGLECT 2021; 116:104143. [PMID: 31522763 DOI: 10.1016/j.chiabu.2019.104143] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 08/13/2019] [Accepted: 08/18/2019] [Indexed: 06/10/2023]
Abstract
Post-exposure prophylaxis (PEP) is a key intervention for preventing HIV acquisition, including following sexual assault. However, uptake and completion rates for HIV PEP are lowest following sexual assault, with only 40% reporting completing the 28-day course. We undertook a systematic review to assess barriers and enablers to adherence to PEP in children and adolescents following sexual assault and identify potential interventions. Five databases and one conference abstract library were searched using adapted search strategies to identify quantitative and qualitative studies reporting patient-reported barriers and enablers to PEP and randomized trials assessing interventions to improve PEP adherence and completion rates. All searches were conducted up to October 2016; the search was updated in PubMed up to 31 July 2018. 14 studies reported barriers and enablers to PEP adherence. The most commonly cited patient/caregiver reported barriers to PEP adherence/completion included side effects, forgetting, stigma/blame, being busy, poor knowledge, and mental health problems. The most commonly reported factors associated with PEP adherence/completion (reported across 7 studies) included health provider encouragement to take PEP (type of encouragement not described), perpetrator known to be HIV-positive, monetary support for transport, the victim of assault attending counseling, being reminded by family/peers to take PEP, and "one-stop" services offering both HIV testing and PEP at initial consultation. Three randomized trials provided limited evidence supporting the potential benefit of enhanced adherence support for HIV PEP; however, data for children were lacking. Despite low completion rates, there is limited research into causes of and interventions to improve adherence to PEP following sexual assault, and no direct evidence for children.
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Affiliation(s)
- Zara Shubber
- Department of Infectious Disease Epidemiology, Imperial College, London, United Kingdom
| | - Nathan Ford
- Department HIV & Global Hepatitis Programme, World Health Organization, Geneva, Switzerland.
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Wangamati CK, Gele AA, Sundby J. Post Rape Care Provision to Minors in Kenya: An Assessment of Health Providers' Knowledge, Attitudes, and Practices. JOURNAL OF INTERPERSONAL VIOLENCE 2020; 35:1415-1441. [PMID: 29294671 DOI: 10.1177/0886260517696863] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Child sexual abuse (CSA) is a major global health challenge. Extant literature in Kenya indicates an alarming rate of sexually abused minors presenting to poorly equipped health facilities with untrained health providers for post rape care. National guidelines on management of sexual violence have been in existence since 2004; however, little is known on the impact of these guidelines on post rape care provision to minors. Therefore, the study aims to assess the knowledge, attitudes, and practices of health providers with regard to post rape care provision in a Kenyan District health facility. The study used a triangulation of different qualitative methods: review of 42 health records of minors seeking post rape care, 15 in-depth interviews, and informal conversations with health providers. Findings indicate that the Kenyan national guidelines on management of sexual violence were nonexistent in the health facility. Consequently, health providers possessed limited knowledge on post rape care administration. The limited knowledge translated to poor collection and preservation of evidence, inadequate psychosocial support, and clinical care. In addition, rape myth attitudes and religious beliefs contributed to survivor blaming and provider hesitance in provision of legal abortion care, respectively. To facilitate provision of quality post rape care, policy makers and health institutions' managers need to avail protocols in line with evidence-based best practices to guide health providers in post rape care administration. In addition, there is need for rigorous training and supervision of health professionals to ensure better service provision.
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Affiliation(s)
| | - Abdi Ali Gele
- Oslo and Akershus University College of Applied Sciences, Norway
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Faus DP, de Moraes CL, Reichenheim ME, Souza LMBDM, Taquette SR. Childhood abuse and community violence: Risk factors for youth violence. CHILD ABUSE & NEGLECT 2019; 98:104182. [PMID: 31561191 DOI: 10.1016/j.chiabu.2019.104182] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Revised: 08/27/2019] [Accepted: 09/03/2019] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To investigate the joint effect of child abuse and neglect (CAN) and community violence (CV) on adolescents with peers that commit youth violence (YV). METHODS This is a school-based cross-sectional study of 699 students enrolled in four public and nine private schools in the municipality of Rio de Janeiro, Brazil. Participants were selected through a complex cluster sampling procedure. CAN was identified using the Childhood Trauma Questionnaire (CTQ). Exposure to CV was assessed by asking students if they have witnessed cases of lethal violence in the community. YV was measured indirectly through questions about having friends who have committed acts of crime. Multivariate logistic models were used to study the effects of emotional, physical, and sexual abuse and emotional and physical neglect in childhood on YV, controlled for confounders, according to different levels of CV. RESULTS Emotional abuse OR = 3.32 (CI 95%: 1.79-6.17), sexual abuse OR = 2.33 (CI 95%: 1.20-4.54), and physical neglect OR = 1.81 (CI 95%: 1.02-3.20) increased the odds of YV in adolescents, whether cooccurring with CV or not. Physical abuse OR = 3.95 (CI 95%: 2.29 - 6.80) and emotional neglect OR = 2.93 (CI 95%: 1.83-4.72) are only risk factors for YV involvement when associated with CV. CONCLUSIONS These findings highlight the relevance of CAN and CV as risk factors for YV and the potential increase in adolescents' vulnerability when exposed to both. Policies aiming at preventing and dealing with CAN are essential strategies to reduce YV, especially in areas with high levels of CV.
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Affiliation(s)
- Daniela Porto Faus
- Maternity-school hospital, Federal University of Rio de Janeiro (UFRJ), Rua das Laranjeiras, 180 - Laranjeiras, 22240-00, Rio de Janeiro, RJ, Brazil; Institute of Social Medicine, Rio de Janeiro State University (IMS/UERJ), São Francisco Xavier Street, 524 / 7th floor, Bloco D, Maracanã 20550013, Rio de Janeiro, RJ, Brazil.
| | - Claudia Leite de Moraes
- Institute of Social Medicine, Rio de Janeiro State University (IMS/UERJ), São Francisco Xavier Street, 524 / 7th floor, Bloco D, Maracanã 20550013, Rio de Janeiro, RJ, Brazil; University Estácio de Sá (UNESA), Rua do Riachuelo, 27, Rio Comprido, 20261063, Rio de Janeiro, RJ, Brazil
| | - Michael Eduardo Reichenheim
- Institute of Social Medicine, Rio de Janeiro State University (IMS/UERJ), São Francisco Xavier Street, 524 / 7th floor, Bloco D, Maracanã 20550013, Rio de Janeiro, RJ, Brazil
| | - Luciana Maria Borges da Matta Souza
- University Estácio de Sá (UNESA), Rua do Riachuelo, 27, Rio Comprido, 20261063, Rio de Janeiro, RJ, Brazil; Faculty of Medical Sciences of the State University of Rio de Janeiro (FCM/UERJ), Avenida Professor Manuel de Abreu Maracanã, 20550170, Rio de Janeiro, RJ, Brazil
| | - Stella Regina Taquette
- Faculty of Medical Sciences of the State University of Rio de Janeiro (FCM/UERJ), Avenida Professor Manuel de Abreu Maracanã, 20550170, Rio de Janeiro, RJ, Brazil
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Schilling S, Deutsch SA, Gieseker R, Molnar J, Lavelle JM, Scribano PV. Improving HIV post-exposure prophylaxis rates after pediatric acute sexual assault. CHILD ABUSE & NEGLECT 2017; 69:106-115. [PMID: 28456065 DOI: 10.1016/j.chiabu.2017.04.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Revised: 03/08/2017] [Accepted: 04/18/2017] [Indexed: 06/07/2023]
Abstract
The purpose of our study was to increase the rate of children with appropriate HIV-PEP regimens among those diagnosed with sexual assault in The Children's Hospital of Philadelphia Emergency Department (ED). The outcome measure was the percent of patients receiving correct HIV-PEP. We retrospectively reviewed 97 charts over 31 months to define the baseline rate of children receiving appropriate HIV-PEP regimens (pre QI-implementation period: 2/2012-8/2014). Among children in which HIV-PEP was indicated following sexual assault, 40% received the recommended 28-day course. Root cause analysis indicated prescribing errors accounted for 87% of patients not receiving appropriate HIV-PEP. Process drivers included standardizing care coordination follow-up calls to elicit specific information about HIV-PEP, ED educational initiatives targeted at HIV-PEP prescribing, revision of the clinical pathway to specify indicated duration of HIV-PEP, and revision of the order set to auto-populate the number of days for the HIV-PEP prescription. During the QI-implementation period (9/2014-4/2015), the rate of appropriate HIV-PEP increased to 64% (median 60%) and the average number of days between incorrect HIV-PEP regimens was 24.5. Post QI-implementation (5/2015-3/2016), the rate of appropriate HIV-PEP increased to 84% (median 100%) and the average number of days between incorrect HIV-PEP regimens increased to 78.4. A multifaceted quality improvement process improved the rate of receipt of appropriate HIV-PEP regimens for pediatric victims of sexual assault. Decision support tools are instrumental in sustaining ideal care delivery, but require ongoing evaluation and improvement in order to remain optimally effective.
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Affiliation(s)
- Samantha Schilling
- Division of General Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, United States.
| | - Stephanie A Deutsch
- Division of General Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, United States.
| | - Rebecca Gieseker
- PolicyLab, The Children's Hospital of Philadelphia, Philadelphia, PA, United States.
| | - Jennifer Molnar
- Division of Emergency Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, United States.
| | - Jane M Lavelle
- Division of Emergency Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, United States; Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, PA, United States.
| | - Philip V Scribano
- Division of General Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA, United States; PolicyLab, The Children's Hospital of Philadelphia, Philadelphia, PA, United States; Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, PA, United States.
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Molyneux EM, Langton J, Njiram'madzi J, Robertson AM. Setting up and running a paediatric emergency department in a hospital in Malawi: 15 years on. BMJ Paediatr Open 2017; 1:e000014. [PMID: 29637093 PMCID: PMC5842997 DOI: 10.1136/bmjpo-2017-000014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2017] [Revised: 04/07/2017] [Accepted: 04/10/2017] [Indexed: 11/16/2022] Open
Abstract
Paediatric emergency care is not recognised as a specialty in many countries in Africa but is being practised increasingly. Setting up a paediatric emergency care unit takes time and often involves trial and error. Here we describe the start of the paediatric emergency department in Blantyre, Malawi, a low-income country and how it has continued to evolve over 15 years, in the hope that our experience will inform and assist others who are already developing their own emergency unit or wishing to do so.
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Affiliation(s)
- Elizabeth M Molyneux
- Paediatric Department, College of Medicine, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Josephine Langton
- Paediatric Department, College of Medicine, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Jenala Njiram'madzi
- Paediatric Department, College of Medicine, Queen Elizabeth Central Hospital, Blantyre, Malawi
| | - Ann M Robertson
- Emergency Department, Macclesfield Hospital, Macclesfield, UK
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Penazzato M, Dominguez K, Cotton M, Barlow-Mosha L, Ford N. Choice of antiretroviral drugs for postexposure prophylaxis for children: a systematic review. Clin Infect Dis 2016; 60 Suppl 3:S177-81. [PMID: 25972500 DOI: 10.1093/cid/civ110] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND This systematic review aimed to assess the safety and efficacy of antiretroviral options for postexposure prophylaxis (PEP). Recognizing the limited data on the safety and efficacy of antiretroviral drugs for PEP in children, this review was extended to include consideration of data on the use of antiretroviral drugs for treatment of infants and children living with human immunodeficiency virus. METHODS The PEP literature was assessed to identify studies reporting safety and completion rates for children given PEP, and this information was complemented by safety and efficacy data for drugs used in antiretroviral therapy. The proportion of patients experiencing each outcome was calculated and data were pooled using random-effects meta-analysis. RESULTS Three prospective cohort studies reported outcomes of children given zidovudine (ZDV) plus lamivudine (3TC) as a 2-drug PEP regimen. The proportion of children completing the full 28-day course of PEP was 64.0% (95% confidence interval [CI], 41.2%-86.8%), whereas the proportion discontinuing due to adverse events was 4.5% (95% CI, .4%-8.6%). One randomized trial compared abacavir (ABC) plus lamivudine (3TC) and ZDV+3TC as part of a dual or triple first-line antiretroviral therapy regimen; this study showed better efficacy in the ABC-containing combinations and no difference in the time to first serious adverse event. Three randomized trials compared lopinavir/ritonavir (LPV/r) to nevirapine (NVP) for antiretroviral therapy and showed a lower risk of treatment discontinuations associated with LPV/r vs NVP (hazard ratio, 0.56 [95% CI, .41-.75]) but no difference in drug-related adverse events. The overall quality of the evidence was rated as very low. CONCLUSIONS This review supports ZDV+3TC+LPV/r as the preferred 3-drug regimen for PEP in children.
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Affiliation(s)
- Martina Penazzato
- Department of HIV/AIDS, World Health Organization, Geneva, Switzerland
| | - Ken Dominguez
- Division of HIV/AIDS Prevention, US Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Mark Cotton
- Division of Paediatric Infectious Diseases, Department of Pediatrics and Child Health, Stellenbosch University and Tygerberg Children's Hospital, Cape Town, South Africa
| | - Linda Barlow-Mosha
- Makerere University-Johns Hopkins University Research Collaboration, Kampala, Uganda
| | - Nathan Ford
- Department of HIV/AIDS, World Health Organization, Geneva, Switzerland
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8
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Ford N, Venter F, Irvine C, Beanland RL, Shubber Z. Starter packs versus full prescription of antiretroviral drugs for postexposure prophylaxis: a systematic review. Clin Infect Dis 2016; 60 Suppl 3:S182-6. [PMID: 25972501 DOI: 10.1093/cid/civ093] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The provision of starter packs for human immunodeficiency virus postexposure prophylaxis (PEP) is practiced in many settings to facilitate rapid initiation by nonexperts and encourage adherence. However, the impact of starter packs on PEP completion rates has not been systematically assessed. We systematically reviewed the evidence on outcomes associated with starter packs for PEP compared to full prescriptions. METHODS Four databases and 2 conference abstract sites were searched up to December 2013; this search was updated in 1 database in June 2014. PEP completion rates, stratified by prescribing practice, were pooled using random-effects meta-analysis. RESULTS Fifty-four studies provided data on 11 714 PEP initiations. Thirty-seven studies, including 3 randomized controlled trials (RCTs) and 34 observational cohorts, provided information on starter packs (although none of the RCTs specifically assessed starter packs), and 17 studies, including 2 RCTs and 15 observational cohorts, provided information on full prescriptions. Overall, outcomes were better when participants were offered a full 28-day course of PEP at initial presentation to healthcare, with fewer refusals (11.4% [95% confidence interval {CI}, 5.3%-17.5%] vs 22% [95% CI, 16.7%-28.1%]) and higher completion rates (70% [95% CI, 56.7%-77.3%] vs 53.2% [95% CI, 44.4%-62.2%]). More than a quarter (28% [95% CI, 21.4%-34.5%]) of individuals provided with a PEP starter pack failed to return for their subsequent appointment and therefore defaulted prior to receiving a full course of PEP. The quality of the evidence overall was rated as very low. CONCLUSIONS The findings of this review suggest that starter packs do not improve adherence to PEP and may result in lower adherence and completion rates.
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Affiliation(s)
- Nathan Ford
- Department of HIV/AIDS, World Health Organization, Geneva, Switzerland
| | - Francois Venter
- Wits Reproductive Health and HIV Institute, University of Witwatersrand, Johannesburg, South Africa
| | - Cadi Irvine
- Department of HIV/AIDS, World Health Organization, Geneva, Switzerland
| | - Rachel L Beanland
- Department of HIV/AIDS, World Health Organization, Geneva, Switzerland
| | - Zara Shubber
- Department of Infectious Disease Epidemiology, Imperial College London, United Kingdom
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Abstract
Potential human immunodeficiency virus transmission makes prompt disclosure of child sexual abuse in Africa critical. The pattern of disclosure of 133 children presenting to the largest hospital in Malawi were analyzed. Eighty percent presented early enough for effective use of HIV postexposure prophylaxis. Seventy-five percent of children made a disclosure of child sexual abuse; 29% spontaneously and 47% after prompting. Disclosures were most commonly made to a parent, and age did not affect the pattern of disclosure. The number of children reporting child sexual abuse is increasing, possibly because of increasing awareness, availability of services, and fear of HIV. Although prompt disclosure rates were relatively high, facilitating easier disclosure of child sexual abuse by a free telephone help-line and better training of teachers may be helpful.
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Molyneux EM, Kennedy N, Dano A, Mulambia Y. Sexual abuse of children in low-income settings: time for action. Paediatr Int Child Health 2013; 33:239-46. [PMID: 24070539 DOI: 10.1179/2046905513y.0000000087] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
In this article, child sexual abuse in low-income settings is reviewed, including the extent of the problem, the way children present, and how they should be managed. Liaising with other agencies, training in all aspects of sexual abuse and creating an environment that is conducive to good care by all groups involved is essential. Technical details of medical examination are not covered as appropriate guidelines are accessible.
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Molyneux EM. Paediatric emergency care in resource-constrained health services is usually neglected: time for change. ACTA ACUST UNITED AC 2013; 30:165-76. [DOI: 10.1179/146532810x12703902516482] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Pereda N, Abad J. Enfoque multidisciplinar de la exploración del abuso sexual infantil. ACTA ACUST UNITED AC 2013. [DOI: 10.1016/j.reml.2012.10.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Du Mont J, Macdonald S, Myhr T, Loutfy MR. Sustainability of an HIV PEP Program for Sexual Assault Survivors: "Lessons Learned" from Health Care Providers. Open AIDS J 2011; 5:102-12. [PMID: 22216082 PMCID: PMC3249643 DOI: 10.2174/1874613601105010102] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2011] [Revised: 06/29/2011] [Accepted: 08/02/2011] [Indexed: 11/22/2022] Open
Abstract
This study explored challenges to continuing an HIV post-exposure prophylaxis (PEP) program of care provided to sexual assault survivors in the province of Ontario, Canada. Data were collected as part of an implementation and evaluation of a universal offering of HIV PEP (known as the HIV PEP Program) at 24 of 34 provincial hospital-based sexual assault treatment centres. Experienced health care providers were surveyed (n = 132) and interviewed in four focus groups (n = 26) about their perceptions of what, if any, factors threatened their ability to maintain the HIV PEP Program. All focus groups were audio-recorded and the recordings transcribed. The transcriptions and open-ended survey responses were analyzed using content analysis. Administrator, nurse, physician, social worker, and pharmacist respondents perceived important barriers to sustainability of the HIV PEP Program. Eight constructs were identified within four broad themes: resources (inadequate funds, overworked and unacknowledged staff), expertise (insufficient external supports, insufficiently trained and knowledgeable staff), commitment (lack of institutional support, physician resistance to offering HIV PEP), and accommodation (lack of flexibility in addressing specific client and community needs, inaccessibility and lack of clarity of tools). We discuss the implications of these findings and the actions that were taken to address the challenges.
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Affiliation(s)
- Janice Du Mont
- Women’s College Research Institute, Women’s College Hospital, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Sheila Macdonald
- Ontario Network of Sexual Assault/Domestic Violence Treatment Centres, Toronto, Ontario, Canada
- Faculty of Nursing Science, University of Toronto, Toronto, Ontario, Canada
| | - Terri Myhr
- Women’s College Research Institute, Women’s College Hospital, Toronto, Ontario, Canada
| | - Mona R Loutfy
- Women’s College Research Institute, Women’s College Hospital, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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Abstract
The medical examination of the sexually abused child may have evidentiary, medical, and therapeutic purposes, and the timing of the examination requires consideration of each of these objectives. In cases of acute sexual assault, emergent examinations may be needed to identify injury, collect forensic evidence, and provide infection and pregnancy prophylaxis. Alternately, most sexually abused children are not identified immediately after assault, and the timing of the examination needs to balance physical and emotional issues with the availability of qualified examiners. In all cases, the best interests of the child should be paramount.
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Affiliation(s)
- Cindy W Christian
- The Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA.
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Chesshyre ELD, Molyneux EM. Presentation of child sexual abuse cases to Queen Elizabeth Central Hospital following the establishment of an HIV post-exposure prophylaxis programme. Malawi Med J 2009; 21:54-8. [PMID: 20345004 PMCID: PMC3345736 DOI: 10.4314/mmj.v21i2.44550] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
AIM To review the presentation and management of child sexual abuse cases presenting to Queen Elizabeth Central Hospital (QECH), Blantyre, since the introduction of an HIV postexposure prophylaxis programme. METHODS Demographic and medical data was collected from all children presenting to Queen Elizabeth Central Hospital, Blantyre, Malawi between January 2005 and February 2007 with alleged child sexual abuse (CSA). RESULTS Between January 2005 and February 2007, 217 children presented with alleged CSA. This an average of 3 more per month since the previous year, a 57 percent increase. Physical examination showed signs of trauma 60% (130/217) of cases. 63% (137/217) of the cases presented within 72 hours of defilement. Overall in 42% (92/217) of children a one month course of HIV PEP was indicated and given. In 58% (125/217) HIV PEP was not indicated in view of normal examination, presentation too late (>72 hrs after abuse), multiple abuse episodes in the last 6 months, HIV test positive or HIV test refused. In 66% (144/217) of assessed children antibiotic treatment was given for the prevention and/ or treatment of sexually transmitted infections (STIs). CONCLUSIONS The introduction of an HIV PEP programme for victims of CSA has lead to increased numbers presenting and being treated. In conclusion it is likely that a significant number of children have been prevented from acquiring HIV and other STIs following CSA. The key area where our service needs to be improved is in establishing documented follow up of all cases to monitor medication compliance, side effects and rates of HIV seroconversion following CSA.
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Girardet RG, Lemme S, Biason TA, Bolton K, Lahoti S. HIV post-exposure prophylaxis in children and adolescents presenting for reported sexual assault. CHILD ABUSE & NEGLECT 2009; 33:173-178. [PMID: 19324415 DOI: 10.1016/j.chiabu.2008.05.010] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/19/2007] [Revised: 04/28/2008] [Accepted: 05/15/2008] [Indexed: 05/27/2023]
Abstract
BACKGROUND The appropriate use of antiretroviral medications to protect against infection with human immunodeficiency virus (HIV) is unclear in cases of sexual assault of children, for whom the perpetrator's risk of HIV is often unknown, and physical proof of sexual contact is usually absent. OBJECTIVE In an effort to clarify prescribing practices for HIV post-exposure prophylaxis (PEP) at our institution, we examined records of all children tested for HIV for prevalence of infection, our experience with prescribing PEP, and follow-up rates. DESIGN/METHODS Medical records at a sexual abuse clinic of all children tested for HIV during a 38-month period were reviewed for information concerning risk factors for HIV acquisition, STI test results, and PEP experience. Children were defined as PEP-eligible if they were within 96 hours of assault, and there was a report of sexual contact with the potential to transmit HIV. RESULTS One thousand seven hundred and fifty children were tested for HIV during the study period. Five children had a positive HIV ELISA, but only one child was confirmed HIV-positive. Three hundred and three children were eligible to receive HIV-PEP, but it was only offered to 16 (5.3%), of whom 15 accepted the medications. None of the children prescribed PEP completed follow-up, but 11 children had limited follow-up. CONCLUSIONS Our results indicate that the prevalence of HIV infection among sexually abused children in our population is low, and follow-up rates are poor. Intensive efforts to try to ensure follow-up are warranted whenever PEP is prescribed. Further research may help better define the efficacy of PEP in sexually abused children and adolescents.
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Affiliation(s)
- Rebecca G Girardet
- Department of Pediatrics, The University of Texas Medical School at Houston, Houston, TX 77030, USA
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Collings SJ, Bugwandeen SR, Wiles WA. HIV post-exposure prophylaxis for child rape survivors in KwaZulu-Natal, South Africa: who qualifies and who complies? CHILD ABUSE & NEGLECT 2008; 32:477-483. [PMID: 18455795 DOI: 10.1016/j.chiabu.2007.05.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/27/2006] [Revised: 05/04/2007] [Accepted: 05/07/2007] [Indexed: 05/26/2023]
Abstract
OBJECTIVE Our objective was to audit the provision and utilization of HIV post-exposure prophylaxis (PEP) to child rape survivors in the Province of KwaZulu-Natal, South Africa. METHODS A prospective design was used to collect data from a convenience sample of 200 consecutive cases of child rape referred for medico-legal assessment to a state hospital located to the north of the City of Durban (South Africa) in the period October to December 2004. For each case, information was obtained regarding demographic characteristics of the child, the child's HIV status at presentation, any excluding factors for PEP therapy, and the extent of adherence to the antiretroviral therapy regimen. RESULTS One hundred and twenty children (60%) qualified for PEP provision, with children being excluded because they refused initial HIV testing (1.5%), tested HIV positive at presentation (6.5%), or because of delayed (>72hour) presentation (32%). Of the 113 children who were followed through the PEP provision system, 40 (35.4%) returned for the full 28-day course, and only 4 (3.5%) returned at both 3- and 6-month follow up. CONCLUSIONS Adherence rates for PEP therapy following child rape in South Africa are extremely low, with low adherence rates being associated with a theoretical risk of both reduced efficacy and drug resistance. In this context, there is a need for further research designed to identify the reasons for such non-adherence as well as a need for secondary prevention programs designed to both encourage more immediate reporting of child rape and to increase adherence to the PEP regimen.
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Affiliation(s)
- Steven J Collings
- School of Psychology, University of KwaZulu-Natal, Howard College Campus, Durban 4041, South Africa
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Merchant RC, Mayer KH, Becker BM, Delong AK, Hogan JW. Predictors of the initiation of HIV postexposure prophylaxis in Rhode Island emergency departments. AIDS Patient Care STDS 2008; 22:41-52. [PMID: 18095841 DOI: 10.1089/apc.2007.0031] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The objective of this study was to elucidate factors that predicted the initiation of HIV postexposure prophylaxis (PEP) for blood or body fluid exposures evaluated at Rhode Island emergency departments (EDs). The study involved a retrospective review of patient visits to all civilian Rhode Island EDs for these exposures from 1995 to mid-2001. Multivariate logistic regression models were created to evaluate predictors of the offering and the acceptance and receipt of HIV PEP from 1996 to 2001. The search identified 3622 patients who sustained a blood or body fluid exposure. Of these, 43.8% were health care workers (HCWs) and 57.2% were not HCWs. Most (52.0%) of the exposures were nonsexual. HIV PEP was offered to 21.0% and accepted and received by 9.4% of all patients. HIV PEP was offered more often after significant exposures, exposures to known HIV-infected sources, when time elapsed after the exposure was shorter, if the patients were HCWs, adults, presented to a teaching hospital, presented during the latter years of the study, or sustained nonsexual exposures. Once offered HIV PEP, patients who were male, adult, sustained a significant exposure, knew the source was HIV infected, sustained a nonsexual exposure, or were HCWs had a greater odds of accepting and receiving HIV PEP. Even when controlling for exposure significance, HIV status, and time elapsed since the exposure, several factors such as gender and type of hospital that are unrelated to the exposure appeared to influence the initiation of HIV PEP. ED providers should ensure that these factors do not inappropriately restrict its initiation.
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Affiliation(s)
- Roland C. Merchant
- Departments of Emergency Medicine and Community Health, Brown Medical School, Providence, Rhode Island
| | - Kenneth H. Mayer
- Departments of Medicine and Community Health, Brown Medical School, Providence, Rhode Island
| | - Bruce M. Becker
- Departments of Emergency Medicine and Community Health, Brown Medical School, Providence, Rhode Island
| | - Allison K. Delong
- Department of Community Health, Division of Biostatistics, Brown Medical School, Providence, Rhode Island
| | - Joseph W. Hogan
- Department of Community Health, Division of Biostatistics, Brown Medical School, Providence, Rhode Island
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Jagannathan P, Landovitz R, Roland ME. Postexposure prophylaxis after sexual exposure to HIV. ACTA ACUST UNITED AC 2007. [DOI: 10.2217/17469600.1.1.35] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Increasing numbers of international, national and state/provincial health organizations in the developed and developing world recommend postexposure prophylaxis (PEP) following potential sexual exposure to HIV. The evidence for these policies is extrapolated from occupational healthcare worker, perinatal prophylaxis and animal studies. There is no direct evidence of PEP efficacy after sexual exposures. Studies addressing potential increases in risk behavior, toxicities and cost–effectiveness are encouraging. Considerations for offering PEP include the timing and characteristics of the exposure and the HIV status of the source and exposed individuals. PEP includes 28 days of a combination antiretroviral drug regimen containing two or more drugs and associated laboratory testing, counseling and referrals. PEP service delivery challenges include ensuring adequate access to services, optimizing PEP adherence and facilitating follow-up HIV testing and counseling. Men who have sex with men, sexual assault survivors, children and adolescents, and individuals in resource-limited settings present unique needs and challenges.
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Affiliation(s)
- Prasanna Jagannathan
- University of California, San Francisco, California, Department of General Internal Medicine, San Francisco General Hospital Ward 13, 1001 Potrero Avenue, San Francisco, CA 94110, USA
| | - Raphael Landovitz
- University of California, Los Angeles, Center for Clinical AIDS Research and Education, David Geffen School of Medicine, 9 911 W Pico Blvd., Suite 980 Los Angeles, CA 90035, USA
| | - Michelle E Roland
- University of California. San Francisco, Positive Health Program, Ward 84, San Francisco General Hospital, 995 Potrero Avenue, San Francisco, CA 94110, USA
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Cambanis A. Child sexual abuse, HIV, and tuberculosis in sub-Saharan Africa: a case report from rural Cameroon. AIDS 2007; 21:887-9. [PMID: 17415052 DOI: 10.1097/qad.0b013e3280f77429] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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