Intended for healthcare professionals

Practice Quality Improvement Report

Comprehensive care and HIV prophylaxis after sexual assault in rural South Africa: the Refentse intervention study

BMJ 2009; 338 doi: (Published 13 March 2009) Cite this as: BMJ 2009;338:b515
  1. Julia C Kim, senior researcher1, clinical research fellow2,
  2. Ian Askew, director3,
  3. Lufuno Muvhango, sexual violence programme coordinator1,
  4. Ntabozuko Dwane, MMed research intern1,
  5. Tanya Abramsky, research fellow in epidemiology2,
  6. Stephen Jan, senior health economist4,
  7. Ennica Ntlemo, research nurse1,
  8. Jane Chege, programme associate5,
  9. Charlotte Watts, Sigrid Rausing professor2
  1. 1RADAR, School of Public Health, University of the Witwatersrand, Acornhoek, South Africa
  2. 2Gender, Violence and Health Centre, Health Policy Unit, Department of Public Health and Policy, London School of Hygiene and Tropical Medicine, London WC1E 7HT
  3. 3FRONTIERS in Reproductive Health Program, Population Council, Nairobi, Kenya
  4. 4The George Institute for International Health, Sydney, Australia
  5. 5FRONTIERS in Reproductive Health Program, Southern Africa, Population Council, Johannesburg, South Africa
  1. Correspondence to: J Kim jkim{at}
  • Accepted 26 August 2008


Problem Although international guidelines specify the central role of the health sector in providing comprehensive care, including HIV post-exposure prophylaxis (PEP), after sexual assault, in both industrialised and developing countries there are many challenges to providing timely and comprehensive services.

Design A nurse driven model of post-rape care was integrated into existing hospital services; the before and after study design evaluated impacts on quality of care, reviewing 334 hospital charts and conducting interviews with 16 service providers and 109 patients.

Setting 450 bed district hospital in rural South Africa.

Key measures for improvement Quality of care after rape (forensic history and examination, provision of emergency contraception, prophylaxis for sexually transmitted infections, referrals); provision of HIV counselling and testing and provision and completion of full 28 day course of PEP; and service utilisation (number of service providers seen on first visit and number of rape cases presenting to hospital per month).

Strategies for change After completing baseline research, we introduced a five part intervention model, consisting of a sexual violence advisory committee, hospital rape management policy, training workshop for service providers, designated examining room, and community awareness campaigns.

Effect of change Existing services were fragmented and of poor quality. After the intervention, there were considerable improvements in clinical history and examination, pregnancy testing, emergency contraception, prophylaxis for sexually transmitted infections; HIV counselling and testing, PEP, trauma counselling, and referrals. Completion of the 28 day course of PEP drugs increased from 20% to 58%.

Lessons learnt It is possible to improve the quality of care after sexual assault, including HIV prophylaxis, within a rural South African hospital at modest cost, using existing staff. With additional training, nurses can become the primary providers of this care.


  • We thank the members of the project advisory committee for their guidance throughout the study, the Department of Health and Social Welfare in Limpopo Province and Mpumalanga Province for their encouragement and support, the Western Cape Provincial Reference Group for Sexual Violence for their technical support in the training workshop and in developing intervention tools, and Carol Wiebe for invaluable contributions and support to the project team. We are indebted to the many dedicated service providers at the study site and the courageous women and children who, as survivors of sexual assault, shared their valuable insights with us.

  • Contributors: JCK was the principal investigator of the study, led the drafting of this manuscript, and contributed to all aspects of the study. IA contributed to the overall design of the study and the initial conceptualisation of the intervention and provided support to the research team. LM contributed to the development of the intervention and conducted patient interviews. ND assisted with the design and conduct of key informant interviews and chart reviews and contributed to data management and analysis. TA was responsible for the statistical analysis. SJ led the design and conduct of the economic evaluation. EN contributed to the development and implementation of the intervention model. JC contributed to the study design and the conceptualisation of the intervention and provided support to the research team. CW contributed to the initial conceptualisation of the study and advised on most aspects of the study. All authors contributed to the drafting of this manuscript. JCK is guarantor.

  • Funding: United States Agency for International Development (USAID) and the US President’s Emergency Plan for AIDS Relief (PEPFAR) under the terms of Cooperative Agreement Number HRN-A-00-98-00012-00 and Subagreement numbers A104.25A and S107019A. The contents are the responsibility of the Population Council and do not necessarily reflect the views of USAID or the United States Government. The sponsors had no role in study design, data collection, analysis, interpretation or writing this report.

  • Competing interests: None declared.

  • Ethical approval: Ethical clearance for the study was obtained from the University of the Witwatersrand Human Research Ethics Committee (#M060335), the London School of Hygiene and Tropical Medicine Ethics Committee (#3036), and the Population Council IRB (Protocol No 352). All research participants provided informed consent. Permission to conduct the study was sought from hospital management, and feedback on study progress and results was delivered to a project advisory committee.

  • Provenance and peer review: Not commissioned; externally peer reviewed.

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