Too many hurdles for rape survivors in accessing PEP

When Margaret closed shop after a routine day at her stall in Nairobi's Kawangware market, the last thing she thought was that she would always remember that day as the most terrifying of her life - that evening, Margaret was violently raped. Fondly known as "wa-Ben" (mother of Ben) by her colleagues at the market, Margaret was walking home in the dark when a man hit her over the head with a sharp object, dragged her into nearby bushes and strangled her with her own sarong before forcing himself on her. "He told me to keep quiet or he would kill me. All I could think of was my children, so I obeyed," she said. "I remember that he was really rough with me and it was very painful." Stories about sexual crime - rape, or the defilement of children - are commonplace in Kenya's daily newspapers. The Kenya Demographic and Health Survey of 2003 estimated that 16 percent of women between the ages of 15 and 49 had experienced some form of sexual assault - for 13 percent of them, this had happened within the past 12 months before the survey. With sexual assault comes an increased risk of contracting HIV, due to tearing and bleeding. In a rape situation there is also likely to be repeated penetration and little opportunity to negotiate condom use with the perpetrator. The Kenya National AIDS Control Council estimates that about 4 percent of all HIV infections in adolescents are as a result of sexual violence. "These are very conservative figures, there are a lot of people who don't report," said Evelyn Wanjiku, a clinical officer at Nairobi's Liverpool voluntary counselling and testing (VCT) centre. "The recording systems in Kenya are very poor because of the stigma attached to rape." Margaret never reported her case to the police or health workers, as she did not want to face the police questioning that would dredge up awful memories and cause her public humiliation. As a result, she, and thousands of women, children and men who experience sexual assault, miss out on crucial Post Exposure Prophylaxis (PEP) that could prevent them from contracting the Hi virus. PEP is a short-term 28-day antiretroviral treatment to reduce the likelihood of HIV infection after potential exposure to the virus, which must be started within 72 hours after exposure. Used correctly, these drugs could reduce the chances of HIV infection after rape by about 80 percent. "Anybody who has experienced rape of any type, has to be given PEP to minimise the risk of infection from HIV," said Dr Juma Mwangi, a reproductive health coordinator for the Ministry of Health. "If the victim doesn't come forward for services before 72 hours are over, we can only treat her for other injuries, because it will be too late to start PEP." PEP offers an excellent intervention to reduce the risk of HIV infection, but there are serious hurdles in Kenya that prevent the majority of survivors of sexual violence from benefiting from it. Top on the list is the availability of the service. Although efforts have been made to ensure that most public hospitals, right down to the district level, offer comprehensive post-rape care, there are concerns about the shortage of the drugs and skilled staff trained in counselling and clinical PEP management. In addition, few hospitals offer PEP free of charge, keeping it out of the reach of thousands of rape victims, in a country where more than half the population lives on under US$1 a day. "Rape services have been offered in Kenya, but not in a coordinated way. It depends on the institution, and whether there is anyone interested," said Liverpool's Wanjiku. "It needs to be streamlined and to be offered in one place." Counselling, another critical part of the post-rape care, is often unavailable. A 2003 report by Liverpool VCT centre found that many public hospitals do not have trained staff to provide HIV counselling. Another major reason rape remains so underreported in Kenya is the fact that so often, the perpetrators are let off with just a slap on the wrist, or worse, get away scot-free. Activists have been fighting for greater justice for the survivors of sexual assault, and currently, a sexual offences bill is being debated in the Kenyan parliament. The proposed bill would, among other things, create stiffer penalties for rape and defilement, introduce several new sexual offences and provide for the treatment of victims, including government-funded counselling. To streamline post-rape services, Kenya launched guidelines on the Medical Management of Rape and Sexual Violence in 2005. The Ministry of Health is also currently working with its partners to ensure that the services are set up as widely as possible to improve access, particularly for those women who could not afford them. "We are also going to approach the private hospitals to ask them to waive fees for rape clients," said Dr Margaret Meme, gender programme manager at the Ministry of Health. "These women have been raped, they've also been robbed, so how can they pay?"