----------1_---------

IN DEFENCE OF THE
VULNERABLE

'Manto, AIDS drugs DO work after
rape: Headlines from the Mail Et
Guardian of 18 January this year

reflect the frustration felt by
both lay and professional people

in trying to convince our
government that there IS

impressive evidence for the
benefit of antiretroviral (ARV)

drugs. The government continues
to object to the administration of

these agents from state

hospitals. Recently the lay press
has reported two very disturbing

accounts of medical travesties.

The first report concerns Rob
Ferreira Hospital superintendent,

Or Thys von Mollendorf, who was

found guilty of gross

insubordination by a government
tribunal last week. His crime was

to allow volunteer workers to
facilitate the provision of free

ARVs to rape survivors. These

volunteers, working for the
organisation 'GRIP' (the Greater

Nelspruit Rape Intervention
Project), provided counselling,

clothes, toiletries and legal advice

to the traumatised survivors. The

Mpumulanga health MEC,
Sibongile Manana, accused Or Von Mollendorf of embarrassing

government and told provincial legislature 'that any non-profi~

non-government or volunteer organisations that continued to

defy provincial policy would be frozen out of the public health

sector: Using 'catch 22' logic she states that the reason for

deferring roll-out of the mother-ta-child transmission (MTCn

prevention programmes is lack of resources, including

counselling, yet she bans voluntary organisations such as GRIP

that are stepping into the breach and supplying these services.

The second episode involves Kimberley Hospital in the Northern

Cape, where the health MEC of that province castigated the

hospital staff and suspended one doctor for administering ARVs

as HIV post-exposure prophylaxis to Tshepang', the 9-month-

old baby who was sodomised and raped last November. These

reports highlight the failure of state health services to provide

life-saving interventions to vulnerable populations, and the

more sinister implication is the

undermining of ethical and
professional autonomy of doctors

working in the state sector.

The value of ARVs to prevent
MTCT has been demonstrated

unequivocally in randomised
controlled trials. In rape, where
such trials in this vulnerable

group are not ethically possible,

the risks of HIV transmission are

even higher.

In Africa the risk of HIV

transmission due to rape is
significant. The World Health

Organisation has reported that
two-thirds of HIV-positive

women in Rwanda have become

infected as a result of rape. In
South Africa, where more than

1.6 million rapes occur annually,

it has been estimated that the
resulting risk of HIV infection may

be as high as 40'¥0 because of
high HIV prevalence rates and the

frequency of gang rape. A local
study reported by Or Adrienne

Wulfsohn at the 2001 IDSA

conference in Stellenbosch

described the 2-year follow-up of
1 ()()() rape survivors. Wulfsohn

reported that no rape survivor

who received ARVs within 72 hours of the rape had be<::ome

HIV-positive, and that prophylaxis was well tolerated. The

findings of this important South African study have influenced

the forthcoming Centers for Disease Control guidelines on HIV

prophylaxis after rape and cannot be ignored by health care

providers; they should be incorporated into health care policy as
a matter of extreme urgency by our state health department. It

is understandable and correct that the doctor facing a woman

who has survived the devastation of rape will do whatever it

takes to administer ARV prophylaxis to prevent the added death

sentence of HIV infection. Not to do so would be to fail one of

the most vulnerable sectors of our society. When these

responsibilities are not met, the health profession must step in

to advocate for these sectors. Those of our colleagues who do so

and in so doing jeopardise their positions and face punishment

by the state must be supported and championed by the rest of

the profession.

11 MARCH 2002 ----------- THE SOUTHERN AFRICAN JOURNAL Of HIV MEOICINE



The World Medical Association Declaration on Physician
Independence and Professional Freedom of October 1986 states

that 'Physicians must have the professional freedom to care for
their patients without interference. The exercise of the
physician's professional judgement and discretion in making

clinical and ethical decisions in the care and treatment of
patients must be preserved and protected: The South African

Medical Association Human Rights, Law and Ethics Committee
adopted the following resolutions in July 2001: 'The committee

affirms its strong support for the rights of medical practitioners
to clinical independence and autonomy. This includes the right to

treat patients without undue infiuence, pressure or victimisation
from employers or government institutions. Medical

practitioners are under an ethical duty to act in the best interest

of their patients, who form an exceptionally vulnerable group in
South African society. The committee also supports the rights of

patients to receive necessary treatment, always with their
informed consent This was further endorsed by a recent

statement put out by the Colleges of Medicine of South Africa on

the controversy about the preventive treatment of HIV infection,

which stated among other things that the Colleges believe it
unethical and against medical principles to penalise doctors in
the public sector who obtain and administer nevirapine to their

patients (for mother-to-child transmission prevention) in the
proper manner.

Indeed we are in serious trouble when South African doctors can
no longer exercise professional judgement in providing the best

perceived care for their patients without government or other
interference. The legacies of the past should have taught us this

lesson. When political ideology, political party lines or other
governmental infiuences override the ethical and professional

obligations of medical practitioners, indefensible acts are

committed or basic medical care omitted by this same
profession, and the memory of Or Steve 8iko will bear testimony

to that.

L1NDA-GAll BEKKER
Managing Editor

TH!: SOUTHfRN AFRICAN JOURNAL OF HIV MtoICIN!: ----------- MARCH 2002 11