South African Sexual Assault Survivors' Experiences of Post-Exposure Prophylaxis and Individualized Nursing Care: A Qualitative Study

Abstract

South African sexual assault survivors face the risk of potential HIV exposure, but relatively little is known about their experiences of post-exposure prophylaxis (PEP) and post-sexual assault care. Researchers conducted 10 semi-structured interviews with sexual assault survivors who had participated in an initial quantitative study of a post-sexual assault intervention that administered PEP and provided proactive individualized follow-up care. The qualitative study examined survivors’ experiences of PEP and their participation in the initial observational study itself. Participants demonstrated a range of emotional reactions to PEP, while almost all equated their study experiences to positive interactions with the study nurses who administered PEP and provided informal psychosocial support. The results highlight important opportunities for nurses to enhance the quality of post-sexual assault care in order to improve patients’ emotional and psychosocial outcomes and potentially increase the likelihood of survivor PEP adherence.

Although a limited number of studies examine the use of post-exposure prophylaxis (PEP) to potentially reduce the chance of HIV infection among sexual assault survivors, relatively little is known about survivor experiences of PEP in the emotionally charged context of sexual assault. Prophylactic antiretroviral therapy has been found to reduce the likelihood of HIV infection after potential occupational exposures (Cardo et al., 1997). Sexual assault survivors are often so traumatized when they seek care immediately after the assault that they are unable to fully understand the risks and benefits of PEP (Wiebe, Comay, McGregor, & Ducceschi, 2000), and PEP adherence in this population is often poor (Carries, Muller, Muller, Morroni, & Wilson, 2007; Kim et al., 2009; Limb, Kawsar, & Forster, 2002; Linden, Oldeg, Mehta, McCabe, & LaBelle, 2005; Sikka et al., 2009; Templeton, Davies, Garvin, & Garsia, 2005).

At 17.8%, South Africa has one of the highest HIV prevalence rates in the world (United Nations Children’s Fund [UNICEF], 2009). Although sexual assault is notoriously underreported, a United Nations (2002) survey found that South Africa also had the highest sexual assault rate per capita of all 66 countries surveyed (115.21 per 100,000 inhabitants; United Nations, 2002). In the same year, a representative community-based survey found that among women ages 17–48, the actual rate of sexual assault was much higher at 2,070 per 100,000 women per year (Jewkes & Abrahams, 2002). Although South Africa developed a policy for post-sexual assault treatment in 2002 that included the provision of PEP (Department of Health, Government of South Africa, 2002), the policy’s implementation still faces several obstacles within the health care system (Kim et al., 2009).

Studies of PEP adherence among sexual assault survivors in resource-poor settings have suggested that psychosocial support facilitates survivors’ PEP adherence. One study of South African sexual assault survivors’ preferences regarding post-sexual assault services showed that “respondents particularly valued the availability of HIV prophylaxis (with an HIV test) and having a sensitive health care provider who could provide counseling” (Christofides, Muirhead, Jewkes, Penn-Kekana, & Conco, 2006, p. 211). A study of sexual assault survivors who received post-sexual assault care in Kenya echoed these findings: 132 (68%) of the 194 participants followed up after 2 weeks to obtain additional doses and counseling, while more than half completed the entire PEP course. Those who received initial trauma and HIV counseling were more likely to complete the full course of PEP (p = .004; Kilonzo, Ajema, Ngari, & Taegtmeyer, 2007).

Two qualitative studies of PEP adherence among South African sexual assault survivors underscored the role of psychosocial support within post-sexual assault interventions in order to facilitate PEP adherence. One study of 52 South African sexual assault survivors found that virtually all “required encouragement and support from health workers, family, friends and counselors” (Vetten & Haffejee, 2008, p. 27) to adhere to PEP. Participant interviews suggested that “when women went to health facilities, they were not only hoping to be treated in relation to PEP but also wanted to be helped with their distress and trauma” (Vetten & Haffejee, 2008, p. 27). Similarly, Abrahams and Jewkes (2010) found that “being blamed and not receiving social support had profound psychological impact” (p. 471) on South African sexual assault survivors, and that the stigma of sexual assault and fear of HIV played very powerful roles in debilitating women's abilities to take PEP. They also found that “important others” facilitated PEP adherence by providing vital support (Abrahams & Jewkes, 2010). Both studies suggested that counseling and other forms of emotional and psychosocial support should be a core aspect of post-sexual assault interventions to support PEP adherence after the trauma of sexual assault (Abrahams & Jewkes, 2010; Vetten & Haffejee, 2008).

Our qualitative study of 10 South African sexual assault survivors was a sub-component of a larger, quantitative observational study of a post-sexual assault intervention that provided PEP and pro-active, nurse-driven, 6-month individualized follow-up (Roland et al., 2011). Its purpose was to develop an in-depth understanding of individual experiences of PEP and participation in the observational study itself. Findings form the basis of clinical recommendations to improve post-sexual assault interventions in resource-poor, high HIV-prevalence settings in order to improve patients’ emotional and psychosocial outcomes and to potentially increase the likelihood of PEP adherence. As it provides critical insight into South African sexual assault survivors’ experiences of PEP and the nurse-driven post-sexual assault intervention in the observational study itself, our qualitative study adds to existing literature by highlighting opportunities for nurses to enhance post-sexual assault care at the initial examination and during follow-up in order to increase the likelihood of survivor PEP adherence and improve survivor emotional and psychosocial outcomes.

Methods

Initial Observational PEP Study

This is a qualitative sub-study of a quantitative, observational PEP study that enrolled sexual assault survivors at risk for HIV infection and provided pro-active, nurse-driven, individualized follow-up care for 6 months (for detailed methods, see Roland et al., 2011). Participants included 135 sexual assault survivors who presented for care at a hospital-based sexual assault clinic outside of Cape Town, South Africa between March and September 2004. Ninety-eight percent of the participants were female; the median age was 21 years. Most participants were single, unemployed, and had completed only some secondary education.

Participants were given a 28-day supply of PEP (zidovudine and lamivudine). Three study nurses were employed to provide intensive case management, including tracking and referrals for clinical services, referrals for mental health services, family planning, and other care needs. A study psychologist, gynecologist, and HIV specialist were available for consultation. The nurses offered follow-up study visits at a hospital-based sexual assault clinic that provided health care, legal, and social services, in the study office or at the participant’s home. With the participant’s consent, appointment reminders were provided by telephone, 1 week and 1 day prior to each visit. In the case of a missed visit, study nurses made repeated attempts to contact the participant for up to 5 days and completed a full tracking protocol before the participant was considered lost to follow-up.

While the observational PEP study did not provide formal adherence or therapeutic counseling, study nurses were encouraged to discuss adherence strategies with the participants and to refer participants to sexual assault counseling as appropriate (Roland et al., 2011). To this end, a study psychologist was available for consultation to ensure appropriate and timely referral for counseling as necessary. In addition, participants with legal and social needs were referred to appropriate governmental and non-governmental organizations and other resources that the researchers determined could meet participants’ needs. Referrals drew on a network of service providers known to the hospital-based sexual assault clinic and to the study psychologist.

Participant PEP adherence was assessed at 1 and 4 weeks after study enrollment by self-report of missed doses in the previous 4 days. Among several findings, the observational study revealed that when nurses provided PEP and sexual assault referrals, as well as intensive follow-up, PEP completion and follow-up HIV testing rates were high (Roland et al., 2011). The Committee on Human Research at the University of California, San Francisco, and the Research Ethics Committee at University of Cape Town approved the study protocols. Each participant provided written informed consent (Roland et al., 2011).

Qualitative Study

Purpose

Our study formed the qualitative component of the observational PEP study and aimed to explore participants’ experiences of PEP and their experiences of the observational study itself. The study’s purpose was to develop an in-depth understanding of individual experiences of PEP and participation in the observational study in order to identify ways to enhance post-sexual assault care. On a much broader scale, the study aimed to contribute to a reduction in HIV transmission as a result of sexual assault in high HIV prevalence settings.

Sample

Because the qualitative study depended on participants’ emotional strengths and abilities to speak in great detail about their experiences, the researchers took a non-probabilistic approach to sample selection. Rather than establishing a random or representative sample, we used this approach to identify specific groups of people who possessed certain characteristics that were relevant to the phenomena being studied (Mays & Pope, 1995). Using this method, we identified quantitative study participants who were willing and emotionally able to discuss their experiences with PEP and the observational study.

Participants were recruited until analysis saturation was reached. A sample size of 10 participants was deemed adequate for our study because, unlike the observational study, the in-depth qualitative study aimed to develop an exhaustive understanding of the sexual assault survivors’ individual, nuanced experiences.

The interviewer, a clinical psychologist, met with study nurses to discuss ways to facilitate sample selection, review the interview schedule, and explain the interview questions. Study nurses were then asked to recommend women who might be willing to discuss their experiences with PEP and the observational study, taking into account the participants’ emotional strengths and abilities to discuss these issues in depth. Study nurses approached potential participants after they had completed the 6-month observational study and selected 10 participants who had been more verbal and willing to speak about their experiences during the observational study. In three cases, however, study nurses specifically recruited participants about whom they were concerned and felt ill-equipped to help, including two who had discussed suicidal ideation and one participant who had seroconverted while enrolled in the observational study. Given that the interviewer was a clinical psychologist, the researchers hoped that the interviews themselves would provide some support and an opportunity to provide referrals for additional psychological support as needed.

Procedure

Participants were offered a choice of being interviewed at a hospital-based sexual assault clinic that provided health care, legal, and social services, or at a hospital research office. All participants opted to be interviewed at the hospital research office. Interviews were conducted by a female interviewer in a private room and in a separate location from the initial quantitative study. A study nurse explained that a female interpreter would be able to explain questions in addition to interpreting the participants’ narratives. Participants received 100-rand ($17 USD) supermarket vouchers for their time and 20 rand ($3.40 USD) for transport to and from the interview location.

Interviews were recorded by digital tape recorder and later transcribed with the female interpreter’s assistance to help with transcription of isiXhosa. A male, isiXhosa-speaking, clinical psychologist, who was not present during the original interviews, conducted back translation. The female interviewer was present for the back-translation and was able to discuss the meanings and choices of words used in each interview by both the participant and interpreter. Although interviews were conducted in the months following the 2004 observational study, these data are still relevant in light of South Africa’s persistently high rates of sexual assault and HIV, the fragmented and poor quality of many post-sexual assault services (Kim et al., 2009), and low PEP adherence rates among sexual assault survivors (Collings, Bugwandeen, & Wiles, 2008). These data are also significant given that the hospital-based sexual assault clinic where this study took place was seen as an international best practice model of integrated post-sexual assault care (United Nations Women, 2011).

Ethical considerations

While we hoped that this study would lead to an enhanced understanding of the needs of South African sexual assault survivors, direct benefit to the study participants could not be guaranteed. Given the extremely traumatic nature of sexual assault and the highly personal questions included in the qualitative interviews, it was likely that some participants would become emotionally distressed in the process. Most participants, however, reported that the interview experience felt emotionally supportive. This was consistent with prior research that indicated that trauma survivors who participated in similar research found the experience to be beneficial (Campbell, Sefl, Wasco & Ahrens, 2004; Griffin, Resnick, Waldrop, & Mechanic, 2003).

In order to protect participants’ identities, numbers were assigned to replace participants’ names. All data were kept locked and inaccessible to anyone except the principal researchers. In order to protect participants’ well being, interviews were conducted in a supportive, safe environment. A female interpreter was present at all times to ensure that participants were able to fully understand and engage in the informed consent and interview processes. It was explained both verbally and in writing that participants could withdraw from the study at any time and with no ramifications on any aspect of their post-sexual assault care.

Data collection

Study nurses explained the study’s aims and objectives to each participant and provided a separate voluntary informed consent document for the qualitative study. The interviewer encouraged participants to tell as much of their stories as possible. Participants were informed that they could refuse to answer a question if it made them feel uncomfortable. The interviewer also explained that the interview could be stopped at any time if it became too distressing. While the participant’s responses directed the interview, the interviewer made sure to explore each participant’s self-reported adherence, her experience of PEP, and her experience as a participant in the observational study.

The researchers decided that an open-ended, semi-structured interview format would best facilitate the development of participants’ narratives. The interview began with the following question: We are interested in all aspects of your experiences, thoughts, and feelings from the time of the assault up until now. You may tell them in any order you wish . . . The interviewer asked this open-ended question in order to avoid imposing any preconceived understandings or expectations on the participant, and allow her to direct her own narrative from the beginning of the interview. This approach was in line with the hope that participants would be acknowledged as active survivors in the study rather than passive victims.

We also emphasized the participants’ agency in constructing her narrative because studies have shown that the very act of creating a narrative with minimal intervention can be therapeutic to survivors of trauma (Rosenthal, 2003). Although the qualitative interviews were not conducted for therapeutic purposes, we hoped that the process would be empowering for the participants. After each woman spoke freely in answer to the first question, questions were asked to elicit discussions about her experiences of PEP and participation in the observational PEP study.

The study proved emotionally evocative for the interviewer, translator, and transcriber. The different emotions experienced in each interview directed the interviewer’s prompts and interjections in different ways, which influenced the construction of each interview, a process that sexual violence researchers argue enables rather than hinders interviews with rape survivors (Campbell, 2002).

Data analysis

Data analysis was an iterative process. Interviews were analyzed using a grounded theory approach, which uses a “systematic set of procedures to develop an inductively derived grounded theory about a phenomenon” (Strauss & Corbin, 1990, p. 24). Data analysis based on this approach is viewed as an emergent process: codes and analytic categories are formed and grounded in the data.

The first phase of analysis specifically involved an open coding process, during which the fully transcribed participant narratives were categorized in order to gather focal points of data. This process entailed initial coding of data, followed by focused coding, in which significant and/or frequently occurring codes were used to guide suitability of codes to large segments of data (Strauss & Corbin, 1998).

In conjunction with the open and focused coding processes, the researcher engaged in extensive memo-writing, which refers to a specialized written record in grounded theory. The memo-writing process involved analysis of the most frequent and/or significant codes, which allowed the researchers to make connections between codes and to formulate theoretical categories (Strauss & Corbin, 2008). In our study, data that reflected participants’ experiences of PEP or of the observational study were organized into categories and assigned a code.

As the researcher’s individual interpretation is an inherent component of the grounded theory approach to analyzing qualitative research, it was essential for the researcher to reflect on her own suppositions and be aware of how her unique “lens,” through which she saw the data, affected her interpretation. The potential for bias to affect the data analysis was mitigated by a reflexive memo writing process, which was intended to help the researcher “take stock of biases, feelings, and thoughts” (Watt, 2007, p. 84), in order to examine how these conditions influence the analysis process.

Results

Sexual Assault Survivors’ Experiences of PEP

Emotional reactions

Interviews revealed a range of sexual assault survivor experiences of PEP. One participant described taking the medication as an emotional experience: “Emotionally? [PEP] was affecting me emotionally…I felt like crying sometimes. Because everything around me wasn’t…the same…I felt…very strange.” Another participant described taking PEP as “very emotional” because it triggered memories of the sexual assault:

I would get upset and have memories. Especially when I was taking the medicine...it was very emotional. Every time when I’m taking the pills, it would just remind me…that I’m taking these pills because of what happened to me. And…I just wanted to finish off the medicine, didn’t want to take any more pills.

The same participant said she “really hate[d] PEP,” as it seemed to suggest that the sexual assault had made her “sick” or “dirty”: “I would really, really hate taking that medicine…as if I’m a sick person, or I have this dirty…whatever thing is, that I have to clean it up…because of him.”

The perception of taking PEP as a means to “clean” oneself was common; one participant said that she received an exam where she was given “some pills to take to clean everything.” Another participant said she had expected to receive “some tablets to clean ourselves” at the sexual assault clinic: “I didn’t expect that…to be taken blood…I thought I would be given tablets, and be cleaned, only.” Despite experiencing physical side effects, one participant explained that taking PEP did not evoke a negative emotional reaction, “Just because I had trust in the doctors, that they will help me by saying that I must take these tablets.”

Although another participant who reported complete adherence said that PEP “is just like…it is with the other medication,” she suggested that adhering to PEP was a way to alleviate a sense of self-blame: “I took the medicine. I made sure…I never even forgot a single one…. I cannot blame myself, and say no, it’s because I once forgot. I never forget. I always took them. I made sure I took them.” Another participant, who also reported complete adherence, seemed motivated by the fear that if she forgot to take PEP, something would be “definitely wrong”:

I will take [PEP] every day, because if I had missed any, if by any chance there would be something wrong with me, I just thought…if I miss my medicine, there will be something definitely wrong. I just felt I should take it…I didn’t forget.

Physical side effects

Instead of sharing emotional reactions to PEP, three participants instead reported experiencing PEP exclusively in relation to physical side effects. One participant said,

[PEP] was horrible. The medication was horrible. I couldn’t eat very well. But I had to eat because I was taking the medication…that was the only reason I was eating, otherwise it was horrible…and I felt all the time…like I want to go [to the toilet] all the time.

Another participant described PEP tablets as “bad”: “I was drinking them…but they were bad…they were like, making me feel like vomiting…I was taking them every day.”

Only one participant who experienced negative physical side effects reported that they affected her adherence. She was also the only participant to report that she did not inform the study nurse of her non-adherence. The participant explained that she sometimes “forgot” to take PEP, but that the main challenge was “the timing and the nausea,” which prevented her from going to a volunteer job:

I forgot sometimes…but when I remember, then I say, hey, take two because…in the morning…my stomach is sick, then I was taking it in the afternoons, then I take two…But I never tell [the study nurse] I was doing it…It’s because I was going to [my volunteer job]. Then I don’t take it, I take it when I come back…it’s only the problem with the timing and the nausea.

Survivors’ Experiences of the Observational PEP Study

Location

When asked about how they felt about their experiences in the study, several participants indicated that it was important to have chosen the space in which they could speak freely to the study nurse. Unlike the observational study, in which most participants chose follow-up care in their homes, all qualitative study participants chose to have follow-up visits in the clinical setting. Most participants explained that this location guaranteed their privacy. As one participant explained,

I didn’t want to go meet [the study nurse] at home…because some of the information and some things...it’s personal…so I decided I wish I can just go with her, not with someone else, so that I can be free, you see?

Another stated that she appreciated the anonymity associated with meeting in a location outside her home and community: “If it was someone I know I wouldn’t feel comfortable…I would never have agreed to do interviews at home or anywhere in [the community] because of people knowing me.”

Several more participants commented on being able to talk openly and feeling “free,” “safe,” “comfortable,” and “secure” in the study environment, as opposed to the restriction they felt in their own homes. As one participant explained, “it’s very helpful, because you can just let it out, and just be free, because you know you’re very safe…in the study, you feel safe…you’re comfortable. You can say anything.”

Consistent psychosocial support as a component of clinical care

Our interviews suggested that study nurses played a critical role beyond providing clinical care, as they met one-on-one with the participants and offered emotional support on a consistent basis. As one participant stated, “Now, 6 months after the sexual assault, I didn’t worry about anything because I was talking with [the study nurse] every Monday…I feel better because…I know, when I’m in a problem, I can phone [the study nurse].”

One participant felt that talking to the study nurse brought a sense of relief and comfort: “I am…relieved to talk to [the study nurse] and…I feel very comfortable…now I feel very relieved. That I spoke to someone.” Another participant echoed this sense of relief, because she could “talk about anything” and let “this thing…go out of me”:

I felt fine to talk to [the study nurse], because I trusted her in the first place…it made it easier so that I can talk about anything…at least it’s a relief to talk about it. It’s a bit of a relief…so, to me it’s been an advantage…I don’t know who to talk to if I have a problem…at least if I can tell someone this thing, it can go out of me.

Another participant expressed how important it was that the study nurse had made her feel comfortable and encouraged her to achieve her goals, when her husband, who had sexually assaulted her, had discouraged her in the past: “[My husband says] you can’t achieve your goals. But…if I talk to her, she says ‘go for it, man’… ‘if you want to do something, then go for it.’…And she’ll always encourage me. Do this, do that…you feel comfortable around her.”

Several participants attributed their “confidence” and sense of freedom and “normalcy” to the study nurses, and even likened them to trusted friends, members of their own families or formal counselors:

I am coping…a lot because of [the study nurse], that’s what I’m telling you. She did a lot of things for me…I feel like free…and just normal. I mean, I now have someone to care, so she’s more like my sister.

She was very nice…It was like…a counseling session with her… I trusted her, that’s the most important of all, and she supported me…[and] when I talked to [the study nurse]…I just…talk as if I’m talking to my mother, or a friend I’d just met…the sort of confidence that I have, and she has motivated me a lot, I’ve grown from that.

In one instance, the study nurse also seemed to directly influence the patient’s PEP adherence. When describing her adherence to PEP, a participant said, “every time I take it, I thought about…sit thinking about [the study nurse], what [she] told me ‘Ja’, she told me I must do this thing (PEP). She would tell me to think about HIV…and the pills.”

Survivors’ overall impression of the observational PEP Study

Although our qualitative study sought to examine participants’ experiences of the initial observational PEP study, participants wanted to discuss the care provided during the PEP process instead. Most participants equated their study experiences with their interactions with the study nurses, who did not provide formal counseling, but still addressed the participants’ psychological and emotional needs in addition to providing clinical care.

One participant said, “In the study, everything for me was right…that was the only time I could express how I felt, by coming out. The most helpful thing was talking and being encouraged.” Another said the study was “helpful” and that she “[couldn’t] wait to see” the study nurse during follow-up appointments because she was able to be “open” and talk about whatever she felt:

Why is [the study] helpful? Because I can talk about whatever I want to say…whatever I want to say to her, I’m just open…and whenever I have an appointment, I can’t wait to see her, because I know now I can talk.

One participant said she benefited from the study because it gave her “someone to lean on,” noting that she might have contemplated suicide if she had not participated:

I benefited a lot… with this study, they helped me, because if I’ve got a problem, [the study nurse] always tells me… “please call me.” If I wasn’t in the study, maybe I wasn’t going to be here, because I was going to think of something, just maybe committing suicide, because now I’m always alone, and no one to talk to. So, now I have someone to lean on.

Several other participants indicated that talking to the study nurse as part of the study experience made them feel stronger, helped them heal emotionally, and gave them a sense of relief:

[The study] has made me strong so I can talk about this. [If I hadn’t been in the study], maybe I would not have been able to talk about this by now…I wouldn’t have the guts to talk about it.

One participant explained that without the study, she “would have been someone else.”

If it weren’t for this study, it was…I would have been someone else…I would have been very lonely, ‘cos I don’t worry with people at home, when I go home, you know? ...so with this study, I’m going out…I’m going to express myself this time. This is what I’m going to do…and [the study nurse] is encouraging me.

Several participants reported that they would not have been “all right” if they had not participated in the study. One participant stated that she “wouldn’t have been OK…wouldn’t have been all right.” Despite having received a great deal of support from her family, boyfriend, and friends, another participant also felt that she “would [not] have made it” without the study and the motivation and strength she developed throughout her relationship with the study nurse:

I don’t think I would have coped… if I had not been in the study…I don’t think I would have made it, because I tell [the study nurse] every day that I’m coming here, I feel a lot better each and every day that I’m there, I’m moving on.

Another participant echoed this statement, claiming that she would have “a problem now” if the study nurse hadn’t helped her: “It seems to help…I don’t think I could help myself without [the study nurse]…if I had not been part of the study, then…I would have a problem now…It made me a different person.”

Discussion

The results highlight important ways in which nurses may enhance the quality of post-sexual assault care in order to improve patients’ mental health outcomes. Our second interest was in whether the interactions had the potential to increase the likelihood of PEP adherence and subsequently reduce HIV transmission through sexual assault.

Sexual Assault Survivors’ Experiences of PEP

Emotional responses to PEP

The participants’ range of emotional reactions to PEP suggested that providers may increase the likelihood of sexual assault survivors’ PEP adherence by normalizing a range of physical and emotional reactions to PEP. Interviews also supported the findings of the initial observational study, which concluded that sexual assault survivors benefited from clinician-initiated discussions about how side effects may interfere with a patient’s ability to adhere to the medication (Roland et al., 2011).

Although strong emotional reactions to PEP did not seem to negatively affect our participants’ adherence, prior research has shown that PEP can trigger traumatic memories and thereby inhibit adherence (Vetten & Haffejee, 2008). Some participants’ perceptions of PEP as a means to “clean” themselves emphasized that sexual assault survivors may not be able to process and retain what they are told about PEP in the context of immediate trauma (Vetten & Haffejee, 2008). Post-sexual assault care providers should be aware that sexual assault survivors may require repeated explanations of the potential benefits and limitations of PEP throughout post-sexual assault treatment and follow-up.

Despite the observational study’s rigorous informed consent procedures, several participants’ experiences of PEP as a means to “clean” themselves suggested that they did not fully understand or accept what was and what was not known about PEP efficacy. This coincided with a prior study that showed that sexual assault survivors were often unable to fully understand the risks and benefits of PEP immediately following the trauma of assault (Wiebe et al., 2000). The participants’ misconceptions of PEP underscored the need for post-sexual assault care providers to explain PEP thoroughly and repeatedly during immediate post-sexual assault treatment and throughout follow-up care.

Physical side effects

Although their positive, trusting relationships with the study nurses may have facilitated participants’ self-reported PEP adherence, one participant reported that she did not adhere to PEP due to nausea and did not tell the study nurse that she subsequently altered the timing of her PEP regimen. While the sample size did not allow us to draw definitive conclusions about the relationships between sexual assault survivor support and PEP adherence, that participant’s interview suggested that even if sexual assault survivors have a positive relationship with their care providers, they may still not discuss critical challenges to PEP adherence, such as the impact of physical side effects. Care providers may need to consider incorporating discussions about adherence challenges and ways in which a patient can accommodate PEP into his or her lifestyle, regular medication counseling, and follow-up care in order to increase the likelihood of adherence.

Survivors’ Experiences of the Observational PEP Study

Location

Offering a choice of follow-up locations was not part of routine practice. However, the results demonstrated the value of offering sexual assault survivors options as to where to receive post-sexual assault care, as some may not feel comfortable at home and could benefit from an environment in which they feel secure and can speak openly.

Consistent psychosocial support as a component of clinical care

Interviews suggested that the observational study’s intensive, individualized follow-up care engendered a strong sense of trust between study nurses and participants and created a critical space in which participants could talk freely and start to emotionally recover from their trauma. Unlike models of post-sexual assault nursing care that focus solely on the documentation of injuries, medical treatment, and referrals for counseling (Ledray & Arndt, 1994), this model allowed nurses to offer encouragement and opportunities for patients to openly express themselves and discuss their problems. Interviews suggested that all nurses, whether involved in research or clinical practice, could have a significant impact on sexual assault survivors’ emotional and psychosocial outcomes and PEP adherence.

Survivors’ overall impression of the observational PEP Study

Many participants perceived the study as an opportunity to express themselves or to get stronger. This suggested that care providers should be aware that the clinical encounter may be experienced as supportive in much the same way as a counseling session, as it may be one of the few opportunities sexual assault survivors have to speak openly in a private, secure environment.

Our participants’ responses supported prior studies that emphasized the importance of psychosocial support in order to improve sexual assault survivor outcomes (Abrahams & Jewkes, 2010; Steiner et al., 2009) and the value that sexual assault survivors place on interacting with a sensitive health care provider who provides counseling (Christofides et al., 2006). They also suggested that care providers could have a significant and positive impact on their patients’ lives by offering patients “someone to lean on,” contributing to their patients’ sense of personal strength, and helping them overcome feelings of hopelessness and thoughts of suicide. In order to maximize the positive psychosocial and emotional impact of post-sexual assault treatment, providers may, therefore, encourage survivors to discuss their feelings and problems openly, and engage in consistent, supportive communication, either in person or by telephone.

Study Strengths and Limitations

This study described the complexity of a group of South African sexual assault survivors’ experiences of PEP and as participants in an observational study of a nurse-driven, post-sexual assault intervention. The participants had overwhelmingly positive experiences in the observational study due to the study nurses’ pro-active follow-up and emotional support, both of which may have enhanced the likelihood of PEP completion and follow-up HIV testing. This study suggested that there are opportunities to enhance post-sexual assault care at the initial forensic examination and during follow-up, which may improve survivors’ PEP adherence and overall emotional and psychosocial outcomes.

Study limitations include reliance on self-reported adherence and the potential for selection and desirability biases. Because the parent study included PEP study participants who sought treatment at a post-sexual assault clinic, they may have been more resilient than women who did not present for post-sexual assault care. The nurses ultimately selected participants based on their ability to speak about their experiences and, therefore, may have demonstrated a higher degree of resilience and resourcefulness than other PEP Study participants. The sample may have been more representative had the study not relied solely upon the study nurses to select participants.

While the nurses had a positive impact on the survivors’ experiences, this study’s model of post-sexual assault nursing care would not have been feasible without modification and integration into existing sexual assault-related services. The absence of adequate care and support for sexual assault survivors likely exacerbated the need for ongoing medical care and psychosocial support.

Conclusion

Our study demonstrated that proactive, individualized nursing care could have a significant impact on sexual assault survivor emotional and psychological outcomes, and highlighted important opportunities for nurses to enhance the quality of post-sexual assault care and potentially increase the likelihood of survivor PEP adherence. Further research, including cost-effectiveness analysis, is needed to understand the emotional and psychosocial health outcomes associated with more and less intensive care and support systems for sexual assault survivors who are a risk of HIV infection.

Clinical Considerations.

• Nurses can help to enhance the quality of post-sexual assault care and increase the likelihood of PEP adherence by normalizing a range of potential emotional responses at the beginning of treatment and eliciting individual reactions while providing individualized support throughout the course of PEP therapy.

• Even if sexual assault survivors have a positive relationship with their care providers, they may still not discuss critical challenges to PEP adherence, such as the impact of physical side effects. Nurses who provide post-sexual assault care should inquire about adherence challenges and discuss ways in which the patient can accommodate PEP into his or her lifestyle in order to increase the likelihood of adherence.

• Nurses who provide post-sexual assault care can have a significant, positive impact on their patients’ lives by offering encouragement and opportunities for patients to express themselves in private, secure environments. In order to maximize the positive impact of post-sexual assault treatment, providers may need to inquire about their patients’ personal lives and emotional well-being, emphasize their willingness to listen, and encourage patients to talk about their problems for as long as needed to address patient concerns.