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Re: HIV post-exposure prophylaxis for sexually abused children in Malawi

Dear Editor

Ellis et al [1] ought to be commended for spearheading and reporting on their experience with the provision of HIV post-exposure prophylaxis (PEP) to children sexually abused (CSA) at the Queen Elizabeth Central Hospital (QECH) in Malawi. I wish to comment on a number of issues raised in the article. Firstly the authors indicated that in the protocols they follow children presenting with previous abuse within the preceding 6 months are not eligible for PEP ‘because of the possibility of the child having already acquired HIV infection and being in the "window period" prior to sero-conversion’. I agree with the authors in that such a situation is one possibility, but not all possibilities. There is also the possibility that the child who had been previously sexually abused may not have acquired HIV infection in the previous assaults. Now, what if it is the index assault that will be responsible for infection? It is not possible to know, until after the fact. It may therefore be prudent to err on the side of caution by nonetheless providing prophylaxis to the child who is HIV sero-negative now regardless of whether they may or may not be in the window period. This ought to be explained to the parents/guardians as in the event that follow-up HIV tests shows HIV sero-conversion, it ought to be considered that one possibility may be that the child was in the "window period". It is important that Ellis et al identifies the shortage of experienced medical personnel to deal with CSA in their setting. I find the suggestion to "make our service to abused children consultant led" may have implications in ensuring timely provision of PEP to eligible children. In Malawi, just like many other African countries, most of the clinical care is provided by nurses and non-specialist medical doctors [2]. Allowing non -consultants to care for CSA potentially endangers the quality of service to be provided, but may permit transfer of skills to the majority of clinicians who most often cares for children and must be able to clinically recognize and manage CSA cases when they occur. Perhaps, currently the service as QECH is yet to mature, consultants could still lead while slowly trying to bring on board the common health cadres. The poor management of sexual assault cases in the pre-PEP era in Malawi has been described before [3]. Finally, I agree with the authors that in a high HIV prevalence setting, as in most of southern Africa, there is need to seriously consider HIV post-exposure prophylaxis in cases of confirmed CSA, even without evidence of genital trauma. As the practice of medicine generally is to be cautious especially when we do not know the possible harms to treatments (like in this case where PEP is just being introduced in a developing country), the authors are justified in how they have trodden so far. However, in a situation where there is a real possibility of getting HIV infection, some of us think that there are very few clinical situations that can outweigh HIV infection in a risk-benefit analysis. Unfortunately we may not have evidence to objectively demonstrate that.

References

1. Ellis JC, Ahmad S, Molyneux ME. Introduction of HIV post-exposure prophylaxis for sexually abused children in Malawi. Arch Dis Child. Published online 20 Sep 2005; doi: 10.1136/adc.2005.080432

2. Dovlo D. Using mid-level cadres as substitutes for internationally mobile health professionals in Africa: a desk review. Hum Resour Health 2004; 2: 7

3. Muula A. The management of sexual assault cases at LCH. Malawi Med J 2001; 13: 34