 Can I now welcome Daphne to talk to us about another no doubt emotive topic, sexual violence in conflict affected and post conflict context. Daphne comes from the Brussels office of MSF and we look forward to your presentation. Thank you. Okay. Thank you very much. Good morning. Thank you as well for the opportunity to talk here again on this topic. Prevention of care for survivors of sexual violence. Standardised or context specific. Let me start with giving you a very brief snapshot on the background. For many years now sexual violence has been widespread in the DRC, giving it a country the name of being the rape capital of the world. In particularly in the eastern DRC being a zone of active conflict rape is used as a weapon of war. At the same time in other regions of the country with labelled as being post conflict still high rates of sexual violence have been reported. And this is equally so for Liberia where during 14 years of active conflict unprecedented high levels of sexual violence have been reported. And despite the war ending still there are high reports of sexual violence. So in response to this MSF wanted to implement different programs to take care of survivors of sexual violence. One was a vertical program in Liberia supporting three sexual violence clinics. Then in two projects in DRC the same package of care was offered or was integrated at hospital level and decentralised at different health centre levels. So with this offer of the same package of care we questioned ourselves is this adapted to this different contextual settings. So for this we wanted to describe and to document on the characteristics of sexual violence survivors, the patterns of sexual violence and what are the medical consequences and its clinical management. So this study is a retrospective analysis of standardised, of standardly collected data. In Liberia data was collected over a period of two years including 1500 individuals. In DRC data was collected over a period of one year including 671 individuals. Ethics approval was obtained. For all survivors coming to the clinics that standard package of care was offered by specifically trained staff to provide sexual violence care. And this package includes psychological support, medical history taking and examination, wound care, post exposure prophylaxis for HIV when a survivor was presenting within the time frame of 72 hours, STI prophylaxis or treatment, emergency contraceptives, termination of pregnancy, hepatitis B and tetanus vaccination and there was a provision of a medical legal certificate. Next to this MSF invested this as well in extensive awareness and health promotion activities. The main message being if you have been raped come for treatment as soon as possible. It is free of charge. So these awareness activities could take on many different forms from leaflets or billboards, talks and community meetings. And here I want to highlight a different strategy which was implemented in DRC in the MSF. Y maen nhw'n consulau o'r ddechrau. These are women living in the community and they were charged with the task to deliver messages on water sexual violence and the importance of going and look for care and treatment. There were trusted persons within the community so they could not take a role of counselling the women of also taking care within the good time. The limitation of this strategy is the number of people it can reach. So looking into some of the results we can see that over the three programs the majority of survivors seeking care were female. Only one in two percent were male survivors. When looking into the distribution of age I'd like to highlight here in red bars in the Masisi program, the conflict setting that most of them were seen were adult women. While looking into Menrovia and Niangara, the blue and green bars we see that the majority were children and adolescents. The type of sexual violence which was most reported was rape. In Masisi here the bar in the middle and I want to highlight the green and red part is that the number of aggressors was higher in that context. And this was also associated of having more brutal forms of assault in Masisi. There was more association with use of weapons and other associated violence. What we know on the side of the perpetrators is that the most common perpetrator in the post conflict zones were known civilians. While in the conflict zone of Masisi the military was the most important aggressor. We also know that amongst children up to 12 years 17% of them reported that the aggressor was a minor. The blue part in the bars at the left graph show here the proportion of survivors presenting within that critical time frame of 72 hours when prophylactic treatment can still be initiated or is most effective. We see that in Masisi 60% of survivors came to our service within that time frame. For both Menrovia and Niangara this was lower. In relation to referral source I want to highlight here that the community talks in Masisi including the system of the moment we are here managed to link 20% of survivors to into care. The drama the other approach that was used in Niangara helped to link 17% of victims into care. Although the package of care was the same the uptake was sometimes different. So this graph represents the coverage of the initiation of treatments. The blue and red bar here shows the initiation of PEP and the STI prophylaxis which had a good coverage with even close to 100% in both DRC programs. At the same time we see that the uptake or the provision of emergency contraceptives in Menrovia the green bar at the left was very low. Not half of the patients being eligible didn't receive the emergency contraceptives. From the survivors who reported of becoming pregnant as a result of the rape more than half of them requested a termination of their pregnancy. In three out of four of these requests the abortion was performed. However in Masisi we see a very different trend where there is a much lower request for the termination of the pregnancy and no abortions were performed in the study period. This is surely a problem within DRC because all voluntary abortions are criminalized by law also on the grounds of rape. So returning to the initial question we could see that there were some important differences in patient characteristics and in patterns of violence. This makes that we need to be able to adapt our services to what we can expect. So should awareness activities be tailored to reach those we expect to see but also to those that we don't see yet in our programs. We need to focus more on collaboration with partners to refer to. For instance in post conflict settings where we can expect more child survivors we need to be able to refer them to child protection services. Also training of staff can include modules to focus more on the victims we see. For instance counselling of children or examination of children is very different from adults. Then adaptation of the package of care needs to be tailored as well to adolescents needs. As we learned here from the experience in Monrovia an important proportion of adolescents reported that they had consensual sex with someone of their own age. The package of care and the counselling they need is different. At the same time we saw some similarities between the different settings. So there was a low proportion of survivors presenting within the 72 hours. We saw only very few male victims although we know that there are more and there's a low number of follow up visits in general. Limitations of the study is that we don't have specific data on the perpetrator's age. Now we do not know why some of the survivors did not receive the treatment they were eligible for such as the emergency contraceptives in Monrovia. And then there was the component of the psychological support but the database was different and we were not able to cross link this data. This is a facility based study and from an operational perspective we can say that both studies in Monrovia and Iangara were rather than late. They were done towards the end of the program. So in conclusion we can say that this kind of analysis can contribute to that we can see that standardized provision of care that it will leave gaps. But at the same time it also contributes to identify where are the areas that we need to reinforce or that we need to tailor our services differently. From there we also like to recommend that an early and tariff analysis of program data should be done quite early on. After six, nine months or perhaps one year of program it's good to go into that analysis so that it can be tailored according to the context. I'd like to thank first of all the patients, the ministries of health involved, the whole team of investigators of the different studies and for your kind attention. Thank you. Thank you very much. There is time for a few questions before we start the panel. There's a gentleman with a blue top in the middle here and someone at the very back will be next. Thanks. Please remember to say where you are from and your name please. Florian, working for MSF in Brussels. Did you look at whether or not the perpetrator was a stranger or known to the victim before the incident or coming from the family even and was it different between the sites? Thanks. Okay. There are more breakdowns. I couldn't present the whole ad, all of the results we have, the different settings we know if there were known, if there were civilians and then if there were known civilians or unknown civilians. And so this we know for the places that mostly in the post conflict settings that a lot of them were civilians but also an important part were known civilians to the victim, which was different from our CC in the conflict setting. The gentleman at the back please. Hi, Petryam from MSF Sweden. I was wondering, you mentioned that MSF provides a legal medical certificate. Is some form of legal assistance also included in the package of care? As for example in Kibera where MSF actively assists the survivors of rape for pressing charge. Okay. Thank you for that question. Because it's one question a lot like should we even provide the certificates because what is done further. It depends a bit on the setting where we are if we can give more support for pressing charges or legal support. What we found out as well is that it's important to link up with services who can do that as we are quite limited in MSF. However it depends on where we are and for instance from here we learned that in the newest setting we have now in Zimbabwe in the clinic there in Harare that we put more efforts as well to support victims who want to press charge that they have to support their need also at that legal site. Hi, my name is Tuan. I volunteer with MSF OCG and the International Office. Thank you for your presentation. What are your thoughts regarding strategies to really get the treatment, the life-saving treatment, emergency contraception perhaps in time for the survivors? Are community-based approaches such as getting a package of drugs in the community maybe with Maman conseiller so that survivors could access them before they could be linked to our services? Would that be considered? And then what are your thoughts about targeting also perpetrators in terms of treatment from a public health point of view? So if you go into the papers there are some more results that we have there and for instance what we did at MSCC was mapping from where were the decentralised health centres and then to see from where did the survivors come from. And then we saw that it was very important to have the decentralised approach as well where at least a minimum package which is like the PEP initiation and emergency contraceptives can be given and perhaps for psychological support there can still be a referral at hospital level. That this contributes to having a better rate of having this treatment provided within the 72 hours. I don't think that we went as far as discussing on the Maman conseiller if they could for instance initiate this kind but definitely decentralisation has shown that it works, that it really increases that. What we know as well from MSCC is that still the reason why survivors came late is that they didn't know about the availability of treatment or the existence of the different treatments. And from Niangara we know that one of the main reasons was given that fear and fear for stigmatisation as well to come to the services. So we know really some points to work on further what we can do and a lot is to make it to make our services known and accessible and acceptable for the survivors. It's definitely a working point. It's as important as being able to provide the medical treatment but to make it accessible. OK Daphne, and would you care to answer the second more controversial and difficult question I think whether you feel that there should be a service for the people who caused the rape or the violence, other types of violence from the point of view as a public health measure? I don't think I can really give something into that but perhaps it could be an interesting one for later on in the panel discussion. I would be very interested to have more an idea of what the origins would think of that. To be honest I'm not very sure if I can give a reasonable answer to that one. That's probably a good point on which to thank you again for your presentation and invite the panelists to come.