NASCOP MARPs Newsletter 2013 Issue 2 - Kenya National AIDS ...

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NASCOP MARPs Newsletter 2013 Issue 2 - Kenya National AIDS ...

EditorialDear Readers,EditorialThe response we received from our readers on the first issue of theHIV key populations newsletter was overwhelming. Weappreciate everyone who shared their thoughts and gave feedbackwhich has been applied to improve the current issue of thenewsletter in quality and content. In our first issue we focussed onthe issued around People Who Inject Drug, with key emphasis ontheir population size estimates and interventions for harmreduction. We are delighted to bring out the second issue of thekey populations bi-monthly newsletter focusing on female sexworkers (FSWs). We at NASCOP hope that you will enjoyreading this second edition and circulate it widely among yourpartners, communities and friends.Sex workers worldwide are a key population in the fight againstthe HIV and even though we know about high levels ofvulnerability to HIV and other sexually transmitted infections(STIs), they face a host of obstacles to accessing good HIVprevention services. These obstacles include severe stigma anddiscrimination, which create hostile environments andviolence against them, which again is directly linked tovulnerability to HIV. So it's not surprising that, in many places,rates of HIV among sex workers are very high. In 2011 in Kenya,29.3% of all SWs nationwide were estimated to be living withHIV.Through estimation studies and the recently published “KenyaMost at risk population size estimate consensus” report shows thatthere are 133,000 female sex workers across the country and withgenerous support from various donor partners, Kenya has beenabove to put in programs that cover most of the key populationsespecially female sex workers. These programs have beenappreciated by the Government and other country programs.NASCOP has initiated two learning sites for sex workers and nowNASCOP is providing routine technical support to the aboveprograms through its technical support unit.This year saw the launch of KIAS 2012 and preliminary results arebeing shared through this newsletter along with other programupdates. We are in gratitude to the community members who havecome forward to share their stories and testimonials and we dohope that we get to hear more of them which we will share with thekey population programmers as good practices.Finally putting together a newsletter once every two months is byno means an easy task and we invite all partners to share with usyour program stories, case studies, best practices, photographs andcommunity voices which you may want to share with the wideraudience.Continued from page 1meaning the child was not placed on antiretroviral medication to treatHIV infection or receiving other medical services to improve health.More work needed to get people who are in needof treatment on antiretroviral therapyNine out of ten people who knew they had HIV were receiving HIV careand ART to treat their infection. More work needs to be done to extendcoverage of antiretroviral therapy (ART) with only 63% of those eligiblefor ART currently receiving antiretroviral medication.Among adults who were aware of their HIV infection and currentlyreceiving ART, 78% had achieved viral suppression. This means that theamount of HIV virus in their bodies has reached a low enough level,allowing them to live healthier and longer and reduce the chance ofgiving HIV to others.Progress made in HIV testing at ANC clinics and PMTCTAbout nine in every ten pregnant women aged between 15-54 yearswere tested for HIV when they attended antenatal care. Of those testingpositive, 90% were given medication for themselves and/or for theirinfants to prevent the infant from getting HIV.All children who were diagnosed with HIV before the survey werereceiving HIV care and 71% of them were on ART.Survey provides essential data on the sexual behaviourand risk among youth and adultsA new feature of the 2012 KAIS was the inclusion of a behaviouralquestionnaire for youth aged 10 to 14 years. Children aged 12 to 14years were asked about sexual behaviour and 7% of them said they hadengaged in sex at least one time.Among youth aged 15-24 years old, 66% of females and 59% of maleshave had sex at least once, with one out of every five reporting that theirfirst sexual encounter occurred before they were aged 15 years. Malesaged 15-24 years were seven times more likely to have had more thanone sex partner in the last year than women in their same age group.Among adults aged 25 to 64 years, only 5% of women and 14% of menreported consistently using condoms when having sex with a personwhose HIV status was not known to them or different from their own HIVstatus.Certain populations are more at risk for HIV infection, although theyrepresent a small proportion of the Kenyan population. Thesepopulations include people who inject drugs, men who have sex with men,and people who give or receive money or favours in exchange for sex.More Kenyans are being tested for HIVThe percentage of adults who reported having been tested for HIV at leastonce in their lifetime has more than doubled since 2007.In the 2007 KAIS, only 34% of adults reported having been tested for HIV.Five years later, 72% of adults reported having been tested for HIV, withmore women having been tested than men (80% and 63% respectively).Of those who have taken the test, 35% have been tested with a sexualpartner.In 2012, almost half (47%) of those who tested HIV positive were awarethey were HIV-infected. This was an increase from 2007 when only 16%of those who tested positive knew they were HIV-infected.One out of 20 couples who were tested together were discordant (onepartner was HIV positive while the other partner was HIV negative).Higher rates of infection occur among more educatedadultsMen and women who completed any secondary education had a higherrate of HIV infection than those who reported no primary education. HIVprevalence was higher among women at all education levels compared tomen. For women, the highest rate of HIV infection was among those whohad completed at least some secondary education (7.1%) while thelowest rate of infection was among those women with no primaryeducation (4%).Men who had completed primary school had twice the rate of HIVinfection compared to those who had not attended school (4.8%compared to 2.4%)2


NASCOP establishes learning sites for sex workers in KenyaA training in session for peer educators at the Nairobi Learinig SiteDr Githuka at a curriculum development workshop for Key Populationsat MombasaThe National AIDs and STIs Control Programme (NASCOP) in Kenya hasestablished two Learning Sites for Sex Workers (SWs) in Nairobi andMombasa in 2013 within existing sex worker programs. The fundingsupport is from World Bank and the Bill and Melinda Gates Foundation. TheLearning Sites will implement comprehensive HIV prevention program forsex workers and offer hands on learning curriculum.The Learning Sites are being implemented in partnership with Sex WorkersOutreach Programme (SWOP), International Centre for ReproductiveHealth Kenya (ICRHK), Bar Hostess Empowerment and SupportProgramme (BHESP) and Kenya Sex Workers Alliance (KESWA). The largersex work interventions in the sites are being funded by PEPFAR.What does the LS offer?The Learning sites aim to enhance the programming in existinginterventions in line with national guidelines and are expected to be amodel SWs programme. Through the Learning Sites, NASCOP aims to buildcapacity of sex work programme implementers and institutions in Kenya byproviding a practical field based curriculum focused on building skills andcompetencies.A comprehensive model programme for sex workinterventionsThe model programme at the LS is working with existing interventionsfunded by PEPFAR and implemented by SWOP and ICRH to enhance the sexworker programmes. Based on gap analysis with the implementers theenhancements include strengthening outreach activities by introducingmicro-planning processes, development of a system to address issues ofviolence and other crisis that the sex workers face, improve communitymobilization by establishing Drop In Centres and solidarity events.This Model Programme will be used to demonstrate how a communityempowerment based comprehensive HIV prevention programme can beimplemented and integrated into an existing SWs HIV preventionprogramme in Nairobi and Mombasa and to document the knowledgegained, and value add, from the experience. This will be a site to field testtools, methods and approaches to be scaled up by NASCOP in other sites.Hands on capacity building opportunitiesThe Capacity Building component is being tailored to build skills andcompetencies of implementers and policy makers working with SWsincluding the community members.Site visits to the Learning Site will be arranged for different cadres ofimplementers from Kenya and other countries in the region where they canobserve and gain field level knowledge about the programme componentsand implementation processes. This will allow them to effectively integrateand apply the knowledge gained into their own programs. Training fordifferent cadres of staff will be done through a 1-5 days curriculum beingoffered in the Learning Sites to build capacities on management, outreach,violence prevention and response, clinical practice and services. These areprovided using not only class room session but through field visits,shadowing LS staff and mentoring.Community to Community LearningThe Learning Site will promote community to community learning bydeveloping a cadre of SW community trainers and facilitators andencouraging community learners to visit the site. Community project staffand volunteers especially from sex work community are encouraged to visitthe site to undergo training on specific aspects of their roles andresponsibilities.3


Epidemiology ofFemale Sex WorkersA Technical Support Unit for thekey population programme set upAs a population whose job involves sex with multiple partners, sexworkers (SWs) are vulnerable to HIV. HIV prevalence among SWshas notably declined over time, with the per-act rate of HIVacquisition among Nairobi SWs falling more than four-fold between1985 and 2005 (Kimani et al., 2008). Although the relative share ofnew HIV infections among SWs and their clients has decreased, SWsin Kenya continue to experience an extremely high burden of HIV. In2011, 29.3% of all SWs nationwide were estimated to be living withHIV. A survey in 2005-2006 of 820 SWs in Mombasa found that35.2% were infected with HIV (Luchters et al., 2010). An estimated3,200-4,148 of new HIV infections occur each year among SWs andtheir clients along the trans-Africa highway from Mombasa toKampala (Morris, Ferguson, 2006).Nearly 1% of SWs surveyed in Nairobi had active syphilis in 2011,potentially increasing their risk of HIV acquisition as well as theodds of onward transmission to clients.Economic hardship not only encourages entry into sex work, butmay also increase the risks faced by SWs. A World Bank study inWestern Kenya found that women involved in formal or informal sexwork were roughly 20% more likely to engage in unprotected sexwhen a family member was ill, presumably in order to secure thepremium available for risky sex in order to cover additionalexpenses (Robinson, Yeh, 2009). While sex work may begin as a parttimeenterprise, it typically evolves over time into full-timeemployment, with a corresponding increase in the number of sexpartners (Luchters et al., 2008).Evidence points towards near-universal awareness of HIV amongSWs (Kenya Ministry of Health, 2005). According to a nationalsurvey in 2011, 87% of SWs report using a condom with their mostrecent client. Sex workers frequently exhibit distinctly differentbehavioural patterns for their regular partners than they do forclients, with condom use notably less frequent with regular partners(Ngugi et al., 2007; Ferguson, Morris, 2007; Voeten et al., 2006).Alcohol use is common among SWs and is strongly associated withincreased sexual risk behaviour (Tegang et al., 2007; Kenya Ministryof Health, 2005; Yadav et al., 2005). A survey of 147 self-identifiedSWs in Meru found that both anal intercourse and dry sex were oftenpracticed, with condoms used less frequently in such instances incomparison with penile-vaginal intercourse (Schwandt et al., 2006).Sex work is highly stigmatized in Kenya. Laws prohibit the sale of sex,although clients are not penalised for purchasing sex (IPPF et al.,2008). As one indication of their social marginalization, SWs areoften victims of violence. Among SWs surveyed in Coast Province in2007, two-thirds said they had experienced at least one form ofsexual violence, half had been forced to have sex without a condom,and nearly 60% had been beaten or verbally abused as a result oftheir line of work (Tegang et al., 2007).Evidence is somewhat more plentiful regarding SWs themselvesthan with respect to their clients, who represent a key epidemiologicbridge to other groups. Nearly one in six Kenyan men (15%)surveyed in 2003 said they had ever had sex with a SW (Hong, 2008),although only 2.9% of Kenyan men reported have had paid sex in theprior 12 months (Central Bureau of Statistics, 2004). Clients of SWsappear to come from all walks of life, spanning the socioeconomicspectrum (Ferguson et al., 2006). Men with multiple partners andwho reported being away from home five or more times in the pastyear were more likely than other men to have sex with a SW (Hong,2008).A Technical Support Unit has been set up within NASCOP to support theNASCOP and NACC Government of Kenya on Key populationsprogramming Key Populations include female Sex Workers, Male sexworkers, Men who have Sex with Men (MSM) and People who InjectDrugs (PWID).The project is implemented by the University of Manitoba and is fundedby the Bill and Melinda Gates Foundation (BMGF) in partnership withthe World Bank. The main objectives of the TSU is to develop technicalstrategies and guidelines, build capacity and provide implementationsupport for the scaling up of HIV prevention programs for Keypopulations in Kenya with the goal being to contribute in reducing HIVincidence in Kenya by improving the scale, quality and impact of HIVprevention programs among Key populations. In addition, the project issupporting National AIDS Control Council (NACC) to develop KEYPOPULATIONS policies and a performance framework for KEYPOPULATIONS programming.This project will support Kenya to scale up Key populations programs,which will directly have positive effects on Kenya’s HIV epidemic,” saidDr George Githuka, MARPs Programme Manager.Dr Githuka said the initiative aims to enable Kenya to be a technicalleader in KEY POPULATIONS programming. “The project will have apositive impact on national programs within Africa and will leverage onbest practices in countries that have implemented successful Keypopulations programs.Upcoming EventsConsultative forum with MuslimLeaders on HIV Preventionin Mombasa, September 2013Kenya HIV Prevention Summitin Nairobi, September 2013NASCOP Technical Working GroupMeeting in Nairobi, October 2013Learning & exchange visits to India AvahanProgram for NASCOP, NACC, MoH and KeyPopulation September and October 2013Learning & exchange visits to MauritiusIDU Programs for NASCOP, NACC, MoHOctober 2013Learning & exchange visits to Tanzaniaon MAT Programs for NASCOP, NACC, MoHOctober 20134


UPDATES from NASCOPKey populations TWG held at NASCOPDr. William Maina, Head NascopFile PictureThe third Key populations Technical Working Group (TWG)meeting of 2013 was held on July 29th at NASCOP bringing together46 participants from NASCOP, NACC, and implementing anddevelopment partners and MARPS led community organisations.The key issues in the agenda included; the role of NASCOP in thedevolved Government, update on completed guidelines andstrategies, and those under review/development, update onongoing studies around KEY POPULATIONS, feedback on thequarterly M & E reports, and from the NASCOP TSU field visits,proposal for Institutional strengthening for KEY POPULATIONSCSOs in Kenya by Regional AIDS Training Network (RATN),proposal for study on sex work and sex worker organizations byBar Hostess Empowerment and Support Programme (BHESP),Concerns on KEY POPULATIONS Program by HOYMAS/KESWAand review and validation of the KEY POPULATIONS IEC materialsby Kenya Red Cross (KRC).The meeting was graced by Dr. William K. Maina, Head NASCOP. Hestated that going forward services targeted to KP will be directlyhandled by county governments. He reiterated that NASCOP underthe devolved system will continue to provide policy on HIVprevention, build capacity for counties, provide technicalassistance and continue to support provision of essentialcommodities for HIV prevention, care and treatment includingTesting kits and condoms to the county Governments.He appreciated implementing partners for their hard work inreaching out to key populations with HIV prevention services. Hereiterated that all implementing partners should endeavor toachieve zero discrimination among Key populations within theirareas of operation. He at the same time expressed his appreciationto NASCOP Technical Support Unit (TSU) for their contributions toKey populations program in the country and urged all partners towork closely with the TSU and accord them necessary support.Deputy Head NASCOP, Dr Peter Cherutich appreciated the workNASCOP was doing in terms of capacity building and advocacy inthe Key populations program. He further cautioned against theapproaches that activists are using in terms of addressing Keypopulations issues and recommended a more sober approach thatwill get things done and issues addressed without eroding gainsalready made.NASCOP is planning for a one day Key populations sensitizationmeeting with the governors to start this October 2013. This will inextension touch on all the HIV Programs implemented within thecounty level.Key populations partners meet to chart a wayforward in improving the quality of peereducation and outreach programsFrom August 6th – 8th, 2013, 30 participants representinggovernmental and non-governmental stakeholders gathered inNaivasha Kenya to design a Quality Assurance and QualityImprovement environment to support the implementation of thepeer-education and outreach (PEO) program standards and plan itsimplementation.The objectives of the PEO programs for Key Populations (KPs) are toreduce HIV risk behaviors and increase risk reduction behaviors toensure correct and consistent use of condoms, safe injecting anddisposal practices, and increase use of services, including HIVcounseling and testing, STI screening and treatment, and ART anddrug treatment for the Key Populations (KPs) they target.The “Quality Assurance for Peer-Outreach Programs for keyPopulations in Kenya” project is a centrally-funded project byCDC/Atlanta, and implemented by FHI 360 through a pass-throughsub-agreement with PATH/Kenya. The main counterpart in Kenya isNASCOP and its Technical Working Group (TWG) for KeyPopulations (KPs). The project aims to standardize PEO programsthrough a country-owned Quality Assurance (QA) and QualityImprovement (QI) strategy.The goal of the project is to improve the quality of the peereducationand outreach (PEO) components of programs targetingfemale and male sex workers in Kenya, leading to increasedcoverage of the target population and effectiveness of theseprograms.In the current phase of the project, eight mechanisms wereidentified to design and implement the standards. The 8mechanisms are all linked to each other:1. The communication of the standards to all PEO programs andpartners;2. The measurement of PEO program performance, using thequality assessment toolkit;3. The supervision of PEO programs;4. The use of QI models to address performance issues;5. The sharing of information across PEO programs andpartners;6. The recognition of PEO programs’ performance and QIactivities;7. The revision of standards; and8. The adoption of NASCOP standards by all partners andsponsors through harmonization and alignmentmechanisms.The percentage of adults who have everbeen tested for HIV in Kenya, has morethan doubled from 34% in 2007 to 72%in 2012KAIS 20125


UPDATES from NASCOPCondom use among female sex workershigh, but misconception surroundingHIV still exist, a survey in Nairobi revealsA baseline survey was conducted from February 4th to 12th,2013 to facilitate subsequent assessment of behavioural andstructural outcomes of the sex workers in Starehe area underNairobi Learning Site initiative.The survey was conducted using a group interview methodologyknown as polling booth survey (PBS). Polling booth survey is ananonymous and unlinked group interview methodology that hasbeen shown to reduce biases in reporting of sexual behaviour,common with face-to-face interviews and self-administeredquestionnaires. The survey was conducted among arepresentative sample of 420 female sex workers selectedthrough a cluster random sampling method to reflect different sexwork spot types, namely: Bars with lodges; Bars without lodges;Streets/highways/parks; Sex dens/strip clubs/night clubs,casinos and Hotels/ lodgings and guesthouses.ResultsThe results indicate that self-reported condom use at the last sexwas high, at nearly 90 per cent, among study participants.However, about 40 per cent of participants also reported to havehad sex without a condom at least once during the last one monthwith a paying client or at last sex with a regular partner. As to thereasons for inconsistent condom use, the most commonlyidentified was clients’ refusal to use a condom (36%). Otherreasons were being under the influence of alcohol (26%), clientspaying more for sex without a condom (23%) and condomunavailability (22%). About two-thirds (68%) of participants hadtaken an HIV test in the past three months, while about a third(35%) had been registered in anti-retroviral (ART) programmeswith 15 per cent of these currently being on ARV. About a third(31%) of the participants reported to be experiencing symptomsof an STI at the time of the survey while 15 per cent had receivedtreatment for STI in the past three months.There were high levels of misconception surrounding HIV withabout a quarter of respondents holding the view that one can tellthe HIV status of another person by merely looking at that person(or that a healthy looking person cannot have HIV), and 16 percent and 12 per cent, respectively, believing that use of condomscannot protect someone against HIV and HIV can be transmittedthrough mosquitoes. About 30 per cent of FSWs reported forcedsex in the past 6 months and 61 per cent reported violence andarrests from police and City Council askraris. About half of FSWswere members of an FSWs group and about half had visited theSWOP Clinic in the past three months.NASCOPs Harm Reduction Partners MeetingNASCOP and partners held a harm reduction partners meeting on 16th July2013 in Nairobi. The purpose of the meeting was to develop a commonunderstanding of the current coverage and range of ongoing harm reductioninterventions by available partners, in order to determine critical gaps.The MARPs Programme Manager Dr. George Githuka explained that althoughthe November 2012 Harm Reduction Partners meeting had given a generalidea of who was doing what, there was need for more specific details in termsof who’s doing what, where, with whom, and with how much resources inorder to guide future scale up efforts. He further informed partners that eventhough People Who Use Drugs (PWUDs) guidelines and Standard OperatingProcedures (SOPs) were signed by previous government officials sinceFebruary 2013, the formal launch was scheduled after the new interventionshad been initiated.The MARPs Programme Manager revealed that NASCOP was experiencingdelays in procurement of Methadone through the government system. “It isproving difficult to procure MAT through the Kenya Medical Supplies Agency(KEMSA) since there is no formal government document that authorizesMAT. An alternative means for procurement was being pursued throughCDC.” he stated.Mr. George Murimi of reported there were 65 drug dependence treatmentcentres in Kenya, 4 of which were in public health institutions -Mathare,CPGH, Port Reitz and MTRH - which caters for North Rift Valley, Western andNyanza regions. He stated that UNODC has supported the rehabilitation of themale drug rehabilitation facility at CPGH while NACADA was currentlyrehabilitating the female drug treatment facility. Despite these efforts, therewas disparity in facility coverage, as 30% were in Nairobi and 83.4% ofrespondents of a national survey of alcohol and drug dependence wereunaware of any drug treatment facilities.Dr. Richard Needle notified members that he was happy with Kenya’s positivesteps but urged members to move more rapidly like their neighboringcountry Tanzania which introduced MAT since 2010 while Kenya waspreparing to establish the first public MAT facility. Dr. Needle also informedparticipants that Tanzania was preparing to initiate take home doses as partof implementation science with PEPFAR support. Dr. Needle concluded byinforming participants that Tanzania’s secret for success was the President’spersonal commitment. Since the Global Fund for AIDs Tuberculosis andMalaria had made a special request to Kenya’s Permanent Secretary to scaleup Needle and Syringe Exchange Programme to cover 60% of PWID, helooked forward to a positive response.Taken together, results from this baseline survey point to the needto strengthen outreach and education among female sex workersfor their improved knowledge, access to condoms and access toand utilization of STI and other HIV prevention, treatment, careand support services. The results also highlight the importance oftackling violence as part of a comprehensive HIV interventionamong female sex workers.Another polling booth survey is currently going on in Starehe(MSWs) and Westlands (FSW and MSW) in Nairobi and among sexworkers in Mombasa.FSWs, MSMs and MSWs gathered at City Hall, Nairobiduring the International Day for sex workers6


NACC Developing an OverarchingKey populations Policy in KenyaKey Implementing Partnerswho work with FSWsProvincePartnerRiftValleyFAIRADAPTGold Star KenyaNeighbours in ActionNorth Star AllianceHOPE WorldWide KenyaFamily health options Kenya (FHOK)Kenya AIDs NGO Consortium (KANCO)Deutsche Stiftung Weltbevolkerung (DSW)Prof. Alloys Orago - NACC DirectorNACC recognizes that integral to strengthening HIV preventionand care for Key populations in Kenya is an overarchingsupportive KEY POPULATIONS policy framework to enhancecommitment and coordination of all Key populations serviceprovision to ensure access to high quality health for KEYPOPULATIONS. In November 2012, NACC established a Keypopulations Policy Development Taskforce that is mandated todevelop an overarching policy framework for Key populationsin Kenya. This committee includes NACC officials, GovernmentMinistries, NGOs, donors, female and male sex workers, femaleand male IDUs and MSM communities.Recognizing the many Key populations initiatives underway inKenya, NACC undertook a series of consultations with key Keypopulations stakeholders in order to articulate the Keypopulations key challenges. The issues identified wereintended to inform the Key populations Policy DevelopmentTaskforce in their policy considerations. There have since beenthree consultations with 33 organizations engaged with Keypopulations as well as government bodies, human rights andresearch organizations and Key populations umbrellaorganizations. A total of 115 Key populations communitymembers from across the country participated.The second Key populations Policy drafting retreat was held inNaivasha from 21st – 24th August 2013. The retreat which wasorganized by NACC with support from Futures Group andUniversity of Manitoba was to finalise the drafting of thenational policy for prevention of HIV among Most at RiskPopulations in Kenya.The meeting brought together representatives of the Keypopulations community who include the MSM, Transgender,FSWs and IDUs together with development partners.CoastNairobiNyanzaEasternCentralWesternInternational Centre for ReproductiveHealth Kenya (ICRH Kenya)Ananda Marga Universal Relief Team (AMURT)Solidarity With Women In Distress (SOLWODI)Teens WatchUniversity of Manitoba - SWOPBar HostessKICOSHEPImpact Research & DevelopmentOrganization (IRDO)International Medical Corps (IRDO)Keeping Alive Societies Hope (KASH)LVCTUniversity Of NairobiNOPE/ APHIAPLUS KAMILIHighway Resource CentreNorth Star AllianceUniversity Of NairobiNOPE/APHIAPLUS KAMILIBusia Survivors GroupAkukurunut Trust (ADT)Kenya AIDs NGO Consortium (KANCO)Action in Community Environment (ACE) AfricaKenya Long Distance Truck Drivers & AlliedWorkersKey Donor Partners Supporting FSW Programs in KenyaKenya has a rich history of key donors as partners to Government of Kenya led HIV prevention, treatment and care programming.Given the strong donor support, Government of Kenya has been able to scale up most of its programs, develop program policiesand interventions. Through this newsletter Government of Kenya appreciates their contribution to the reduction of the HIV and AIDS epidemic.The Donors are:PEPFAR through Centre for Disease Control (CDC)PEPFAR through United States Agency for International Development (USAID)UNAIDS/UNFPAWorld BankGlobal Fund for AIDS, Tuberculosis and MalariaElizabeth Glaser Pediatric AIDS Foundation (EGPAF)Bill and Melinda Gates Foundation (BMGF)7


FSW Population Size Estimates by ProvinceENational FSW Estimates(Total 133,675)WR.V.N.E.FSW size estimates for Kenya based on recent studies,routine program monitoring and IDU experts consensus.NCNCEasternPoint estimate 14,258Lower estimate 4,505Upper estimate 19,930NairobiPoint estimate 29,494Lower estimate 15,540ndUpper estimate 54,467Rift ValleyPoint estimate 21,929Lower estimate 18,524Upper estimate 28,892CoastPoint estimate 20,143Lower estimate 12,422Upper estimate 43,469CentralPoint estimate 12,271Lower estimate 4,360Upper estimate 16,210NorthEasternPoint estimate 2,039Lower estimate 660Upper estimate 2,488NyanzaPoint estimate 19,406Lower estimate 15,243Upper estimate 23,569WesternPoint estimate 14,135Lower estimate 5,400Upper estimate 19,686Compared with IDU and MSM, population size data for FSW in Kenyaare relatively plentiful. Still, sex work in Kenya is illegal and somewhatstigmatized, presenting challenges for estimating the size of thepopulation and conducting research. A recent study indicated HIVprevalence of 29.3% among FSW in the Nairobi (NASCOP, 2011).Consensus for upper, lower and point estimates were developed fromsize estimates and programmatic data for eight provinces: Central,Coastal, Eastern, Nairobi, North Eastern, Nyanza, Rift Valley, andWestern.The diagram above shows the size estimates and the percent of both totaland urban female population age 15-49 that they represent. The nationalestimate of FSW based on the consensus exercise was 133,675.The Table below shows the estimates for Kisumu, Mombasa and Nairobicentral business district (CBD). Among the three cities for which there werepopulation estimate data available. Mombasa had 7.6% of FSW among thefemale population aged 15-49 years while Kisumu has 1.6%. The percent ofFSW among adult females was not estimated for Nairobi CBD, since censusdata are not available for the same geographical area.FSW Population Size Estimates by CityGEOGRAPHICALAREAPOINTESTIMATELOWERESTIMATEUPPERESTIMATEPERCENTAGE OFTOTAL FEMALEPOP. 15-49 YRSKisumu City 2,524 1,578 4,854 1.6%Mombasa City 11,660 6,719 18,350 7.6%Nairobi CBD 6,834 5,230 8,296 ---8


Voices from the fieldMicro-planning is taking Peer-Education and Outreach Programs in Kenya a notch higherMicro planning in peer led outreach has enabled peer educators and outreach workers better manage their time and achieve optimum results. We spoke topeer educators and outreach workers in Nairobi and Nyanza regions who have given a testimony of how the micro planning training they have been undertakinghas helped improve their work.Caroline Sewe OpodiMy name is Caroline SeweOpodi. I am 34 years old and apeer educator at ImpactResearch and DevelopmentOrganization, Impact Researcha n d D e v e l o p m e n tOrganization, IRDO targetingfemale sex workers at thehotspots in River Yalla, ka-jack,kasamboi, kojwang and palosbar in Kisumu East.As a peer educator, I reach outto fellow sex workers in thementioned hotspots withsexual reproductive health information, safe sex practices andHIV/AIDS risk reduction information.I also promote the use of male and female condoms and waterbased lubricants and ensuring that they are able to use them well.Micro planning has helped me know the FSWs very well. I am ableto tell the number of partners they have in a day/week to give themthe right number of condoms through the use of the peer plans.Through the information given to my peers I’m able to distributethe consumables with a lot of ease without wastage unlike beforewhere I just distributed condoms to those who wanted. The peerplans has also enabled me to know at a glance the number ofcondoms and water based lubricants that I’m supposed to supplyat a particular hotspot to specific FSWs in a month since I coverdifferent hotspots. Furthermore, with the help of the microplanning tools that were developed by us through the support fromNASCOP, I have improved in the way I conduct my outreaches. Forinstance, the list of hotspots has helped me identify and map myarea of coverage and also understand my spots better by knowingboth the peak day and time for each spot and the average numberof FSWs in each hotspot. With that knowledge I am able to tell thepercentage of the FSWs I am reaching out to in a particular hotspot.I am also able to plan for my outreaches at a time when I’m able toget majority of the FSW. The tracking tool has also played a majorrole in assisting me track and follow up of my peers to the drop inCentre and maintain ongoing contact with them.I am Petronilla Nyambura, a Kenyan citizen and an active sex worker aswell as an Outreach Worker at the SWOP clinic in Nairobi. l support andsupervise the peer educators who are based at different hotspots (sites)through micro planning. These tools help me identify which peer issuitable to work at which site, checking on their outreach forms andcalendar to ensure that they give accurate reports on a weekly andmonthly basis, marketing the services provided by SWOP clinic andempowering all the sex workers and peer educators in the field.I train peer educators on how to be good role models and proper planningof their work at designated hotspots, facilitate capacity building, ensureaccurate reporting, principles of management and instilling disciplinethrough leadership skills. I also motivate them into being moreknowledgeable and involve them in decision making and visiting them onregular basis at their hotspot.I motivate the peer educators by assisting them to assess, decide, plan, act,and continue (KADPAC) so they can feel better about themselves and thusthey become more independent, have more self-confidence and teachthem on negotiation skills. I teach communication skills, practice low riskbehavior and always practice safe sex and most importantly use condomscorrectly every time they have sexual intercourse.MICRO PLANNING: Micro means the small unit, could be a hotspot or anindividual in the hotspot. The micro planning helps an outreach workerand peer educator to reach to the sex worker at their hotspots.We have adopted 5 tools of micro planning: They are Site Load Mapping,Site Analysis, Contact Listing, Peer Plan and Gap Analysis. Micro planninghas been and will continue to be the best method to adopt in reaching outto many out there; it has helped us to be orderly, that is: Work right toachieve a lot in a very short time. To sum it up, Micro Planning has helpedme to plan what l need to do, see what l have done, and improve my work.Challenges: We face many challenges in our work notably; harassment byCity Council askaris and the police, hostility by some bar workers,managers, watchmen and the SWs, violence and insecurity such as beingmugged at night, lack of cash to buy something for myself and my PE attheir hotspots, poor mobility – transport from one hotspot to anotherincluding airtime.Some of the challenges I faced while using the micro planning toolsis that when a peer migrates to another hotspot tracking becomesdifficult in that it needs referral to another peer educator whichsome of my peers are not comfortable with.Since the micro planning tools were new to me they werechallenging to use but with the assistant from the NASCOP teamand the IRDO field staff I now understand them better and I havethe confidence to educate fellow peer educators on how to usethem.Microplanning is a process that de-centralises outreachmanagement and planning to grass-roots - level workers,outreach workers and peer educators - and allows them tomake decisicons on how to best reach the maximum numberof community members with programs and services.Petronilla training her peer educators at the Drop in centre9


Paralegals making a differencein the lives of Coastal residentsChild prostitution thrives on Kenya's Coastland with Mombasaquickly gaining the dubious reputation as sex tourism. Soserious is the problem of child prostitution that a specialsecurity team has been formed to fight the vice in the region.International Centre for Reproductive Health Kenya is trainingparalegals at the Coast to help curb this vice among other legalaid they offer to residents. We speak to a paralegal who recentlyrescued a 12 year old girl who was defiled. He recounts thedisturbing story in his own words.On the 14th day of July 2012 at around noon RoseGwada,Joshua Mwaega and I, were approached by a primaryschool teacher from Shimo la Tewa who hinted on a 12 year oldgirl at the school , a minor who was being violated by amzungu,(white man) a 59 year old Belgian National, in Shanzuarea. I quickly called the media and the Officer CommandingStation (OCS) Bamburi Police station and headed to thesuspects house since it was noted that the girl usually visitedthe house from Friday evening through to Sunday evening or attimes until Monday morning. At the gate, we were met with thegateman and after some interrogation; he showed us thesuspect’s house. We went in and unfortunately the minor hadjust left a while ago. We tried searching for any evidence likephotos on the laptop and videos that could prove our case. Wefound evidence but the Officer in Charge of the Station, declinedon taking this evidence to the station citing various reasons.The OCS then ordered us to leave the place. We left the offender,the Belgian National at the house. On our way out, we tried topersuade the OCS to get the minor from her residential areawhich was just a walking distance from where we were but hedeclined. He told me he will send for the mother the followingday.That night I consulted my fellow paralegal from the ICRHKYouth Centre Joshua Mwaega, who resides in Shanzu. Wedecided to go against the OCS’s wishes because we had thechild’s best interests as cited in article 53 of the Constitution ofKenya (COK 2010). We went to the school and explained to thehead teacher and the class teacher what we intended to doabout this matter and they were in agreement that it bepursued further. We took the girl and her cousin to the Bamburipolice station and reported the matter afresh at the occurrencebook then to the Gender Desk. We then proceeded to the CoastGeneral Gender Based Recovery Centre (GBVRC) run by ICRHKin collaboration with the Ministry of Health for MedicalExamination. Luckily, the girl had not contracted any viralinfection.The following day the OCS, media people and 3 police officersaccompanied me to the suspect’s house where he was arrested. Ireceived a phone call from the Provincial Police Officer telling me notto take the case to court and he asked me a lot of intimidatingquestions. The tourism department OCS also tried to intimidate mesaying I should not involve the media next time in any way or else theywill not work with me. I would later receive phone calls from strangepeople threatening me. I almost gave up but I asked God for guidanceand this rejuvenated me to continue. I was determined to reach mygoal which was JUSTICE TO PREVAIL AMONGST ALL regardless ofage, status, race color, origin.I took the matter to court as the complainant and the suspect wasreleased on bond of Ksh 1,000,000 with a surety of the same amount.He requested the court to reduce the bond on grounds that he wasdiabetic and that his sugar levels had shot up. His bond was reducedto Ksh 500,000 with a surety of the same amount. After all thewitnesses had testified ,including the Government Doctor,Investigating officer, the violated minor and myself, the magistrate atShanzu Law Courts found that he the accused had a case to answer.We are awaiting the next hearing date set for the end of this monthwhere the accused is set to bring his witnesses and defend himself aswe await the court’s ruling.From the left to right: Rose Gwada, Millicent Okello and MarilyneLaini who are paralegals trained by ICRHK.Thereafter, we proceeded to the Kisauni Children’s Office inFrere town area but unfortunately it was locked. I had to act fastsince it was illegal to take custody of the child without consentfrom the relevant authorities. We went to the OCS andexplained our case and he took the initiative to provide us witha stamped document stating that I could have custody of thechild overnight then take her to the children’s office thefollowing day. The officer secured a children’s home in Nyaliarea for her and her other 4 younger siblings, where she is todate. Later on I went to Coast Provincial General Hospital(CPGH) where I took her for age assessment then later toBamburi police station to record statements.The definition of a paralegal is a persontrained in legal matters, who performsroutine tasks requiring some knowledgeof the law and procedures.10


Q and ACoalition for sex workers in Kenya : A discussion withPhelister Country Coordinator: KESWAPhelister AbdallaAbout KESWA: The Kenya Sex WorkersAlliance (KESWA) is a coalition led by maleand female sex workers led groups,organizations and individuals. The Kenya SexWorkers Alliance was formed in 2010 afterthe establishment of the African Sex WorkersAlliance (ASWA) which was founded in 2009at the first ever African Sex Workerconference brought together over 200 sexworkers held in Johannesburg.The conference brought together over 200 sex workers from 10African countries. KESWA became the first operational countrycoalition proceeded by South Africa, Uganda, Zimbabwe, Botswana,Mozambique, Namibia and Nigeria.KESWA mission and partners: Our mission is to contribute toimproved Human Rights status of all Sex Workers by designing andimplementing innovative, evidence-based and cost-effectiveadvocacy campaigns capable of influencing public policy and practicein the field of human rights. KESWA is now comprised of more than 30organizations, varying form health to human rights organizations,women's rights groups, donors, government institutions, LGBTIgroups etc.Future of community mobilization and organization: First, wemake the sex workers know that they are human beings and haverights and entitlements just like anyone else. We make the communitycome out and form their own community led groups and explain tothem how they will benefit in their own groups. Through communitymobilisations sex work groups have been able to grow as more andmore sex workers are coming out to form their own groups just likeHOYMAS which is a male sex workers organization. We capacity buildthem and show them the benefits of being together.”Q: Challenges Yes. Some community members are skeptical aboutorganizing since sex workers are a hidden community but with timeas we move on and as more sex workers go out and talk about theirissues the scared ones get courage to come out and also voice theirissues.“As KESWA we come out and say we know our rights and entitlementsas sex workers and demanding our right to fair treatment just likeanybody else.” We make sex workers who are still not empowered toknow that they have to begin by accepting themselves first beforeeveryone else accepts them.KESWA influence on MARPs programming in Kenya: As sexworkers we understand that such programs are for us and we mustparticipate in them. We say: “nothing for us without us.”As a national movement for the community we speak for the wholecommunity. “We tell NASCOP and partners that the entry point to thecommunity is through the movement (KESWA) and we should havethe full information about the programme or project because if we donot have an idea about it then the community will not participate andwho will you be doing this for?”We ensure that before you do anything with the community you mustsensitise them. As KESWA we have been fighting for communityinvolvement in the MARPs programme . “You can just be doing anddeciding everything for us. Let us be involved in issues that affect usand make you understand our needs.|”Community involvement is key in MARPs programming.Creating Safe Spaces for sex workers in Kenya: A discussionwith Penina: Executive Director Bar Hostess Empowermentand Support ProgramQ: Why did you start working on violenceagainst female sex workers?We started BHESP because there was so muchviolence meted on sex workers and barhostesses by bar owners, patrons, manager,police and city council. In Kenya most sexworkers are venue based and are found in thebars. In addition, HIV was high in the bars andmany bar hostesses and sex workers weredying at the time.Penina MwangiIn addition, HIV was high in the bars and many bar hostesses and form acommunity based organisation (CBO) which was registered in 1998 to fightfor the rights of sex workers and bar hostesses. The organisation has sincegrown.Q: How do you address violence?We use a multi-pronged approach realising very well that sex work is ahighly stigmatised occupation within the Kenyan cultural milieu. Culturalattitudes towards sex work and sex workers are predominantly negativeand conservative. Our biggest problem has been violence towards sexworkers directed by the police, city council guards mostly, and by pimpswho are like brokers, bar managers, security guards and clients.Under the Kenyan law Sex work is categorised as an offence against morals,a threat to the moral fabric of society and a nuisance. In Kenya any womanfound out late at night, or walking along certain streets or wearing shortand/or revealing clothes will be arrested and charged with “prostitution.They are normally charged with loitering with the intention of committingprostitution.We have been involved in advocacy work and have recruited two advocacyofficers to be on standby 24 hours to respond to any violence report fromthe sex workers. The Advocacy Officer attached to the Learning Site inNairobi has been working with sex workers around the clock to mitigatethis violence. She is on call twenty four hours to respond to distress callsfrom sex workers and intervenes when a client refuses to pay sex workersand goes to the police stations to bail out sex workers who are arrested . “Wetell the sex workers not to be bribe the police or city council and instead askto be taken to court. We tell them to deny the charges in court and let thepolice prove that they were doing prostitution. Mostly the sex workers whoare put in custody are released after our intervention because the policehave no evidence to show that they are prostitutes. We have made someachievement on this as we have never lost any case. We have so far won fivecases and 28 others are still on trial. The point we want to pass across is thatsex workers rights must be protected. Police have no right to arrest sexworkers at will and extort money/bribes from them all the time.” She notes.However, the biggest challenge is that most sex workers prefer to bribepolice men and city council soldiers to avoid long and tedious court battlesand have their identities revealed.We also do sensitisation training for police and city council staff regardingSW, human rights and public health and the importance and cover theimportance of protecting SWs from client or public officer violence. In thesefora, the police tell us the problems they face with sex workers and we tellthem the problems we have with them.Q: Who funds this programme?Open Society Institute (OSI), Global Fund, National AIDSids Control Council(NACC) through Total War against Aids (TOWA), USAID, World Bank, Billand Melinda Gates Foundation.Q: What are your plans for the future?We plan to lobby for decriminalization of sex work, build stronger networksand to work towards zero HIV infection of female sex workers.11


MINISTRY OF HEALTHTHE WORLD BANKAdvisory TeamDr William Maina - Head NASCOPDr George Githuka - Program Manager, MARPsJohn Anthony - Head, NASCOP Technical Support Unit (TSU)Phelister Abdalla - Country Coordinator, KESWAPenina Mwangi - Executive Director, BHESPEditorial TeamEditors: Redemtor Atieno - Technical Officer Advocacy andCommunications NASCOP TSU and Steven AdalaDesign and Layout: Steven Adala - Communications Officer, NASCOPand Redemtor AtienoContributorsParinita Bhattacharjee Willis Odek Memory Melon Rose Gwada Millicent Okello Marilyne LainiJohn Anthony Caroline Sewe Opodi Dr George Githuka Margaret Njiraini Janet Musimbi Petronilla NyamburaBernard EdieduShem KaosaFor more information, contact us at:National AIDS & STI Control Programme (NASCOP)Kenyatta National Hospital Grounds P. O. Box 19361 - 00200, Nairobi, Kenya Tel: +254 (20) 2729502 E-mail: info@nascop.or.ke Website: www. nascop.or.ke

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