Search

Problem Comprehensive service delivery models for providing post-rape care are largely from resource-rich countries and do not translate easily to resource-limited settings such as Kenya, despite an identified need and high rates of sexual violence and HIV. Approach Starting in 2002, we undertook to work through existing governmental structures to establish and sustain health sector services for survivors of sexual violence. Local setting In 2003 there was a lack of policy, coordination and service delivery mechanisms for post-rape care services in Kenya. Post-exposure prophylaxis against HIV infection was not offered. Relevant changes A standard of care and a simple post-rape care systems algorithm were designed. A counselling protocol was developed. Targeted training that was knowledge-, skills- and values-based was provided to clinicians, laboratory personnel and trauma counsellors. The standard of care included clinical evaluation and documentation, clinical management, counselling and referral mechanisms. Between early 2004 and the end of 2007, a total of 784 survivors were seen in the three centres at an average cost of US$ 27, with numbers increasing each year. Almost half (43%) of these were children less than 15 years of age. Lessons learned This paper describes how multisectoral teams at district level in Kenya agreed that they would provide post-exposure prophylaxis, physical examination, sexually transmitted infection and pregnancy prevention services. These services were provided at casualty departments as well as through voluntary HIV counselling and testing sites. The paper outlines which considerations they took into account, who accessed the services and how the lessons learned were translated into national policy and the scale-up of post-rape care services through the key involvement of the Division of Reproductive Health. [ABSTRACT FROM AUTHOR]

Summary: The rapid expansion of voluntary counselling and testing (VCT) for HIV in sub-Saharan Africa has led to concerns over the quality and equity of the services. Kenya has seen an unprecedented scale-up of VCT, and valuable lessons have been learnt at national as well as at district and community levels. We combined quantitative and qualitative research methodology and showed how the results of gender analysis can be used to develop equity in VCT scale-up. A gender-disaggregated analysis of VCT client data was conducted for the first 8 months of 2003. These quantitative data revealed that despite an increased vulnerability to HIV, women are underrepresented in VCT sites in all settings in Kenya. Our data also showed that women were also less likely to use condoms or to take home condoms after a VCT visit than their male counterparts. Further exploration through in-depth qualitative work with women and men allowed a better understanding of the reasons behind gender differences in Kenyan VCT sites and helped to develop strategies to address gender inequity. We conclude that there is an ongoing need to mainstream gender in monitoring and evaluation strategies to ensure services meet the needs and priorities of all groups. [Copyright &y& Elsevier]

In Kenya many people who have been affected by sexual violence turn to the health sector for clinical treatment and preventive therapies. This interface provides a vital opportunity to impact on the dual epidemics of HIV and sexual violence. Despite this, the uptake of post-rape care services in health facilities as low and health care providers felt ill-prepared to deal with the consequences of sexual violence. A qualitative study was conducted to better understand the reasons for the low uptake of services and to establish perceptions of sexual violence in Kenya. Thirty-four key informants were interviewed and sixteen focus group discussions with women and men were held in three districts in Kenya. Blurred boundaries between forced and consensual sex emerged. Important implications for the delivery of HIV post exposure prophylaxis (PEP) after sexual violence include the need for gender-aware patient-centred training for health providers and for HIV PEP interventions to strengthen on-going HIV-prevention counselling efforts. Further research needs to determine the feasibility of on-going risk reduction measures in the context of PEP delivery. [ABSTRACT FROM AUTHOR]

Background: The noncommunicable disease (NCD) burden in Kenya is not well characterized, despite estimates needed to identify future health priorities. We aimed to quantify current and future NCD burden in Kenya by human immunodeficiency virus (HIV) status., Methods: Original systematic reviews and meta-analyses of prevalence/incidence of cardiovascular disease (CVD), chronic kidney disease, depression, diabetes, high total cholesterol, hypertension, human papillomavirus infection, and related precancerous stages in Kenya were carried out. An individual-based model was developed, simulating births, deaths, HIV disease and treatment, aforementioned NCDs, and cancers. The model was parameterized using systematic reviews and epidemiological national and regional surveillance data. NCD burden was quantified for 2018-2035 by HIV status among adults., Results: Systematic reviews identified prevalence/incidence data for each NCD except ischemic heart disease. The model estimates that 51% of Kenyan adults currently suffer from ≥1 NCD, with a higher burden in people living with HIV (PLWH) compared to persons not living with HIV (62% vs 51%), driven by their higher age profile and partly by HIV-related risk for NCDs. Hypertension and high total cholesterol are the main NCD drivers (adult prevalence of 20.5% [5.3 million] and 9.0% [2.3 million]), with CVD and cancers the main causes of death. The burden is projected to increase by 2035 (56% in persons not living with HIV; 71% in PLWH), with population growth doubling the number of people needing services (15.4 million to 28.1 million) by 2035., Conclusions: NCD services will need to be expanded in Kenya. Guidelines in Kenya already support provision of these among both the general and populations living with HIV; however, coverage remains low., (© The Author(s) 2019. Published by Oxford University Press for the Infectious Diseases Society of America.)

Introduction: Integrating services for non-communicable diseases (NCDs) into existing primary care platforms such as HIV programmes has been recommended as a way of strengthening health systems, reducing redundancies and leveraging existing systems to rapidly scale-up underdeveloped programmes. Mathematical modelling provides a powerful tool to address questions around priorities, optimization and implementation of such programmes. In this study, we examine the case for NCD-HIV integration, use Kenya as a case-study to highlight how modelling has supported wider policy formulation and decision-making in healthcare and to collate stakeholders' recommendations on use of models for NCD-HIV integration decision-making., Discussion: Across Africa, NCDs are increasingly posing challenges for health systems, which historically focused on the care of acute and infectious conditions. Pilot programmes using integrated care services have generated advantages for both provider and user, been cost-effective, practical and achieve rapid coverage scale-up. The shared chronic nature of NCDs and HIV means that many operational approaches and infrastructure developed for HIV programmes apply to NCDs, suggesting this to be a cost-effective and sustainable policy option for countries with large HIV programmes and small, un-resourced NCD programmes. However, the vertical nature of current disease programmes, policy financing and operations operate as barriers to NCD-HIV integration. Modelling has successfully been used to inform health decision-making across a number of disease areas and in a number of ways. Examples from Kenya include (i) estimating current and future disease burden to set priorities for public health interventions, (ii) forecasting the requisite investments by government, (iii) comparing the impact of different integration approaches, (iv) performing cost-benefit analysis for integration and (v) evaluating health system capacity needs., Conclusions: Modelling can and should play an integral part in the decision-making processes for health in general and NCD-HIV integration specifically. It is especially useful where little data is available. The successful use of modelling to inform decision-making will depend on several factors including policy makers' comfort with and understanding of models and their uncertainties, modellers understanding of national priorities, funding opportunities and building local modelling capacity to ensure sustainability., (© 2020 The Authors. Journal of the International AIDS Society published by John Wiley & Sons Ltd on behalf of the International AIDS Society.)

Introduction: We aimed to quantify health outcomes and programmatic implications of scaling up cervical cancer (CC) screening and treatment options for women living with HIV in care aged 18-65 in Kenya., Methods: Mathematical model comparing from 2020 to 2040: (1) visual inspection with acetic acid (VIA) and cryotherapy (Cryo); (2) VIA and Cryo or loop excision electrical procedure (LEEP), as indicated; (3) human papillomavirus (HPV)-DNA testing and Cryo or LEEP; and (4) enhanced screening technologies (either same-day HPV-DNA testing or digitally enhanced VIA) and Cryo or LEEP. Outcomes measured were annual number of CC cases, deaths, screening and treatment interventions, and engaged in care (numbers screened, treated and cured) and five yearly age-standardised incidence., Results: All options will reduce CC cases and deaths compared with no scale-up. Options 1-3 will perform similarly, averting approximately 28 000 (33%) CC cases and 7700 (27%) deaths. That is, VIA screening would yield minimal losses to follow-up (LTFU). Conversely, LTFU associated with HPV-DNA testing will yield a lower care engagement, despite better diagnostic performance. In contrast, option 4 would maximise health outcomes, averting 43 200 (50%) CC cases and 11 800 (40%) deaths, given greater care engagement. Yearly rescreening with either option will impose a substantial burden on the health system, which could be reduced by spacing out frequency to three yearly without undermining health gains., Conclusions: Beyond the specific choice of technologies to scale up, efficiently using available options will drive programmatic success. Addressing practical constraints around diagnostics' performance and LTFU will be key to effectively avert CC cases and deaths., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: The MSM population in Kenya contributes to 15% of HIV incidence. This calls for innovative HIV prevention interventions. Pre-exposure prophylaxis (PrEP) has been efficacious in preventing HIV among MSM in trials. There is limited data on the willingness to take daily oral PrEP in sub-Sahara Africa. PrEP has not been approved for routine use in most countries globally. This study aimed to document the willingness to take PrEP and barriers to uptake and adherence to PrEP in Kenya. The findings will inform the design of a PrEP delivery program as part of the routine HIV combination prevention., Methods: Eighty MSM were recruited in 2 Counties in December 2013. Quantitative data on sexual behaviour and willingness to take PrEP were collected using semi-structured interviews and analysed using SPSS. Qualitative data on knowledge of PrEP, motivators and barriers to uptake and adherence to PrEP were collected using in-depth interviews and FGDs and analysed using Nvivo. Analysis of data in willingness to take PrEP was conducted on the HIV negative participants (n = 55)., Results: 83% of MSM were willing to take daily oral HIV PrEP. Willingness to take PrEP was higher among the bi-sexual and younger men. Motivators for taking PrEP were the need to stay HIV negative and to protect their partners. History of poor medication adherence, fear of side effects and HIV stigma were identified as potential barriers to adherence. Participants were willing to buy PrEP at a subsidized price., Conclusions: There is willingness to take PrEP among MSM in Kenya and there is need to invest in targeted education and messaging on PrEP to enhance adherence, proper use and reduce stigma in the general population and among policy makers.

Background: Epidemiological data show substantial variation in the risk of HIV infection between communities within African countries. We hypothesised that focusing appropriate interventions on geographies and key populations at high risk of HIV infection could improve the effect of investments in the HIV response., Methods: With use of Kenya as a case study, we developed a mathematical model that described the spatiotemporal evolution of the HIV epidemic and that incorporated the demographic, behavioural, and programmatic differences across subnational units. Modelled interventions (male circumcision, behaviour change communication, early antiretoviral therapy, and pre-exposure prophylaxis) could be provided to different population groups according to their risk behaviours or their location. For a given national budget, we compared the effect of a uniform intervention strategy, in which the same complement of interventions is provided across the country, with a focused strategy that tailors the set of interventions and amount of resources allocated to the local epidemiological conditions., Findings: A uniformly distributed combination of HIV prevention interventions could reduce the total number of new HIV infections by 40% during a 15-year period. With no additional spending, this effect could be increased by 14% during the 15 years-almost 100,000 extra infections, and result in 33% fewer new HIV infections occurring every year by the end of the period if the focused approach is used to tailor resource allocation to reflect patterns in local epidemiology. The cumulative difference in new infections during the 15-year projection period depends on total budget and costs of interventions, and could be as great as 150,000 (a cumulative difference as great as 22%) under different assumptions about the unit costs of intervention., Interpretation: The focused approach achieves greater effect than the uniform approach despite exactly the same investment. Through prioritisation of the people and locations at greatest risk of infection, and adaption of the interventions to reflect the local epidemiological context, the focused approach could substantially increase the efficiency and effectiveness of investments in HIV prevention., Funding: The Bill & Melinda Gates Foundation and UNAIDS., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

While much discussion has been devoted to defining the standards of care required when offering services to survivors of sexual violence, much less attention has been given to procedures for evidence collection to allow the successful prosecution of perpetrators. In Kenya there are no comprehensive guidelines that outline the roles of the survivor, the community, health care workers, and the police with regard to the handling of forensic evidence, a deficit that contributes to delays in prosecuting, or even a failure to prosecute sex offenders. This study examines some of the obstacles in Kenya to the adequate handling of forensic evidence in sexual violence cases. It was based on in-depth interviews with respondents drawn from health facilities, police stations, civil society organizations and with the Government Chemist in three Kenyan provinces. The study's objective was to examine the existing policy requirements regarding the maintenance of an evidence chain by the health and criminal justice systems, and how effectively they are being implemented. The findings indicate that the quality of the evidence obtained by the health care workers was often deficient, depending on the time elapsed before the rape survivor reports to the health facility; the equipment available at the health facility; the age of the survivor; and the level of knowledge of the service provider regarding the types of evidence to be collected from survivors of sexual violence., (Copyright © 2011 Elsevier Ltd and Faculty of Forensic and Legal Medicine. All rights reserved.)

The rapid scale-up of HIV counselling and testing programmes in Kenya has led to quality concerns, including the potential for abuse within the private, confidential setting of client-initiated voluntary counselling and testing (VCT). A qualitative study was conducted in three provinces of Kenya, involving 26 VCT service providers and 13 key informants. First and second hand accounts of emotional, physical and sexual abuse emerged in all three study sites in spite of measures to mitigate such occurrences. Whilst uncommon, abuse was perceived by service providers to be serious and sufficiently widespread to raise significant concerns. Abuse occurred client to counsellor, from counsellor to client and from counsellor to counsellor. In all cases the person suffering the abuse was female. While the potential for abuse was demonstrated in VCT sites, we argue that experiences of abuse are not confined to VCT and are largely shaped by gender and power relations within the Kenyan cultural context. The international impetus for scale-up of HIV services provides an urgent rationale for the need to address and highlight these difficult issues at multiple levels. International guidelines, policy and methods need adapting in recognition of the potential for abuse. Systems for investigating and deregistering counsellors have been developed in Kenya but require formalizing. Institutions providing VCT should consider unlocked doors, semi-opaque windows and the use of 'mystery clients' as a quality assurance measure.

Promotion of male condoms and voluntary counselling and testing for HIV (VCT) have been cornerstones of Kenya's fight against the HIV epidemic. This paper argues that there is an urgent need to promote the female condom in Kenya through VCT centres, which are rapidly being scaled-up across the country and are reaching increasingly large numbers of people. Training of counsellors using a vaginal demonstration model is needed, as well an adequate supply of free female condoms. In a study in five VCT centres, however, counsellors reported that most people they counselled believed female condoms were "not as good" as male condoms. In fact, many clients had little or no knowledge or experience of female condoms. Counsellors' knowledge too was largely based on hearsay; most felt constrained by lack of experience and had many doubts about female condoms, which need addressing. Additional areas that require attention in training include how to re-use female condoms and the value of female condoms for contraception. VCT counsellors in Kenya already promote male condoms as a routine part of risk reduction counselling alongside HIV testing. This cadre, trained in client-centred approaches, has the potential to champion female condoms as well, to better support the right to a healthy and safe sex life.

While the concept of gender mainstreaming has gained acceptance among many national and international development organizations, many obstacles are faced in translating the concept into tangible improvements in the health and well-being of women and men. This paper presents two qualitative case studies, one from Kenya and one from Uganda, of experiences of mainstreaming gender at district level; experiences which are set against the context of decentralization and sector-wide approaches (SWAPs). The conceptual framework of social movement theory, as used by Hafner-Burton and Pollack, is drawn upon to analyze the findings of both case studies. This paper has been written in conjunction with a paper by Theobald et al. which explores gender mainstreaming at national level.