First Kenya Women’s HIV Prevention Symposium August 31 - 1 September, 2010
First Kenya Women’s HIV Prevention Symposium Making HIV Prevention Responsive to Women’s Needs August 31st- 1st September, 2010 Panari Hotel, Nairobi 1 Table of Contents Executive summary ................................................................................................................................. 5 Introduction ............................................................................................................................................. 6 Symposium outcomes and Objectives .................................................................................................... 6 Methodology ........................................................................................................................................... 6 Linking women HIV prevention to the new Constitution ........................................................................ 7 Women and Girls Vulnerability to HIV ................................................................................................... 8 National HIV response: Policy and Programs ......................................................................................... 9 International and Regional Frameworks Guiding HIV Prevention for Women ....................................... 9 Gaps in women and HIV prevention .....................................................................................................10 Gaps in STI Detection and treatment-PEP/PRC ..................................................................................... 10 Gaps in prevention strategies................................................................................................................ 11 Role of research in prevention among women ..................................................................................... 13 Women’s meaningful involvement in research-ethical considerations................................................ 14 Kenya HIV and AIDS research strategy-Does it work for women? ........................................................ 14 Priority research issues that contribute to better planning for women in the context of HIV ............. 15 Emerging prevention tools for women .................................................................................................15 Pre-Exposure prophylaxis (PrEP) ........................................................................................................... 16 Vaccines ................................................................................................................................................. 17 New HIV technologies, what are the implications for women? ............................................................ 17 Group work............................................................................................................................................ 18 Towards a gender responsive research agenda: What are the different categories of women? ........19 Recommendations.................................................................................................................................19 Proposal for research agenda………. ......................................................................................................19 Proposal for women’s prevention priorities ......................................................................................... 20 Key recommendations for Symposium .................................................................................................20 Conclusion and way forward ................................................................................................................. 23 Annexes ................................................................................................................................................. 25 2 List of Acronyms AAK AIDS ART CACC CEDAW CHIVPR CSO FGM GBV GCM GIPA GTC HIV ICC JAPR KAIS KANCO KNASP III LGBT LVCT M&E MARPS MTEF NACC NASCOP NGO PHDP PLHIV PrEP PwD STIs SWAK UNAIDS UNDP UNIFEM VCT Action Aid Kenya Acquired Immune Deficiency Syndrome Antiretroviral Therapy Constituency AIDS Control Committee Convention on the elimination of all forms of Discrimination against Women Centre for HIV Prevention and Research/ University of Nairobi Civil Society Organizations Female Genital Mutilation Gender Based Violence Global Campaign for Microbicides Greater Involvement of People Living with HIV and AIDS Gender Technical sub-committee Human immune-deficiency virus Inter-agency Coordinating Committee Joint Annual HIV and AIDS Programme Review Kenya AIDS Indicator Survey Kenya AIDS NGOs Consortium Kenya National HIV and AIDS Strategic Plan Lesbian, gay, bisexual, and transgender Liverpool VCT, Care and Treatment Monitoring & Evaluation Most at Risk Populations Medium Term Expenditure Framework National AIDS Control Council National AIDS and STI Control Programme Non Governmental Organizations Positive, Health, Dignity and Prevention People Living with HIV Pre-Exposure Prophylaxis Persons with Disabilities Sexually Transmitted Infections Society for Women and AIDS in Kenya The joint United Nations Program on HIV &AIDS United Nations Development Program United Nations Development Fund for Women Voluntary Counselling and Testing 3 Acknowledgements The Kenya Women’s Symposium was organized under the auspices of the National AIDS Control Council (NACC)and the Global Campaign for Microbicides (GCM). The conference would not have been possible without the financial contribution of the following co-sponsors: the National AIDS Control Council (NACC); International Partnership for Microbicides; UNIFEM; UNAIDS; UNDP; KANCO; Liverpool VCT, Care and Treatment; Action Aid Kenya; and UNFPA. The symposium was organized under the Gender Technical Committee (GTC) whose leadership is provided by the Head of the Stakeholder Coordination Division at NACC, Harriet Kongin. A task team for its development and delivery included: Pauline Irungu (Chair Taskforce - GCM), Eunice Odongi (Secretary, GTC), Dr. Nduku Kilonzo (LVCT), Anne Mumbi (KANCO), Prof. Elizabeth Ngugi (CHIVPR/UoN, SWAK, KVORC), Ruth Masha (UNAIDS), Sari Seppanen (UNAIDS), Pascaline Kang’ethe and Lucy Wanjiku (AAK), Ursula Sore-Bahati (UNIFEM),Lucy Ghati (NEPHAK), Renaldah Mjomba (VSO), Ludfine Anyango (UNDP), Wafula Wanjala (Coexist Initiative)and Rukia Yassin (GTZ Health Sector Programme), Rehab Mwaniki (NEPHAK), and Rosemary Mburu (KANCO). We further acknowledge the contributions of all participants, chief guests, speakers and presenters, session chairpersons, panelists, parallel sessions group leaders and rapporteurs; the full list is annexed to this report. 4 Executive Summary The National AIDS Control Council in partnership with Global Campaign for Microbicides and with support from Action Aid Kenya, Kenya AIDS NGOs Consortium (KANCO), Liverpool VCT, the joint UN team (UNDP, UNAIDS, UNIFEM, UNFPA), German Agency for Technical Cooperation (GTZ), and Centre for HIV Prevention and Research of the University of Nairobi (CHIVPR cohosted the First Kenya Women’s HIV Prevention Symposium from 31 August to 1 September 2010 at the Panari Hotel, Nairobi. The aim of the Symposium was to explore in-depth the HIV prevention needs for women. The Symposium provided an opportunity for HIV service organizations, women, men, PLHIV, Faith organizations, policy makers and HIV researchers to evaluate the current programming approaches and identify what needs to be done to make them more responsive to women’s needs. The Symposium also offered a platform for identifying what needs to be done to develop an HIV prevention research agenda that addresses the real-life needs of women. Objectives of the symposium The Symposium objectives were to: (1) explore HIV prevention needs for women; (2) identify priorities for women’s HIV prevention in current response (based on the Kenya National HIV/AIDS Strategic Plan III priorities); (3) and identify research gaps to fill to better inform HIVprevention interventions. Key recommendations (Priority research and prevention areas) Kenya has put in place HIV-prevention policies and guidelines, but these must be urgently implemented and monitored to track their impact. Proposal for research agenda The following priorities were identified for Kenya Women’s prevention research agenda: Translation of policy and research into practice; Community based research: Formative, community-based, social, behavioral and operational research; Exploration of gender issues/ dynamics that impact on sexual relations; Disclosure among couples; Alignment of current research to KNASP III indices and Resource tracking. Proposals for women’s prevention priorities: The following key prevention priorities were identified: Political Commitment; Meaningful participation by women living with HIV; Capacity building and relevance to KNASP III; Prioritize gender issues as recommended by KNASP III and factor in opportunities provided by the new constitution; Strengthening coordination and linkages;Reconstitute, strengthen the GTC and align it with KNASP III; Program development; Prevention, diagnosis, treatment, and care programs; Services that are responsive to women and Equitable resource allocation: The outcomes of the Kenya Women’s HIV Prevention Symposium will inform key national HIVprevention planning processes, including the National HIV Prevention Summit and the Joint AIDS Programme Review (JAPR)—both being held before the end of 2010. Partners pledged to fully support implementation of the recommendations arising from Symposium. 5 1.0 Introduction The Kenya AIDS Indicator Survey Report 2007 affirms the reality that HIV affects women disproportionately. For people aged 15-55 years, the national prevalence rate for women was 8.4%, compared to 5.4% for men.1 Vulnerability to HIV infection among women is driven by gender inequalities and exclusions that are experienced differently by various categories of women based on age, socio-economic status, marital status, geographical location, and occupation, among others.HIV risk is also a result of multifaceted, context-specific interacting factors operating at policy and service-delivery levels, as well as the socio-cultural realities in the lives of women. The Symposium provided an opportunity for grassroots organisations, civil society, policy makers, researchers, academics, and representatives of medical associations, funding agencies and the UN joint team to discuss factors that heighten women’s vulnerability to HIV. Participants identified key women’s needs and made recommendations for prioritisation in prevention and research agenda for women that require urgent action to turn the epidemic around. Symposium outcomes The Symposium outcomes were to inform key national HIV prevention planning processes including the National HIV Prevention Summit and JAPR among others,on women’s HIV prevention priorities and provide a platform for achieving the following over the next one-year: Develop a research agenda for women. Catalyze change in the way that interventions for prevention are done by developing standardized quality operational tools for women. Challenge the current status quo in prevention for women by amplifying and disseminating what works best for women. Objectives The objectives were: To explore HIV prevention needs for women. To identify priorities for women’s HIV prevention in current response (based on the Kenya National HIV and AIDS Strategic Plan III). To identify research gaps tobetter inform HIV-prevention interventions. Methodology: The symposium adopted a participatory methodology to ensure optimumparticipation. A mix of facilitation strategies were utilized ranging from presentations, case studies,sharing of best practices, and group discussions on a variety of thematic areas focusing on HIV prevention among women and girls. Plenary and panel discussions were also employed with panellist from various sectors represented who provided clarification on queries from participants. 1 National AIDS and STI Control Programme, Ministry of Health, Kenya, (2009). Kenya AIDS Indicator Survey 2007/8. Nairobi, Kenya 6 Participants included representatives from the government, civil society organizations drawn from the HIV arena including women’s and men’s movements, organizations of PLHIV, FBOS, private and public sector agencies, research, and academic institutions and development partners, involved in Kenya’s HIV and AIDS response. To capture the broad range of issues, participants were divided into groups with each having a facilitator and a rapporteur. Discussion guides and reporting templates had been pre-prepared in order to articulate the key issues and recommendations discussed during group work in the following thematic areas: 2.0 HIV Counselling and Testing, test and treat, PMTCT STI detection and treatment; PEP/PRC BCC, Condoms (female and male), VMMC Male engagement PHDP and discordance, alcohol and substance abuse Current bio-medical interventions (HTC, PMTCT, STI, Treatment, Test and treat, TB etc) Complex social sexual issues (discordance, MCR, GBV) Structural interventions Emerging HIV prevention technologies: Microbicides, PrEP and HIV vaccine and VMMC Different categories of women Linking women HIV prevention to the new Constitution Hon. Njoki Ndungu, former nominated member of parliament and member of the Committee of Experts on Kenya’s new Constitution, presented on opportunities created for women and HIV prevention in Kenya’s new Constitution. She emphasized that violence was a huge contributor to HIV infection among women through rape, coerced sex, and other forms of violence including domestic violence. It is due to this reason that two bills; the Sexual Offences Act and the HIV and AIDS Prevention Bill were passed into law by the 9th Parliament. Despite the high prevalence of violence against women and girls in Kenya, no cases have been taken to court to date. Therefore the law has not been applied. This is a major gap in the national response to HIV and addressing women’s prevention needs. The new constitution provides an opportunity to remedy this since it willnow be affordable to go to court, as there will be no fees associated with filing cases falling within the Bill of Rights.In the past, people shied away from going to court due to cost implications and lack of trust for fair judgment by the judiciary. In addition, it was emphasized that the new constitution is the supreme law of the land and no other law can supersede it. She further noted that review of legislation and legal frameworks that support women’s empowerment would strengthen efforts to address social and cultural issues that continue to increase women’s vulnerability to HIV. The new constitution now allows Kenyans to take human rights cases to local and international courts. Although Kenya has signed on numerous international protocols, their implementation and follow up has been inadequate. The new constitution provides for enforcement of protocols such as Convention on the Elimination of all forms of Discrimination against Women (CEDAW). Kenyans can take the Government to task if it does not meet its obligations. For example, women can now take the government to task on the basis of discrimination for the subsidy on the cost of male condoms and not female condoms. As well, customary practices such as wife inheritance; cleansing (of 7 HIV) and other practices that increase women’s risk ofHIV infection have been addressed by the new constitution. Other key constitutional provisions that were highlighted include: upholding the rights of the child and equal parenting regardless of marital status; rights of PLHIV employees (including a section on hate speech) and protecting the rights of vulnerable groups such as domestic workers. All these can be applied to promote HIV prevention for women and girls. Access to legal aid clinics should be scaled up and more awareness created on available legal structures established by both government and CSOs at the community level. Recommendations The following recommendations were made: The implementation of the new Constitution as a tool to deter behavior that continues to subject women to increased risk of HIV should be fast tracked. Intensifyadvocacy for Government to implement national laws and international conventions to create an enabling environment to address women’s vulnerabilities to HIV. Continuous monitoring of the utilization of the Sexual Offences Act and HIV Prevention Bill is critical to understand lack of application to date sincepresenter regarded the biggest influence of behavior change is the law. Women’s Vulnerability to HIV The NACC Director Prof. A. Orago laid the ground for discussion on vulnerability of women by highlighting the gender disparities in HIV infection. He noted that the number of women infected in the ages 15 – 49 almost double that of men (8% women and 4.3% men). This is more pronounced in the younger ages 15 – 24 where girls are four times more infected compared to boys. The causes of vulnerability among women and girls were identified as: income disparities and gender norms, roles and relations; gender based and sexual violence including rape and defilement; and policy and structural environments that are not sensitive to women’s needs. It is therefore imperative that the country addresses these challenges in order to realise the targets set in the Kenya National HIV and AIDS Strategic Plan (KNASP III) of: reducing by half the current 134,000 new infections per year by 2013; reducing AIDS related deaths by 25%;ensuring interventions that effectively reach of the most at risk population (MARPs), and couples in long term relationships. Recommendations To achieve the above targets it is necessary to: Create an AIDS competent community. Address stigma,, which hampers women’s access and uptake of services. Address institutional factors that hinder HIV positive women from seeking medical interventions. Identify barriers to HIV prevention among women and girls. 8 Intensify research to understand underlying social issues in the shift of the modes of HIV transmission to inform evidence based program design and to help determine successful innovative HIV prevention models. Accelerate the KNASP III operational plan to address individual and social factors contributing to women and girls’ vulnerability. National HIV Response: Policy and Programs Kenya has developed and implemented policies unfortunately their implementation lack followup to establish their effectiveness in responding to women and girls’ needs in the context of HIV prevention. Several sector specific policies are not engendered and if they are, implementation is biased against women. The major causes of poor policy implementation highlighted included inadequate research to identify gaps; limited co-ordination, networking and weak partnerships; limited capacity and resources to integrate gender at all levels of planning and structures; new and un-equitably distributed programs for special categories of women and girls and clients of female sex workers; limited capacity to implement policies that respond to gender issues; unwritten cultural practiceswhich continue to negatively impact women and girls; inadequate empowerment programs involving men to address the power imbalances and promote rights of women and girls, and limited resources and capacity to co-ordinate, monitor and address identified policy gaps. TheThree Ones Principles wasseen ascrucial to delivering the national response. To this end NACC, the coordinating body for HIV and AIDS in the country, has established a national Monitoring and Evaluation framework that captures information/data from implementing organizations to annually track progress in the national response. This was lauded as an important process that provides justification for programming and negotiation for resources. Although Kenya has made commendable progress in its HIV and AIDS response, the following challenges/gaps were identified in delivering a national response that is tailored to women’s HIV prevention needs: heavy dependence on external funding (80-90%) and reliance on global directions and externally driven policies. This complicates matters especiallyat the local level because numerous implementing partners are funded by a wide range of partners. Furthermore, there is minimal funding for gender related factors and there is hardly any emphasis on gender indicators by donors. Also noted was the inadequate evidence to inform programming. Recommendations In order to deliver the national response as it relates to women and HIV prevention it is important to: Strength the national capacity to address gender issues. As such, the National Gender Technical Committee (GTC) should be strengthened. Intensify investment in research on gender related aspects and scaling up of bio-medical interventions to enhance a HIV prevention response that takes into account women issues. Laystrong emphasis on accountability for results by defining specific indicators for performance and ensuring gender analysis and follow up of recommendations. 9 International and regional frameworks guiding HIV prevention for women The session drew heavily from the UNAIDS action framework for women and girls and HIV and AIDS. The framework provides clear action points on how the UN can work together with governments, civil society and development partners to produce better information on the specific needs of women and girls in the context of HIV(“knowing your epidemic and response”); turn political commitments into increased resources and actions so HIV programmes can better respond to the needs of women and girls; and support leaders to build safer environments in which women’s and girl’s human rights are protected. Cultivating a conduciveenvironment that ensures women’s participation and developing mechanismsto address current weaknesses in the implementation and follow-up of national policies is crucial. It was notedthat better governance, strong and supportive leadership, upholding human rights, empowerment of women and girls would aid in achieving theseobjectives. Recommendation Engagement of men and boys as partners in women and girls’ HIV prevention todrive the transformation of social norms and power dynamics especially in addressing violence against women including sexual abuse and exploitation. Gaps in Women and HIV Prevention HIV Testing and PMTCT Adolescence and Youth Gaps: Testing of adolescents and youth was indicated as challengingdue to the generic programming and messaging as well asthe long procedures and referrals. Stigma from health care workers was also cited as a major drawback to testing. Follow-up for youth post testing was noted as being weak anddisclosure to parents remains a challenge. Successful disclosure models after testing HIV positive are not available and close monitoring and evaluation of interventions to ascertain their success and limitations are lacking. This is compounded byinadequate systems to generate timely and accurate data and under utilization of this data to inform programmes. Recommendations: Establish youth friendlyintegratedservices at one service delivery point that includes counsellor supported disclosure. Develop a community strategy aimed at building strong PLHIV networks to help ease the challenge of referrals and follow-up and ensure that those tested find necessary psychosocial support within the community. There is need for continued training ofservice providers to ensure provision of quality youth friendly services. Gaps in STI Detection and treatment- PEP/PRC Women and girls do not have comprehensive messages that specifically target them on issues of sexuality and STIs including HIV and AIDS. This leads to lack of awareness of STI symptoms. Also 10 some STIs remain asymptomatic for long periodsand therefore women and girls do not seek care in a timely manner. There is limited discussion between parents and youth on sexuality issues leading to young girls turning to peers for advice and not reporting cases of sexual abuse that may lead to contracting STIs and or HIV. Therefore girls do not receive early diagnosis and treatment for these infections. Furthermore, the environment at the service delivery points is not conducive for open and honest discussions with girls and women. Medical professionalism and ethics required of health personnel have been eroded creating a non-conducive environment for women and girls seeking services for STI and HIV. Those seeking these services experiencestigma from the health providers, for example older women feel uncomfortable seeking medical assistance from younger medical personnel. In some areas, religion plays a great role in influencing treatment access with some people preferring spiritual healing to medical assistance. Recommendations Responding to the above issues will require: Health personnel to provide comprehensive services. Intensifiedawareness raising and education on PEP including service delivery points for easy access. Gender based violence survivors should be placed on PEP immediately for three days and the health sector to institute a trace system to facilitate follow-ups; Inclusion of a trainingcomponent in addressing GBV and PEP in the curricula for health personnel to improve theattitudes of the health personnel towards clients seeking STI treatment especially among young girls and older people;and strategies to ensure adherence to the Health Care Code of conduct by health personnel will result in improved service delivery. A client satisfaction survey that includes an opportunity to give confidential feedback immediately after a particular service has been received by a client should be initiated; Culture and religion plays a big role in the way women and girls’ rights are violated necessitating mechanisms for dealing with cultural and religious attitudes that negatively impactwomen and girls. Assigningmore female doctors to provide health services to older women as a measure to encourage more women to seek treatment and be more open Gaps in Prevention Strategies Behaviour Change Communication (BCC), Male and Female Condom promotion and Voluntary Medical Male Circumcision (VMMC) Gaps Behaviour Change Communication,use of both male and female condoms and VMCC are among the key prevention strategies promoted in Kenya. Gaps identified in these prevention mechanisms range from erratic supply of male condoms and little if any supply of female condoms; high cost of female condoms making them inaccessible; low knowledge and information on use; lack of programs addressing school going and HIVpositive youth. 11 Recommendations Intensified knowledge and information on female condoms as well as a consistent supply of both female and male condoms. Make female more accessible through reduction of cost or available at no cost similar to male condoms.; Training more staff on VMMC in response to the increasing number of men seeking VVMC and sensitizing older married men on the benefits of VMMC. Intensifying mobile VMMC and iintegration with other services e.g. mobile VCT. Training caregivers on disclosure and addressing related stigma.. Male engagement Gaps: Studies conducted show that women access services more than men. Male-specific interventions that could help address inherent male attitudes’ around reproductive health as a woman’s issues are inadequate.In addition, access to male-friendly reproductive health services is minimal and many men seekingHIV testing and counseling services fear results especially in the context of high-risk behavior. Recommendations Deliberate engagement of men and establishment of male friendly health services including reproductive health coupled with provision of mobile services is essential. Outreaches targeting men with tailored messages to address issues of masculinity and femininity should be encouraged including strategies that enhance communication in marriage and during courtship. Positive, Health, Dignity and Prevention (PHDP) for PLHIV and engagement of women and young girls Gaps There is a paucity of information targeting youth especially girls living with HIV. Although centres that target youth in general for HIV and AIDS awareness and education exist, lack of health centres providing services to young PLHIVprevents full participation by the girls. There is also a general assumption that PLHIV will automatically adopt behaviour change after receipt of prevention messages that are not tailored to their specific needs. Recommendations: Provision of sexual and reproductive health information and services should start at a young age; sex and sexuality programs in schoolsare vital and early character formation/ education by parents and guardians is essential. Empowerment programs for HIV positive couples or those who aspire to get married are needed that provide; intensive counselling around relationships including rights and obligations among other services. Linking HIV preventionprogrammes with other livelihood interventions must take place. There is a need to build capacity around PLHIV disclosure as well as prevention programs in the context of PHDP in order to prevent HIV transmission. 12 Role of research in HIV prevention among women KNASP III2 emphasizes the need for evidence-based interventions that are informed by sound research. The Symposium recognized research as a vital process in the identification of women’s prevention needs and in determining effective interventions for women and girls. There are various types of research including behavioral, socio-cultural and biomedical research. Behavioral research in HIV and AIDS prevention and control is the part of social science research that helps to reveal the determinants of sexual risk behaviors and identify the factors that motivate or influence behavior change related to the prevention and/or transmission of HIV and AIDS and other STIs. Socio-cultural research, for the purpose of this symposium and report, is defined as the study of attitudes, behaviours, cultural norms and practices and social conditions which either protect people or make them more vulnerable to HIV. Biomedical research for the purpose of this report is defined as research conducted to aid and support the body of knowledge in the field of medicine. It is important to note that the Symposium concentrated on clinical research that is, involving human participants. When undertaking research it is important to ask the following questions to ensure that the research is not only answering the research question but it is relevant to the target community and especially women: Who are the target community? How is the research relevant to women in Kenya? What are some of the advantages the research will bring? In addition, positive outcomes of research at the community level including improvement of services and infrastructure such as laboratories and clinics should be shared with participants. It was noted that when participants understand research to have potential benefit for them, they could be motivated to participate through volunteering for clinical trials. Motivating factors that clinical trial participants have identified include: desire to do something to end the epidemic, and to do something that helps their families who have been affected by HIV and to protect themselves. Challenges that face clinical trials Clinical trials face various challenges. Among communities, clinical trials are not always popular due to some negative perceptions often based on insufficient information. Media can also play a major role in acceptance by participants and any form of misreporting may negatively affect the clinical trial. Participation in clinical trials is not easy, as volunteers are often required to disclose very intimate personal details about their sex life. 2 Kenya National Strategic Plan (KNASP-2009/10-20012/13) 13 Women’s meaningful involvement in research: Ethical and practical considerations Ethical considerations in meaningful involvement of participants in clinical trials centre on the informed consent process. Getting informed consent from women is particularly complex due to various reasons such as gender power relations, educational levels that influence understanding of the informed consent forms and even the power relations between the researchers and the women. Challenges Some key challenges in involving women in clinical trials include: ensuring that trial participation will not increase risk of exposure to HIV; reinforcing unknown efficacy of test product; ensuring participants do not feel a false sense of protection or ¨therapeutic misconception¨ which could lead to increased risk behavior. Other factors that influence informed consent and women’s participationwere: women are not sufficiently empowered to have the autonomy or legal right to make the kind of decisions required in the informed consent process; the premise that individuals make their own decisions regarding consent is normally not the case; in many occasions, a family member, family group, employer and even the community is responsible for the decision taken by the participant; personal gain through remuneration and fair compensation often present themselves as undue inducement that influences the decision of the participant; defining ¨trial participant (s)´´ in Microbicide trials – partners/couples act as bystander participants resulting in loss of autonomy and confidentiality by female participants. Factors external to the trial process may also have implications to the trial success/results for example:; inherent beliefs, stereotypes, judgment,vulnerability due to poverty, sexual orientation, education, injecting drugs, sex work, institutional powers, real or imagined and inaccurate media information. All these may increase stigma and creates fear among participants, which may lead to discontinuation. Recommendations: To address gaps in the Informed consent process especially among women the following was suggested: The process should not be mechanistic, legalistic and signature-centered approach but should embrace new forms of consent such as an agreement between researcher and participant based on dialogue reinforced through an ongoing and dynamic process throughout the trial; One-on-one counseling and support for trial participants by well-trained staff. Development and use of supplemental tools such as audio visual equipment and booklets to ensure that participants and community fully understand the process followed by a systematic assessment of comprehension. The Kenya HIV and AIDS Strategy: Does it work for women? Presentation outlined the major objectives of HIV and AIDS research as: Research Priority setting-intended to promote priority biomedical and social science HIV and AIDS research. Capacity building-aimed at building capacity for HIV and AIDS research through collaboration and resource mobilization. 14 Coordination – aimed at strengthening the co-ordination of HIV and AIDS research and tracks all the related undertaken research. Evidence to inform and influence policy-intended to provide a platform for policy dialogue on HIV and AIDS research and create evidence that would influence appropriate HIV and AIDS policies and programs for community and institutions. Community participation and communication-intended to enhance community participation in the planning and execution of HIV and AIDS research and ensure widespread and timely dissemination of research results at various levels. Gaps There are diverse knowledge gaps that require research. Finding out the implications on behaviour change when people test negative is not well understood, currently, the focus has mainly been on positive persons. . There is need for better understanding of what influences the behaviour in persons exposed to HIV but not infected. New testing methodology, which focuses on ‘window period’,is necessary. There is minimal understanding of why men prefer the option of vaccine and why more men participate in clinical trials targeting both men and women. Operational research is needed to understand various issues in the HIV response for example we know PMTCT works but not all women have access, what is the reason? Priority socio-cultural and behavioral research issues that would contribute to better planning for women in the context of HIV Highlighted priority research areas included: Research requiredtodetermine the best models for negotiating safe sex practices for women and girls. Research to inform roll out of emerging women’s HIV prevention methods like Microbicides when they become available. Research on gender related aspects in the scaling-up of bio-medical interventions. Emerging HIV prevention tools for women One volunteer in a clinical trial was asked to what extent she would go to access a microbicides and she said, –“I would travel further for microbicides than male condoms because with the microbicide, it is mine. With condoms I still have to negotiate with my partner’’. General rationale for developing new HIV prevention tools include the fact that new HIV infections are still occurring despite the efforts to stem the epidemic. For every two patients started on treatment five people are newly infected despite an unprecedented outpouring of resources and proliferation of programs. Kenya has estimated that new infections range from 55,000 to 110,000 (KAIS 2008) per year, providing justification for development of new HIV prevention tools since treatment will not be affordable in the long term. Microbicides A microbicides is a substance that can reduce the transmission of HIV and other STI pathogens when applied vaginally and, possibly, rectally.Microbicides were still under trials and therefore not yet available for use. Currently, Microbicides are being developed in the form of 15 Formatted: Normal, Justified, No bullets or numbering gels creams and rings. Other methods of delivery are also being explored to ensure that women have options that meet their needs. While there have been a lot of setbacks in the research for a Microbicide, a clinical trial in South Africa called CAPRISA 004 showed 39% effectiveness. This for the first time proved that it is possible to prevent HIV infection among women using a topical (vaginal) product. The trial tested an ARV based Microbicide – Tenofovir gel among women at high risk in Kwa-Zulu Natal, South Africa. Vulindlela a rural area in South Africa, prevalence is nearly 51.1%, study conducted indicated by age 24 the probability for a woman of being infected is 1 in 2: Tenofovir Gel used due to various reasons including that it is an effective therapeutic agent; has a good safety profile; is currently used for PMTCT; is rapidly absorbed and has a long half-life; is known to have low systemic absorption and therefore fewer side effects; and is also known to protect against SIV in studies conducted among monkeys. Impact of adherence on effectiveness of Tenofovir gel was given as 54% for the high adherers; 38% for the intermediate adherers and 28% for low adherers. Once confirmed and implemented, Microbicidehas the potential to alter the HIV epidemic.In modeling studies, it is estimated that Tenofovir gel could prevent 1.3 million new HIV infections and over 800,000 deaths in South Africa alone. Plenary discussion on what the CAPRISA Study results meant for Kenya highlighted the following: Confirmation through research that indeed young women especially in sub-Saharan Africa are at greater risk of acquiring HIV than their male counterparts. Now more than everresearchers havehope that they are close to getting a product that works well for women. Additional studies are urgently needed to confirm and extend the findings of the CAPRISA 004 trial. Prof. Elizabeth Ngugi, a well known advocate for women’s rights and HIV, summed up sentiments of many people in the HIV prevention research field saying that, “Ifully support the need for additional studies and pledge to support research by mobilizing women for a similar study when the time comes.” Pre-Exposure Prophylaxis (PrEP) PrEP was defined as taking medical products to prevent (rather than treat) a disease or condition before one is exposed to it.In HIV field, it means HIV uninfected individuals taking ARVs to reduce the risk of getting infected with HIV. Why PrEP? It is a product that is Individual-controlled, and more importantly, may be women-controlled and women-initiated as well as no known interference with fertility intentions. The currently tested products have well known safety profiles among HIV infected individuals. Studies in non-human primates have shown both oral and topical applications of ARVs before exposure reduces risk or completely prevent infection with animal version of HIV (SIV); Truvada has high concentrations in vagino-cervical area, thus could be effective in reducing risk of 16 heterosexual transmission;ARVs are already used to prevent vertical transmission and infection after medical accidents or rape. Challenges facing PrEP PrEP vs. treatment – will there be sustained funding for both? How do we justify giving ARVs to uninfected people when there are still huge numbers of people who are infected and do not have access to treatment. Would the pills/gel be safe for adolescents, pregnant women, and breastfeeding women? Is a daily pill a feasible regimen? How fast will fatigue set in? (i.e. how much room do we have for compliance?) The roll-out will be challenging and needs more work: which population, How often will we need to test for safety, for HIV, What will be the distribution points? HIV Vaccines3 A vaccine is described as a product that works by triggering the body’s immune system to produce antibodies and cells that recognize and destroy invading pathogens before they cause disease. An HIV and AIDS vaccine was described as necessary because despite an unprecedented outpouring of resources and proliferation of programs, there are still new infections; basic and epidemiology research in HIV and AIDS indicates that it is possible to discover a HIV vaccine; the RV144 trial in Thailand demonstrated for the first time modest protection against HIV infection. There is also a new and exciting discovery that showsthat neutralizing antibodies which revealed vulnerable targets on the virus that are now being explored for vaccine design;acceleration of candidates to clinical trials and advancing the most promising of these candidates to efficacy trials is critical and sustaining interest from communities, policy makers and all other stakeholders fora HIV vaccine while ensuring sustained funding forintensifying research trials globally. New HIV Technologies: how will they be incorporated into the daily lives of women? Women have proved themselves as adopters of technologies especially those they understand and/or perceive to make a positive difference in their lives. It is therefore important for researchers, policy makers, and other stakeholdersto consider the incorporation of emerging HIV prevention technologies in the everyday lives of women. It is therefore important to consider the following questions even as the research advances: Will the products be available within thelocality of the target users? Will the products be affordable? How easy will the productbe to use/apply? Comfort in storing the products: – does the packaging afford women the privacy they desire? Are there any negative myths especially linked to fertility of women that may lead to women not using the product even if it poses no safety issues scientifically? 3 This Presentation was made by Prof. Omu Anzala of KAVI 17 Are there any social influences around the woman e.g. the family and friends that might affect usage? 18 Group work discussion considered the following questions: 1. What are the areas/gaps that require further (consider action, behavioural and clinical research)? 2. How do we generate and utilize sex disaggregated HIV clinical data for effective prevention programming for women (testing and treatment data on women). Key Research Gaps Identified gaps in research Low utilization of modern family planning technologies by positive women resulting an unmet need for contraception. Limited understanding of re-infections among couples living with HIV. Low adherence to PMTCT guidelines on breastfeeding requires further investigation to inform appropriate interventions. Gaps in strategies on how to reach the different categories of women Need to explore why some individuals in a discordant relationship continue to remain HIV negative? Lack of enough data on practices such as anal sex; group sex (‘’swinging as is commonly known’’), men who have sex with men (MSM) and bisexuality in Kenya. These practices and preferences impact on HIV risk for women. Need to understand risk factors associated with religious/spiritual rituals and cultural practices such as inheritance of widows and cleansing. Further research to understand masculinity norms that encourage risk behaviour such as boys who have been recently circumcised being encouraged by older men to have sex (normally with older – sexually experienced – women) in order to test ones “new tool”. Recommendations for Areas requiring further research Exploring models to strengthen the integration of HIV and SRH services for women and especially those living with HIV. Need for social behavioural research to inform prevention programs for PLHIV especially womenthrough operational research. Targeted research and programming for the different categories of women particularly those at high risk. Intensified research to understand both behavioural and scientific factors why persons exposed to HIV in discordant relations remain HIV negative to inform program design. Identify successful models to facilitate disclosure among couples and especially discordant couples. Need to intensify education on HIV and AIDS aimed at addressing risk factors for MARPs by changing negative societal attitudes and integrating a human rights approach to service delivery assuring their health needs are met. Research to understand behavioural practices, myths and misconceptions associated with MARPs including MSM, sex workers, bisexual individuals, group sex including ‘spousal exchange for sex’ is crucial to inform design of appropriate interventions. Research to understand why religious and cultural practices continue within communities despite knowledge on their increasing risk to HIV infection as a result of these practices. 19 Research required to understand why men who have undergone VMMC and know the risk of sexual activity prior to the recommended 6-week period still engage in sex. Towards a gender responsive research agenda: What are the different categories of women? In designing research protocols, it is important to take into account the different categories of women to ensure that any research carried out responds to the special needs of all women. The different categories of women were described as follows: Geographic categorization - urban and rural Socio-economic statuse.g. low-domestic workers,chang’aa brewers, casual labourers; middle -contractual sex e.g. for job promotion and high income; age-girls/adolescents; the young; the elderly Marital status- single, married, separate and widowed. Education level – primary, secondary, colleges and universities. Sexual diversity – heterosexual, lesbian, bi-sexual, trans-sexual, trans-gender. MARPs: sex workers, women truck drivers, bar hostesses, injecting drug users, street girls and women, persons with disability Women in fishing industry Women in institutions of higher learning Women as care-givers of PLHIV Women in the armed forces. Recommendations Proposal for research agenda 1. Translation of policy and research into practice through: Accountability for results for women: o Through the review of the national M&E framework for HIV and health. o Gender analysis: required for the response within planning processes and M&E systems at all levels. o Enhancing understanding of the new constitution and its implication for women and girls. o Provision of guidance by the GTC around new constitutions and implication on programming. 2. Community based research: Formative, community-based, social, behavioral and operational research is needed to identify and improve structural factors such as poverty, housing instability, violence, and mental health status, which increase vulnerability for women living with and affected by HIV. 3. Explore gender issues/ dynamics that impact on sexual relations and how these can be manipulated to inform ongoing scale up of interventions (VMMC, couples interventions etc). 4. Disclosure among couples: Commission research to understand, design, and implement successful models for disclosure among sexual partners, couples, and families. 5. Align current research to KNASP III indices. 6. Resources tracking to understand whether interventions are providing value for money, determine what works for women, and analyze the results. 20 Proposals for women’s prevention priorities: 1. Political Commitment: need for political commitment and improved visibility to translate technical assistance and resources for prioritizing women’s issues and HIV. This will be achieved through advocacy to strengthen political commitment and increase visibility aimed at translating resources into action. Commitment is required from stakeholders including development partners, donors and civil society, private and public sector. 2. Meaningful Participation by Women Living with HIV: Should be present all levels of decision-making regarding policies that affect their lives. This is necessary to determine the elements that will be used to implement the pillars of KNASP III. Meaningful involvement means that HIV-positive women and girls are involved in all levels of policy decision-making and program design that impacts their lives. 3. Capacity Building and Relevance to KNASP III: strengthen capacity of stakeholders at all levels to translate gender guidelines into practice. 4. Prioritize Gender Issues as Recommended by KNASP III and factor in opportunities provided by the new constitution. 5. Strengthening Coordination and Linkages-deepen linkages of HIV to other services such as sexual and reproductive health. Strengthen linkages across and within all stakeholders in coordinating partnerships across CSOs. 6. Reconstitute, strengthen the GTC and align it with KNASP III by: Positioning GTC to be recognized as one of the sub-committees for coordination under Pillar 4. This will require institution and financial support from NACC and partners. Advocating for a member of GTC to sit on the Inter-agency Coordinating Committee (ICC). Develop ToR that will guide the recruitment of GTC members and define the mandate of GTC. 7. Program development -Gender issues/ dynamics that impact on sexual relations and how these can be manipulated to inform ongoing scale up interventions (VMMC, couples interventions etc)and effectively address the needs of women. Strengthen coordination and integration of sexual and reproductive health services and HIV across prevention, diagnosis, treatment, and care programs. Intensify female condom distribution mechanisms that ensure all priority target groups are reached. 8. Services that are Responsive to Women: Women specific HIV prevention, care and support services to cater for their unique needs must be holistic and integrated based on models that respect women’s’ rights to dignity, body autonomy, and relevant information that influence voluntary medical decisions. Currently, most areas lack women-specific services highlighting huge disparities in access to effective and culturally appropriate care for women. 9. Equitable resource allocation: Data collection and risk assessment often underestimate the population of women at risk and living with HIV resulting in inequitable resources allocation and distribution for programming including service provision, and capacity building especially for women living with and affected by HIV. Key recommendations from the symposium 21 Intensify advocacy for Government to implement national laws and international conventions to create an enabling environment to address women’s vulnerabilities to HIV. Continuous monitoring of the utilization of the Sexual Offences Act and HIV Prevention Bill is critical to understand lack of application to date since the presenter regarded the biggest influence of behavior change is the law. Engage with the Parliamentary Health Committee among others in order to enhance advocacy for women’s health issues. Economic empowerment should be used, as a broader strategy for prevention by having affirmative action that ensures that women-owned small businesses are financed. The need to strengthen representation of PLHIV rights at policy levels such as parliament to address the high level of stigma. Create an AIDS competent community. Address stigma, which hampers women’s access to and uptake of services e.g. PMTCT because they fear the outcomes of disclosing an HIV positive status to their male partners. Ensure provision of holistic literacy. Increase efforts to retain girls in school. Address institutional factors that hinder HIV positive women from seeking medical interventions. Improve access to SRH (including family planning) services and revise current PMTCT guidelines to facilitate intended pregnancies among women living with HIV. Identify barriers to HIV prevention among women and girls. Examine uptake of female and male condoms to enhance availability, accessibility, and utilization of female condoms by women. Intensify research to understand underlying social issues in the shift in modes of HIV transmission to inform evidence based program design and to help determine successful innovative models for negotiating safe sex for women and girls. Accelerate the KNASP III operational plan to address individual and social factors contributing to women’s and girls’ vulnerability including:biological and socio- cultural issues with younger females, disability as an added vulnerability for women and girls, economic disempowerment which accounts for a large number of girls aged 10-18 entering sex work. Strength the national capacity to address gender issues, through reinforcing the National Gender Technical Committee (GTC) by establishing a ‘think tank’ to guide strategic thinking. In addition, a ‘watch dog’ committee should be created to ensure accountability as well as acceleration of the implementation of KNASP III. A strong GTC will drive capacity building initiatives informed by the recently concluded gender analysis aimed at generating gender responsive programming and involvement of women by all stakeholders. This, coupled with an intensified investment in research on gender related aspects and scaling up of bio-medical interventions will be necessary to enhance an HIV prevention response that takes into account women issues. More emphasis should also be placed on accountability. Engagement of men and boys as partners in women and girls’ HIV prevention to drive the transformation of social norms and power dynamics especially in addressing violence against women including sexual abuse and exploitation Establish youth friendly integrated services at one service delivery point that includes counsellor supported disclosure. 22 Develop a community strategy aimed at building strong PLHIV networks to help ease the challenge of referrals and follow-up and ensure that those tested find necessary psychosocial support within the community. There is need for continued training for service providers to ensure provision of quality youth friendly services. Health personnel to provide comprehensive services STI detection and treatment Intensifiedawareness raising and education on PEP including service delivery points for access. Gender based violence survivors should be placed on PEP immediately for three days and the health sector to institute a trace system to facilitate follow-ups. Inclusion of a trainingcomponent in addressing GBV and PEP in the curricula for health personnel to improve their attitudes towards clients seeking STI treatment especially among young girls and older people; and strategies to ensure adherence to the Health Care Code of conduct by health personnel will result in improved service delivery. A client satisfaction survey that includes an opportunity to give confidential feedback immediately after a client has received a particular service should be initiated. Culture and religion plays a big role in the way women and girls’ rights are violated necessitating mechanisms for dealing with cultural and religious attitudes that negatively impact women and girls. Assigningmore female doctors to provide health services to older women as a measure to encourage more women to seek treatment and be more open. Intensified knowledge and information on female condoms as well as a consistent supply of both female and male condoms. Training more staff on VMMC in response to the increasing number of men seeking VVMC and sensitizing older married men on the benefits of VMMC. Intensifying mobile VMMC and integration with other services e.g. mobile VCT. Training caregivers on disclosure and addressing related stigma. Deliberate engagement of men and establishment of male friendly health services including reproductive health coupled with provision of mobile services is essential. Outreaches targeting men with tailored messages to address issues of masculinity and femininity should be encouraged including strategies that enhance communication in marriage and during courtship. Provision of sexual and reproductive health information and services should start at a young age Sex and sexuality programs in schools are vital and early character formation/ education by parents and guardians is essential. Empowerment programs for HIV positive couples or those who aspire to get married are needed that provide intensive counselling around relationships including rights and obligations among other services. Linking HIV prevention programmes with other livelihood interventions must take place. There is a need to build capacity around PLHIV disclosure as well as prevention. Programs in the context of PHDP are necessary in order to prevent transmission of HIV. The research consent process should not be mechanistic, legalistic and signaturecentered approach but should embrace new forms of consent such as an agreement between researcher and participant based on dialogue reinforced through an ongoing and dynamic process throughout the trial. One-on-one counseling and support for trial participants by well-trained staff 23 Development and use of supplemental tools such as audio visual equipment and booklets to ensure that participants and community fully understand the process followed by a systematic assessment of comprehension. Conclusion and Way Forward It was unanimously agreed the momentum that had begun with the Women’s HIV Prevention Symposium should be sustained. The recommendations will be shared during the prevention summit with the aim of inclusion in the national HIV and AIDS prevention priorities. Various organizations pledged to support the implementation of the recommendations from the symposium as indicated below. 1. National AIDS Control Council’s Commitment Ensure that the priority areas identified will inform programming thus ensuring women and girls’ prevention issues are recognized. Support evidence based activities to meet agreed upon indicators. Coordinate implementation of meeting recommendations. 2. Global Campaign for Microbicides Ensure that the steering group stays active. Promote stronger civil society involvement to engage with research and clinical trials in Kenya especially in determining implications of the CAPORISA 004 trials in Kenya. Mobilize and sustain the existing political good will especially with the new constitution in order to ensure that it responds to issues affecting women and their vulnerability to HIV infection. 3. UNAIDS’ Commitment To champion issues of women and girls, gender equality and HIV and AIDS. To provide global leadership in advocating for a multi-stakeholder HIV prevention response for women and girls. Continue to pressure the international community to act based on evidence – know your epidemic and your response. Always ask where is the money for women? Focus on where the resources are and commit to turn around the resources to benefit women and girls. Address factors underpinning risk for girls and women to respond to the questions: o What do we really believe is the problem? o Why are young girls affected earlier than their male counterparts? o Why are younger girls engaging into inter- generational sex? o What is the role of older men having resources and this facilitating sex with the young girls? o By age 20, more than 50% of Kenyan girls are married, how do we keep them from getting married so early and retain them to in school? 4. NASCOP’s Commitment NASCOP commits to become available and give all the necessary support in addressing women’s issues. 24 Making available and accessible new technologies to women as soon as they are proven efficacious through research. 25 Commissioning of the HIV Prevention Champion As a strategy to intensify HIV prevention efforts that take into account women and girls vulnerabilities, the GTC envisioned identifying a young lady advocate to provide visibility to women’s issues in prevention and Ms. Sharon Mina Olago, a 28-year old artist and community activist and a Masters Degree student was commissioned and awarded a trophyas the 2010 HIV Prevention Champion. Final Quotes “We at NASCOP are committed to availing new technologies to women as soon as they are proven through research.... the Kenya Women’s HIV Prevention Symposium should be an annual event”---Dr. Peter Cherutich, Head of Prevention-NASCOP. “This Symposium should have happened a long time ago so that we can understand how to deal with the epidemic. Women should have been involved a long time ago”---Dr. Sobbie MulindiDeputy Director Coordination and Support NACC 26 ANNEXES Annex List of Guests, Speakers, Group Leaders, Rapporteurs and Discussants: 1. Guests - The Chief Guest on Day 01, Hon. Njoki Ndung’u presided over the opening ceremony - Chief Guest on the last day, Dr, James Nyikal, PS, Ministry of Gender, Children and Social Development was represented by Mrs Beth Mutugi (Senior Deputy Secretary in the Ministry of Gender, C & SD), presided over the closing ceremony and commissioned the 2010/11 Women Prevention Champion. - Key Note address was delivered by Prof Alloys Orago, the Director of the National AIDS Control Council on the ‘Feminization of the HIV and AIDS epidemic in Kenya:the current status and future direction for women specific intervention.’ Formatted: Line spacing: single Formatted: Line spacing: single, Numbered + Level: 1 + Numbering Style: 1, 2, 3, … + Start at: 1 + Alignment: Left + Aligned at: 0.25" + Indent at: 0.5" Formatted: Line spacing: single, Bulleted + Level: 1 + Aligned at: 0" + Indent at: 0.25" Formatted: Line spacing: single 1. 2. 2. Speakers Prof. E. Ngugi, CHIVPR/UoN 3. 4. 5. Leah Wanjama, Kenyatta University Ruth Masha, UNAIDS Dr. Nduku Kilonzo, LVCT Yasmin Halima, GCM 6. Dr. Elizabeth Bukusi 7. Kawango Agot 8. Prof. Omu Anzala 9. 10. 11. Pauline Irungu, GCM Prof. Violet Kimani, UoN Dr. Nelly Mugo 12. 13. 14. 15. 16. Dr. Elizabeth Bukusi, Yasmin Halima, GCM Dr. Erasmus Morah Dr. Cherutich, NASCOP Dr. Sobbie Mulindi Topic -Women’s and girls vulnerability to HIV infection: Individual and socio-cultural factors -Women’s and girls vulnerability to HIV infection: Policy gaps on gender and HIV prevention -International and Regional frameworks guiding HIV prevention for women -Issues and challenges in delivering the national response -The place of research in HIV Prevention (biomedical, social and behavioural research) -Looking for new HIV prevention tools: updates from clinical trials: Microbicides (including an update on CAPRISA 004) -Looking for new HIV prevention tools: updates from clinical trials: PreExposure Prophylaxis -Looking for new HIV prevention tools: updates from clinical trials: Vaccines -Real life application of HIV prevention technologies by women -Social behavioural research: updates and way forward -Considerations for women’s meaningful involvement in research: ethical and practical -Kenya’s HIV research strategy: does it work for women? -The role of GCM in HIV Prevention for women -UNAIDS commitment to HIV prevention for women in Kenya -Commitment of NASCOP to Programme Implementation -Wrap Up, Closing Remarks and Vote of Thanks 3. Session Chairs, Panelists, parallel sessions Group leaders and rapporteurs Session Chairs, panelists and parallel group leaders and rapporteurs included the following: Wangui Ng’ang’a (PATH), Dr. Florence Manguyu (IAVI), Harriet Kongin (NACC), Ursula Sore Bahati (UNIFEM), Eunice Odongi (NACC), Sari Seppanen (UNAIDS), Moses Ogola (Min of Planning), Anne Njeru (DRH), Rosemary Mburu (KANCO), Dr. P. Muriithi (NACC), Anrita Ikahu (LVCT), Rukia Yassin (GTZ), Pascaline Kang’ethe (AAK), Ludfine Anyango (UNDP) and Wanjala Wafula (Co-Exist, Kenya). 27 Annexe 1 Symposium Programme Kenya Women’s HIV Prevention Symposium: Making HIV prevention responsive to women’s needs Date: Tuesday 31st August – Wednesday 1stSeptember 2010 Venue: Panari Hotel, Nairobi ________________________________________________________ Overview of the Symposium The Kenya Women’s HIV Prevention Symposiumis a critical opportunity for a national, in-depth discussion on the HIV prevention needs of women. The Symposium provides a valuable forum for bringing together HIV service providers, women’s organisations including rights of women, policy makers and HIV researchers to evaluate current programming approaches and their impact. Importantly, the Symposium will identify the crucial next steps to making the national HIV response appropriate to women’s needs, including the integration of existing and emerging prevention technologies into women’s lives. Expected Outcomes Primary outcome of the Symposium is: To inform the agenda of the national HIV prevention summit – to be held before the end of the year - on women’s HIV prevention priorities. Secondary outcomes of the Symposium Symposium aims to deliver the following over the next year: A HIV prevention research agenda for women; Catalyse change towardsstandardised quality interventions appropriate for women; Challenge the status quo in HIV prevention for women by amplifying and disseminating what works for women 28 Kenya Women’s HIV Prevention Symposium: Making HIV prevention responsive to women’s needs Programme DAY ONE, August 31, 2010 Time Topic Presenter 8.00 – 8.30 Registration VivoNaidu, GCM 8.30 – 9.00 Introductions Pauline Irungu, GCM Symposium Overview 9.00 – 9.20 The feminisation of the HIV and AIDS epidemic in Kenya: the current status and future direction for women specific interventions Prof. Orago, NACC 9.20 – 9.50 Key note address –Women the pillars of society: urgency for a commitment towards women’s HIV and AIDS prevention as a priority Hon. Njoki Ndung’u, Chief Guest 9.50 – 10.30 Women’s and girls vulnerability to HIV infection Prof. E. Ngugi, CHIVPR/UoN Individual and socio-cultural factors 29 Chairperson Harriet Kongin, NACC Esther Gatua, Policy Consultant Policy gaps on gender and HIV prevention International and Regional frameworks guiding HIV prevention for women 10.30 – 11.00 Tea Break 11.00 – 12.40 Issues and challenges in delivering the national response Ruth Masha, UNAIDS Dr. Nduku Kilonzo, LVCT Panel discussion (Policy environment for delivering a national HIV and AIDS response, Panel Discussion RH/HIV integrations, Kenya’s prevention priorities) (Panelists: MoFP, John Owuor; Pauline, Gender Commission, Rep; DRH, Anne Njeru) 12.40 – 1.00 What is working well and what are the gaps for women? Group1:HIV Counselling and Testing, test and treat, PMTCT Group 2:STI Detection and Treatment; PEP/PRC Group 3:BCC; Condoms (female and male), VMMC Group 4: Male engagement Group 30 Group 5: PWP and discordance, Alcohol and substance abuse Eunice Odongi, NACC (overseeing) Leader: Annrita Ikahu, LVCT Leader: David Nyaberi, DRH Leader: Ndung’u Kiriro, PSI Rapporteur: Rukia Yassin Rapporteur: Rapporteur: Ruth Masha Anne Mumbi Leader: Fred Nyaga, Engender Health Rapporteur: Pascaline Kang’ethe Leader: Pauline Mwololo, NASCOP Rapporteur: Nduku Kilonzo 1.00 – 2.00 Lunch Break 2.00 – 3.15 Group discussions and finalising presentation to the plenary Groups Eunice Odongi, NACC (overseeing) 3.15 – 4.15 Group Report back and plenary discussions Group Rapporteurs Florence Gachanja, UNFPA 4.15 Tea Break 4.30 De-brief for women Lucy Ghati 31 DAY 2, September 1, 2010 8.15 -8.30 Recap of the previous day Symposium Rapporteur 8.30 – 10.30 The place of research in HIV Prevention (biomedical, social and behavioural research Yasmin Halima, GCM Looking for new HIV prevention tools: updates from clinical trials Drs. Betty Njoroge, Kawango Agot and Prof. Omu Anzala, Yasmin Halima Microbicides PrEP Vaccines An update on CAPRISA 004 Real life application of HIV prevention technologies by women Pauline Irungu, GCM Prof. Violet Kimani, UoN Social behavioural research: updates and way forward 10.30 – 11.00 Break 11.00-12.00 Considerations for women’s meaningful involvement in research: ethical and practical 32 Dr. Lucy Muchiri, UoN Dr. P. Muriithi, NACC Dr. Bukusi, KARSCOM Kenya’s HIV research strategy: does it work for women? Pauline Irungu Discussant 12.00 – 1.00 Towards a gender responsive research agenda Group1:Current Bio-medical interventions (HTC, PMTCT, STI, Treatment, Test and treat, TB etc) Leader: Ursula SoreBahati, UNIFEM Group 2:Complex social sexual issues (discordance, MCR, GBV) Group 3:Structural interventions Leaders: Leader: Wafula Wanjala Rapporteur: Rukia Yassin Group work Group 4: Emerging HIV prevention technologies: microbicides, PrEP and HIV vaccine and VMMC Edward Marienga, UNFPA and Rapporteur: Wangui Ng’ang’a, PATH Leader: Dr. Florence Manguyu, IAVI Rapporteur: Pauline Irungu, 33 Group 5:Different categories of women Leaders: Prof. E. Ngugi Rapporteur: Mboje Mjomba Pascaline Kang’ethe, AAK (overseeing) Rapporteur: Eunice Odongi GCM Nduku Kilonzo Dr. Sirengo, NASCOP, 1.00 – 2.00 Lunch 2.00 – 2.45 Groups Report back Group Rapporteurs Dr. Sobbie Mulindi, NACC 2.45 –3.15 Symposium Rapporteur’s report back Symposium Rapporteur 3.15 – 4.00 Prioritising next steps: Ludfine Anyango, UNDP a) Programmatic priorities & b) Research priorities 4.00 - 5.00 Commissioning the HIV Prevention Champion and Official Closing Dr. Peter Cherutich, NASCOP NASCOP’s commitment to women’s HIV prevention Yasmin Halima, GCM The role of GCM in HIV Prevention for women (5 min) Dr. Erasmus Morah, 34 UNAIDS UNAIDS commitment to HIV prevention for women in Kenya (5 min) Dr. Sobbie Mulindi, NACC Closing remarks and introducing the Chief Guest Beth Mutugi, the Senior Deputy Secretary, Ministry of Gender, Culture and Social Development Official closing and Presenting the Prevention Champion 35 ANNEXE 2 Opening Ceremony 36 Annexe 3: Presentations Annexe 3A Overview of the Kenya Women’s HIV Prevention Symposium Outline Background of the event Co-sponsors Objectives Beyond this Symposium Background of the event Idea was mooted last year modelled on similar work done in South Africa by GCM Idea pitched to civil society organisations namely Action Aid Kenya and KANCO who thought it timely Civil society seeks collaboration with NACC through the Gender Technical Committee A steering committee was put in place to deliver the Symposium Objectives of the meeting The primary expected outcome of the Symposium is: To inform the agenda of the national HIV prevention processes such as the upcoming national HIV prevention summit, the JAPR and others, on women’s HIV prevention priorities Secondary outcomes of the Symposium Symposium aims to deliver the following over the next year: A HIV prevention research agenda for women; Catalyse change towards standardised quality interventions appropriate for women; Challenge the status quo in HIV prevention for women by amplifying and disseminating what works for women Co-sponsors National AIDS Control Council (NACC) Global Campaign for Microbicides UNIFEM UNAIDS UNDP KANCO Liverpool VCT, Care and Treatment Action Aid Kenya International Partnership for Microbicides Steering Committee Pauline Irungu (GCM), Eunice Odongi (NACC), Harriet Kongin (NACC), Dr. Nduku Kilonzo (LVCT), Rosemary Mburu (KANCO), Anne Mumbi (KANCO), 37 Prof. Elizabeth Ngugi (CHIVPR/UoN, SWAK, KVORC), Ruth Masha (UNAIDS), Sari Seppanen (UNAIDS), Pascaline Kang’ethe (AAK), Lucy Wanjiku (AAK), Ursula Sore-Bahati (UNIFEM), Ludfine Onyango (UNDP) 38 Annexe 3B THE FEMINISATION OF THE HIV AND AIDS EPIDEMIC IN KENYA: CURRENT STATUS AND PROPOSED FUTURE DIRECTION FOR WOMEN SPECIFIC INTERVENTIONS Prof. Alloys S.S. Orago, Director - NACC August 31, 2010 Outline of the Presentation Introduction Kenya: Demographic Profiles (UNGASS, 2010). Gender differentials in HIV prevalence. Causes of women’s vulnerability to HIV infections Current interventions: focus on KNASP 2009/10 – 2012/13 (KNASP III). Pertinent concerns for HIV infection among women. Future direction on HIV prevention among women. Last Word. Kenya: Demographic profiles (UNGASS, 2010) Population estimate (2009) 39.4 million Distribution 52% female, 48% male o 79% rural, 21% urban Life expectancy at birth 58.9 years Number of PLHIV in 2009 ~ 1.45 million Adult HIV prevalence 15 – 49 years National 6.3% Men 4.3% Women 8.0% Young women 15 – 24 years ~ 4.5% Young men 15 – 24 years ~ 1.1% Female-to-male HIV prevalence ratio is ~ 1.9:1 HIV and AIDS related illness are the leading cause of death among women reproductive age Number of HIV-related annual deaths ~ 71,000 Adult ART coverage 308,610/463,599 ~ 67% Pediatric ART coverage 28,370/52,712 ~ 54% ART reduces morbidity and mortality substantially (Palelaetal, 1998: Lancet, 2010) KNASP III (2009 – 2013) targets 80% of all adults and children in need of ART fully covered by 2013. Calls for a rapid scale-up 39 40 41 42 43 SOURCES OF NEW INFECTIONS (KMOT 2009 From Kenya Modes of Transmission Study (KMoT, 2008); the sources of new infections were as follows: Heterosexual couples within a union/steady partnerships - 44.1% Casual heterosexual sex - 20.2% Men who have sex with men/prison populations - 15.2% Sex workers and their clients - 14.2% Injecting Drug Use 3.8% Healthy facility – related infections 2.5% Suggesting a need to redesign programme implementation modalities and also address systems strengthening issues Causes of women’s vulnerability to HIV infection Income disparities and gender norms, roles and relations.Socio-economic disparities lead to social exclusion which limits, and sometimes entirely prevents, people’s voice and participation within their communities in shaping, implementing, monitoring and evaluating actions that are likely to have a considerable impact on their own lives. Casual heterosexual relationships thought to include unprotected sex among multiple concurrent partners that impact on HIV discordance in couples (45%). Vulnerability to HIV among women are also a result of complex context specific interacting social factors that are in operation at: o Policy and legal environments that inform national planning and prioritization processes, financing, reporting mechanisms and requirements. o Service and infrastructure that influence uptake and delivery of services. o Interpersonal/social levels where gender power relations informed by cultural considerations, notions of masculinity and femininity all interact to impact on women’s sexual health options. 44 Current Interventions: Focus on KNASP 2009/10 – 2012/13 What is being done currently? IMPACT RESULTS: The number of new infections reduced by at least 50%. AIDS-related mortality reduced by 25%. A reduction in HIV-related morbidity. Reduced socio-economic impact of HIV at household and community level. Current Interventions: Focus on KNASP 2009/10 – 2012/13 OUTCOMES Outcome 1: Reduced risky behaviour among the general, infected, most-at-risk and vulnerable populations. Outcome 2: Proportion of eligible PLHIV on care and treatment increased and sustained. Outcome 3: Health systems deliver comprehensive HIV services. Outcome 4: HIV mainstreamed in sector-specific policies and sector strategies. Outcome 5: Communities and PLHIV networks respond to HIV within their local context. Outcome 6: Stakeholders to this Strategic Plan aligned and held accountable for results. Pertinent Concerns for HIV Infection among women Evidence for programming: One of the greatest set-back in Gender Programming has been insufficient evidence (including statistical evidence) and insignificant data on baselines. Most at Risk Populations o Emerging high risk trends and practices amongst populations. Rising infections that occur in couples (44%) who engage in heterosexual activity within a union or regular partnership. 400,000 secondary school students who graduate yearly in Kenya - Out-of-school youth especially girls and young women aged 12 to 24 years represent an even harder to reach group in terms of BCC, character formation and peer education. Future direction for women HIV prevention Address root causes of vulnerability such as gender norms and relations, human rights and gender dimensions of HIV. Innovativeness by stakeholders given the prevailing constraints in service delivery systems, 45 limited technical capacity and funding. Models that can be replicated. Male engagement. Programming that focuses on specific measurable results with clear indicators. Prioritization of mobilization of resources. Intensified research on social issues for evidence-based program design. Capacity building among all stakeholders’ on understanding of gender, gender considerations and gender analysis in programming. Sustained advocacy to inform program design, implementation, monitoring and evaluation and budgeting. Last Word The new constitution with the provision to review legislations, policies and development frameworks offers grand opportunities for every sector and programme including HIV prevention to formulate and implement legislation and policies and develop constitutional frameworks that promotes gender equality. 46 Annexe 3C KENYA WOMEN’S HIV PREVENTION SYMPOSIUM Making HIV Prevention Responsive to Women's Needs Women and girls vulnerability to HIV infection individual and socio-cultural factors By Prof. Elizabeth N. Ngugi 31st August 2010 Panari Hotel , Nairobi To day is the day I am going to focus on women and girls only they are the centre of analysis: because by and large and for a variety of bio/socio/cultural reasons they are more vulnerable to HIV infection and impact of AIDS. And the younger the female is the higher the risk of HIV infection. Girls are the gem of the society yet her vulnerability to HIV increase 5 folds compared to boys of the same age group Figure 1: HIV Prevalence by Age and Sex (KDHS 2003) Reproductive track immaturity more trauma during sex thus facilitating HIV infection. 47 May have an asymptomatic and therefore untreated STI facilitating HIV transmission. Social Cultural Risk Factors Reproductive track immaturity more trauma during sex thus facilitating HIV infection. May have an asymptomatic and therefore untreated STI facilitating HIV transmission. Disempowered to negotiate safe/ safer sex with men particularly males old enough to be the girls father even grandfather. It is the whole equation of power relations. Many are socialized to be meek and blindly obey. Early marriage (forced) dowry to pay boy’s school fees. Early sexual experience i.e. as early as 10 years of age Female Genital Mutilation and depending on the type it disfigures a beautiful organ and cause scarring that may result into obstructed labour with many known adverse biosocial effect . Here too the girl is exposed to HIV infection. Social Cultural Risk Factors Cont. Defilement is rampant in this country to a level that even 6 month old babies are known to have been violated. Besides HIV this is death like and some remain traumatized for life. Mentally and physically challenged women and girls To make it worse some are raped and infected with HIV. 48 To emphasize this point further a mentally challenged 15 year girl was repeatedly being defiled by her father who also infected her with HIV (Naivasha Jan2006-May 2007) This category of women and girls have an added vulnerability to HIV because of the disabilities. Other Gender Based Violence In Kenya 43% of 15-49 year old women (KDHS 2003) reported having experienced some form of gender based violence in their life time. 29% had experienced violence in previous year 16% of women reported having ever been sexually abused Other Gender Based Violence Cont. 13% sexual abuse had happened in last year It has been documented that every three minutes a woman is raped (kenya) AND THEN THERE is the controversial issue of marital rape. Other Gender Based Violence Cont. This is so controversial that it caused a woman's death in Nairobi (1st Aug. 2010) killed his wife over this. He came at wee hour at the night drunk and demanded his “conjugal right’ the wife declined and was strangled to death. Sex Work/GBV/HIV/ Woman /Girls There are unacceptable number of girls 10-18 years entering sex work daily. These are not sex-workers but sex slaves they are being violated daily several times (3-5) and almost always without a condom. She is disempowered ----how can she negotiate condom use with a sugar daddy? These are highly vulnerable to HIV infection Sex Work/GBV/HIV/ Woman /Girls Cont. Thus being highly exposed to HIV infection unplanned pregnancy and other form of trauma. Do not doubt it they exist .In one organization (Kvowrc 700 cumulative number have been reached and protected). This is a form of sex slavery of children <18 years, poor ,or orphaned by AIDS Adult Sex- Workers These exist in every town I have ever visited in Kenya because there is demand The reason I highlight this here is to register the fact that we will ignore then at our peril. Sexual interaction is wide and varied 49 CUTTING HIV TRANSMISSION CHAIN Adult Sex- Workers Cont. Study done in Kibera to find out Path ways for entering into sex-work and other characteristics came up with the following results in part. HIV/AIDS and partners ( Kibera) FSW & Alcohol Alcohol and other habit forming drugs reduce ability to negotiate for condom use 50 The graphic below underscores the point Link between Alcohol,violence and HIV and AIDS Violence Violence Alcohol HIV and AIDS Mackenzie and Kiragu K 2007 (Kenya) Widow inheritance Widow inheritance facilitates HIV spread The widow should be “non-sexually” inherited FSW INJURIES (Kibera 2009) “This study also revealed that they are often gang raped or raped i.e. one was raped sodomized and taken to police as a “criminal” “Raped by two men , took advantage & they tore me” “Cut in the face with a knife by the client who refused to pay” “Hit with a bottle on the head” Conclusion & recommendation Ladies and gentlemen we are a new country and new people a new people . There is therefore opportunity to push for women’s issues through well researched processes: poverty reduction holistic health literacy including that of HIV and AIDS , PreP, PEP, ART and support for care. Retention of girls school to institutions of higher learning Some proposed research issues for HIV prevention for women and girls Evaluation of the institutional factors that hinder HIV positive women from seeking medical interventions Barriers to exclusive breastfeeding by HIV positive women Barriers to ARV uptake and adherence among HIV positive women. Some proposed research issues for HIV prevention for women and girls Characteristics of barriers to HIV prevention profiling Women's and girls concerns in the uptake of female and male condom separately Emerging women’s HIV prevention methods i.e microbicide: how and when should this be rolled out 51 Some proposed research issues for HIV prevention for women and girl Protecting girl child from predisposition factors to HIV infection : what does the voice of the girl child say. Determine the best model for negotiating safe/safer sex practices for women and girls Violence against girls and women has reached an unbearable level : how should Kenya respond No girl child need ever go to the street to sell sex : what is the best protection strategy ? Girls 52 Annexe 3D Women & Girls Vulnerabity to HIV - Policy Gaps PAPER PRESENTED AT THE WOMEN AND HIV/AIDS SYMPOSIUM: Dr Leah Wanjama & Esther W. Gatua What Are the Key Issues? Kenya national prevalence 7.1%( KAIS 2007) New infections annually -majority occurring in couples - 166,000 (KAIS 2007). Young women and girls (15-19yrs) three times more infected than boys in the same age group. Key Issues Cont: KDHS 2003 – more women infected than men : 8.7 % and 4.6% men . Infections among commercial sex workers at 14.1% of all new infections and 36% among injecting drug users KDHS 2008-2009 - sexually active men using condoms more than women- 35% women against 62% Why the situation Above? Lack of policies? OR Lack of policy implementation? OR Policies exist, are implemented but No Follow up to establish effectiveness of the policies in responding to gender issues, women and girls vulnerability? The Reality Kenya has made several strides in policy development. (see the list in the hand copy) Policies not implemented Several sector specific policies not engendered and if they are implementation is biased. Limited or lack of integrated approach and co-ordination at planning levels by government, implementers and development partners. Why No Policy Implementation Inadequate research to establish gaps and why. Limited or lack of effective co-ordination, networking and partnerships. Limited capacity and resources to integrate gender at all levels of planning and structures. Few and un-equitably distributed programmes for special categories of women and girls and their clients. Limited sector specific capacity to implement policies that respond to gender issues. Unwritten cultural policies continue to negatively impact women and girls. 53 Inadequate empowerment programmes involving men to address the power imbalances and promote rights of women and girls. The HIV/AIDS taskforce - limited resources and capacity to co-ordinate, monitor and address the policy gaps. STRATEGIC ADVOCACY : Is the answer. Together we continue with the policy struggle on gender, HIV and AIDS. 54 Annexe 3E International frameworks for addressing HIV in women and girls Ruth Laibon-Masha Partnership Adviser UNAIDS 55 Enabling Environment What’s new: Action and Results Strategic actions to catalyze movement at the country level Human rights based approach Participation-Broad coalition building Partnership Evidence informed and ethical responses Engaging men and boys Strong and courage leadership Building synergies between the women’s right movement and the AIDS response 56 Time-bound and measurable deliverables for results for accountability Results 1 Quantitative and qualitative evidence on the specific needs, risks of and impacts on women and girls in the context of HIV with their participation Harmonized gender equality indicators are used to better capture the socio-cultural, economic and epidemiological factors contributing to women's and girls' risk and vulnerability to HIV. Evidence-informed policies, programmes and resource allocations that respond to the needs of women and girls are in place at the country level are in place. Results 2 Stronger accountability from governments to move from commitments to women's rights and gender equality to results, for more effective AIDS responses. All forms of violence against women and girls are recognized as violations of human rights and are addressed, in the context of HIV. Women and girls have universal access to integrated, multi-sectoral services for HIV, tuberculosis and sexual and reproductive health and harm reduction, including services addressing violence against women. Strengthened HIV prevention efforts for women and girls through protection and promotion of human rights and increased gender equality. Results 3. Women and girls empowered to drive transformation of social norms and power dynamics, with the engagement of men and boys working for gender equality, in the context of HIV. Strong, bold and diverse leadership for women, girls and gender equality for strengthened HIV responses. Increased financial resources for women, girls and gender equality in the context of HIV. 57 Mutapola framework ActionAid Atieno, Wanjiku, Chebet....., Comprehensive prevention, treatment, care and support; Sustainable livelihoods; Freedom of association and voice and an enabling policy environment Prevention 58 Mutopola in Action Eunice Aged 50 years old Married in 1973 to EllyOgwel Resident of Bar Okwiri Village Chair person of PLWHAs Support Group A widow taking care of 8 orphans(1 girls and 7 boys) Husband died in 2006 A member of BAMA CBO 59 The Turning Point in my Life Loss of a loved husband meant a complete change in Eunice’s life Challenges of widowhood soon set in: She became head of household with 9 members to feed Wife inheritance-unwritten policy of her people she had to deal with rumors that AIDS killed her husband? Deal with stigma associated with HIV/AIDS? 60 I am HIV Positive In 2006, Eunice joined Stepping Stones team She and other widows picked courage to go for VCT to know their HIV status Her fear was confirmed-she was positive Her status reinforced her resolve not to be inherited Joined 25 widows in BAMA villages and formed a group to protect their rights 61 PLWHIV Support Group AAIK supports BAMA Bama supports the women, Eunice included with oxens and plough to increase cultivation and food production Support Groups……………… 62 Through the group, Eunice claims back her right to association and deals with stigma. She participates in community development activities Eunice and her peers provide psychosocial support to each other. Amba Village Pharmacy…… 63 Eunice is a frequent customer of Amba VP She suffers skin wounds and she gets ointment from VP Amba Village pharmacy serves a population of 60 PLWHIVs, 18 of which are pediatric cases. The pharmacy has helped management of malaria, diarrhorea, and opportunistic infections amongst PLWHIVs Food and Nutrition…….. 64 Eunice is an active member of BAMA Local Foods Campaign. She grow local vegetables as well as kales for her use and sale BAMA in collaboration with Maseno University did research on medicinal and food value for 42 traditional vegetables The research has informed campaign to promote production, preservation and consumption of these vegetables as well as local grains like sorghum. Eunice and other villagers mainly women sell to BAMA grains and vegetables. 65 Food and Nutrition…… BAMA keep purchased food at its center where they are preserved and stored using traditional technologies This village food bank, as it is called by BAMA community, provide fall back during food stress period Food and Nutrition continue…… 66 The poor, PLWHAs, the aged and orphans are ring fenced to benefit from the village food bank. Eunice has been a beneficiary of the food bank on many occasions. She is also a beneficiary in the local goats upgrading project. 67 Food and Nutrition continue…… Goats project targets orphans, widows and PLWHAs and aims at providing milk and income. Over 541 orphans and 382 widows have benefited from this project Between 2007 to 2009, beneficiaries have realized Ksh 1.5m from this project. Food and Nutrition…… Between 2007 to 2009, beneficiaries have realized Ksh 1.5m from this project. The local foods, village food bank and the goat project is sustaining lives of many poor and excluded in BAMA villages 68 Adult Literacy Class …. Eunice realized she needed to learn how to read and write and do simple arithmetic if she was to manage her goats and those of her children She joined BAMA Adult Literacy class and is proud to be one of the beneficiaries with good records on goats. 28 learners have graduated from BAMA Adult Class and 82 are currently enrolled. 69 Literacy classes has improved women participation in community development activities in BAMA villages Human Rights Awareness….. Eunice has participated in Child Rights, Gender Violence, Succession And Inheritance, and Rights of PLWHAs Backed by the projects, civic education has increased HR awareness level amongst women in BAMA 70 Annexe 3F Issues and Challenges for delivering the national HIV prevention response for women Nduku Kilonzo, PhD Director, Liverpool VCT, Care & Treatment (LVCT) Chair, Health NGOs Network (HENNET)s Presentation outline What is risk and where do the issues for response lie? The Kenya HIV service/response delivery frameworks Structures National planning and prioritization processes Reporting Implementing partners engagement Funding Considerations for a response for women’s HIV prevention New infections? What does prevention mean What are the levels of impact? Behavioural (social inform individual – what drives multiple concurrent relations, risky sex?) Notions of masculinity & femininity Gender based violence & ability to negotiate safer sex Health seeking behaviours Biomedical interventions Tested: HTC; PMTCT; OVC; VMMC, Prevention with Positives (PLHD) Under testing: Microbicides/Vaccine/PEP/PrEP; Treatment as prevention (TEST & TREAT) Structural interventions*** (drives the national response through which programme results are achieved) Policy & legal environments Service/programme delivery infrastructure National HIV response framework NACC BOARD NACC SECRETARIAT NACC ICC & ADVISORY COMMITTEE OVERSIGHT & MONITORING COMMITTEE PILLARS 1 – 4: Health sector – NASCOP/DRH & MOH Community services - NACC Sectoral mainstreaming - MOFP Leadership/governance - NACC 71 A range of committees (prevention, M & E etc) NACC sub-national levels – Provincial/District and constituency (aligned to national systems at these levels) Over-arching issues for delivery of the national response Policy:KNASP III provides a policy frameworks to guide integration of issues HR, gender, GIPA, youth, Challenges: articulation of systems & structures for monitoring this International directions: Focus on ‘risk’ categorization: - risk is driven by vulnerability? What does this mean for our HIV prevention Scale up of bio-medical interventions: to what extent have key gender power dynamics been explored for optimal manipulation to enhance results? Evidence: Research & utilization of routine data/information collected through M&E Structures & systems for the response? Pillar 1 – 4: health sector based, community services, sectoral mainstreaming, leadership/governance Alligned to sectoral and government programming Issues: National & sub-national key committees e.g. HIV prevention taskforce; oversight committee; ICC advisory – no deliberate gender expertise Weak health sector coordination e.g. RH and HIV separate Links btwn health & community structures weak – women’s issues very community located Lack of accountability for gender analysis and women’s specific response within structures Lack of gender sensitive, value based training Planning & prioritization? Includes systems & series of activities through which priorities are identified, planned for, funded NACC: JAPR, HIV prevention summit, GF mechanisms Health sector (pillar 1): Health summit Issues: No gender analysis in review of progsesp in the context of scale-up & universal access; focus on numbers e.g. PMTCT uptake, GBV issues in couples interventions Lack of use of routine data – e.g. new infections among female youth – coerces sex interventions HMIS does not capture women specific issues 72 Mismatch between services and expenditure/ funding Limited knowledge sharing – govt., private, CSOs Reporting? M & E requirements and mechanisms at sub-national & national levels Issues: Data tools does not capture gender related indicators but, indicators are now in the M & E framework o Disconnect between M & E frameworks: o COBPAR (NACC) & Community based strategy (MOH) MOH HMIS & NACC reporting requirements e.g. form 721 does not capture ‘risk’ categorizations No obligation for reporting by CSOs to the national, so lack of comprehensive, timely, accurate data for utilization Limited utilization of data and feedback from national levels (across pillars) to accumulate ‘sound’ evidence Implementing partners? Many & diverse at community, sub & national levels Funded by a range of partners Issues: Many CSOs and NGOs with limited coordination Lack of collaboration between health/HIV and women’s rights and gender integration CSOs Disregard for national reporting mechanisms in favour of funders – so, limitations for regulatory gender integration Few local CSOs with capacity for national level facilitative engagement and policy reforms – technical, financial and accountability capacities Limited advocacy for HIV prevention & women’s priorities The National Incidence Model 2008 Funding? 80-90% of HIV funding Priorities based on international directions Issues: Minimal funding for gender, human rights in programmes, supporting structures and systems, monitoring national frameworks for accountability GF mechanisms do not require gender expertise No gender indicators among donors e.g. PEPFAR 73 Shifting paradigms (the judge balance) - Move away from HIV towards issues such as systems strengthening visa viz strengthening integration Funding local needs? e.g. 70% of new infections – casual heterosexual sex & couples (primarily women) - funds focus now on MARPs Programmes? Universal Access needs to be achieved Issues (focusing on current interventions Counselling and Testing (CT): 56% but more women. What is needed for couple uptake (men sexual decision-makers) PMTCT: focus on WOMEN (MOTHER’s) as Vectors? Behavior change: homogeneic prevention messaging; access to female condoms; age (girl) friendly services; VMMC: impact of the protective effect of VMMC on sexual behavior/masculinities – MCRs? Unprotected sex? Prevention with PLHIV: gender dynamics of disclosure & required skills/services – unknown Transmission in health care settings: 85% throughput is women; HIV PEP - impact on chronic exposures of gender based violence is unknown. Programmes? Universal access needs to be achieved Issues (focusing on current interventions): STIs: Many of women infections are asymptomatic; lack of information; poor linkages btwn services; ltd access Treatment, care and nutrition: poor access - 300,000 Kenyans (majority of whom are women) not on Rx; service availability at health facilities TB/HIV services: access and service provider attitudes OVC: women/girls – disproportionate burden Evidence? RESEARCH, RESEARCH, RESEARCH Data utilization Evidence informed programming Issues: Limited availability of ‘evidence’ – what sort of evidence? (Gray scale 1?) e.g. feedback from results Evidence – investment in research Understanding gender dynamics in scalable interventions Funding for women specific research? 74 Considerations & way forward? ‘think tank/initiative’ to guide the strategic thinking: Deliberate, consistent action & monitoring – NACC, the pillars, coordination, prioritization processes, identify quick wins within TOA, NPO, Global Fund applications, JAPR strengthening, pillar evaluations Watchdog committee for advocacy strategy Capacity building on utilization of gender analysis, gender responsive programming and women specific focus Continual advocacy on the new constitution, on KNASPIII, implementation, M & E and budgeting using a gender lens Intensified investment in research on gender related aspects within scale up of bio-medical inteventions Accountability for results - defined indicators, performance measures, ensuring gender analysis and follow up of recommendations KEY MESSAGE FOR TODAY AND TOMORROW: UNDERSTANDING WHAT DRIVES DELIVERY OF THE HIV RESPONSE AND PROGRAMME RESULTS, WHAT CAN YOU DO DIFFERENTLY FROM WHERE YOU SIT? HOW DO WE ENSURE THAT THIS PROCESS ENSURES RESPONSE TO WOMEN IF WE ARE TO GET THE RESULTS WE DESIRE? Acknowledgements Women’s HIV prevention steering committee Consultant – background paper development Partners: UNDP, Trocaire LVCT staff – Gender team, research team 75 Annexe 3G Zambia: No more Microbicide clinical trials on women – Mazabuka Central MP Dec 29, 2009 Za mbia: MPs roar at botched microbicide trials Feb 25, 2010 76 Annexe 3H Incorporating emerging HIV prevention technologies into the everyday lives of women Pauline Irungu, Global Campaign for Microbicides Incorporating emerging HIV prevention technologies into the everyday lives of women Women have proved themselves as adopters of technologies especially those they understand and/or perceive to make a positive difference in their lives (ranging from cosmetics, for food production and even for health) What influences women to adopt and apply technology in their everyday lives? Availability o Is it within their locality? o How much does it cost? o How easy is the procedure for getting the tool? Cost of the product Comfort in using o privacy while using and also storage o The form in which it comes o Ease of application o Economic status of the individual woman – vs – the competing needs in her life Assurance of safety of the product Faith in the product – if there are negative myths especially linked to fertility women may not use a product even if it has no safety issues scientifically Social influences around the woman e.g. the family and friends The status and kind of sexual relationship she is in Age status Considering these array of factors among others, how should we be designing our programmes and advocacy to facilitate women to use emerging HIV prevention technologies? 77 Annexe 3I KENYA WOMENS HIV PREVENTION SYMPOSIUM: Making HIV responsive to women’s needs Social-Behavioral Research By Violet N. Kimani Combined methodologies Quantitative & Qualitative Complimentary Interactive & educational Facilitates self appraisal Consensus building Key Issues Barriers to HIV prevention among women Stigma Gender power relations Socialization process Compliance to socio-cultural expectations Gender Based Violence Most times GBV is synonymous with violence against women. Special Groups (i) Children 7 – 36% of all girls } 3 – 29% of all boys } suffer SV 33% of all child SV in intra familial, someone the child trusts Special groups (ii)Men 78 NBI women’s hospital reports 7% of survivors are men. Sexual violence SV accounts for more than 80% of all GBV in Kenya. ARV Adherence Ideal ARV facility as per women users: “Where Service Providers/Clinicians are HIV positive …..able to understand well and treat me well…” “More training for clinicians on how to serve clients…” “There should be more trained and informed doctors skilled in their areas of expertise. Because I may look at some doctors and immediately tell that they don’t have the skills and education to go with it….” “As far as possible treatment of OIs should also be provided at the ART clinics…….” “ART clinic to operate 24hrs & week ends …there is a time I was sick and had to walk at 2am to Mbagathi District Hospital………” Adherence To ART Access to ART much improved yet adherence not yet 100% Drugs taken for life unpopular Disclosure issues Gender & Power relations Socio-economic diversity KAP on ART Consensus ART working effectively Location of HIV diagnosis Majority at VCT centres Women disclose more often to spouse Gender diversity in health seeking patterns Socio-economic status & Access issues Contraceptive use by women in discordant unions Non use of available services Exposure to risk of infection Many children to ensure survival Fear of partner negative response Secrecy & non communication 79 Recommendations Institutional level: Sensitize all staff on SV Forensic training to all staff Proper records & code for SV Operational 24 hours daily Child friendly facility & services Marital Unions Recognition of diversity of unions Cohabiting, polygamous/monogamous Women marginalization & disclosure remains same (fear/stigma) Single never-married by choice Single widowed/separated Widowed remarried Barriers Challenges Access issues Gender power relations Decision making processes Fears to any issues impacting on fertility 80 Annexe 4 Prevention Champion’s Voice “At 28 being a woman, an artist and an activist, I often find myself questioning my role and purpose in doing what I do in this community. I have lived a significant part of my life trying to achieve what I define as success, that which brings the utmost fulfillment; in the physical, emotional and psychological realms. I will admit that life has been generous to some of us, when we lacked we were provide, the doors we knocked were opened, and any effort or lack of, was still rewarded with a presence of our basic rights and freedoms. In contrast, what I have witnessed signifies how removed some of our realities are, especially in sight of the lives of the vast majority of women in Kenya who can barely describe the art of living. We are in a country where women and girls stand as the most vulnerable in the society, with no access to basic rights, and when granted access, are still repressed through the social and cultural practices that hinder them from progress. This leaves me to believe that the only success any woman in this country may attest to is in opening spaces for other women to succeed; in allowing their voices to being heard, their faces seen and efforts finally rewarded. With this, I commit myself to being successful, for my success must convey her success as well.” 81 82 83 84 ANNEX 5 Participants list Kenya HIV Prevention Women Symposium Venue: Panari Sky Hotel Date: August 30-September 1, 2010 Name Edwin Were Paul Mwangi Ludfine Anyango KuleWario HellenMatete Teddy Warria James Kamau Mboje Mjomba Esther Soti Anne Chepkoech Sharon Olago Jane Mukiri Margaret Masara Violet Kimani Stephen Makau Fredrick M. Mwanzia Anne Njeru Dennis Gaturuku Betty Njoroge DolphineOketch Salome Wasike JanefarWaitherero Patrick Mwai Charity Mwangi Kawango Agot Faiza Hussein Beatrice Awino Jacinta Mulatya Rose A. Ondego Patrick Muriithi Maureen Wanjiku Mary Kiragu Anyango Ojwang Millicent Opar DorineAchieng Jacinta Amollo Susan Kagimbi Anthony R. Hulula Stacy Hannah Anne Nduta Pascaline Kange'the Ruth Masha Fredrick Nyagah Organization MU/AMPATH KIRAC UNDP COVAW AAIK NHI KETAM VSO Devlink Bomet Youth Centre MTV Staying alive KVOWRC MAWEPI VCT UON WorldView Kenya MMM-Mukuru DRH/MOPHS KANCO KEMRI KEFEADO KAP KANCO KANCO-Coast KANCO Impact-RDO KCIU KANCO SAFUA-CBO KENEPOTE NACC Action Aid LVCT/Kijabe Hospital Chako Chon Action Aid Action Aid Action Aid Action Aid St. Joseph UzimaPrg AVAC A for Change Action Aid UNAIDS Engenderhealth 85 Email [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] bawino@kanco [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] [email protected] Phone 0733-759942 0720-748523 7624724 0716-535518 0734-210580 0733-275415 0722-886694 0722-678995 0725-674218 0722-325411 0728-177154 0721-571116 0722-793712 0722-445120 0722-734167 0727-729986 0733-606404 0720-281592 0735-350432 0720-996532 0721-658744 0721-310779 0734-143848 0723-245586 0729-390100 0724-909538 0722-858103 0721-971429 0721-750546 0722-864580 0728-687320 0724-963194 0712-157508 0720-985072 0734-252466 0727-596267 0720-439980 0723-335704 0713-142705 0720-402704 0733-889140 7625124 0722-439024 Beverly Achieng Betty M. 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