Effectiveness of the program for Prevention of Mother to Child Transmission of HIV in Nyanza province, Kenya

• 
  To determine the effectiveness of PMTCT program in Nyanza province.
  
• 
  To compare the effectiveness of PMTCT program of Nyanza province with programs from other areas.
  

Operational analysis of Antenatal care activities using adapted Piot's Model, and comparative Analysis using standardized PMTCT indicator.

During the 1^st quarter of 2003, out of 9871 first-visit pregnant women, 7770 (78%) were counselled, and 5439 (70%) were tested; 1577 (29%) were HIV positive, 398 mothers (25%) took Nevirapine, with a possible 55 cases of perinatal HIV averted.

• 
  Therefore, the effectiveness of the program was 14 %
  
• 
  The effectiveness is very low, but comparable to similar programs elsewhere.
  
• 
  Recommendations for Nevirapine should be considered in light of home deliveries without antenatal care and knowledge of serostatus.
  

• 
  1 There IS need to address primary prevention in this community with avery, high background prevalence.
  
• 
  2. There is need to integrate family planning with prevention efforts to prevent unwanted pregnancies in HIV positive women
  
• 
  3. There is need to focus on the youth (10-24 year-olds) especially the girls who are disproportionately affected
  
• 
  4. There is need to strengthen postpartum continuum of care to support the women and their families.
  

One of the most pressing challenges for health providers in sub-Saharan Africa is how to supply male condoms, and promote their correct and consistent use at the community level for dual protection against unwanted pregnancy and STI/HIV-AIDS. In spite of condom distribution and promotion efforts, male condom use remains low in countries such as Kenya and Tanzania. Hence, HIV infection and unwanted pregnancy rates continue to escalate. Little is known about the feasibility of supplying condoms through outlets other than health facilities, CBD programs and pharmacies and/or whether people in slum settings are willing to promote, distribute, or use condoms, if they are provided free of cost.

To identify potential structures and resources at community level that can be utilized to support condom promotion for dual protection and provide baseline data to inform a design of a Reproductive Health Initiative (RHI) on dual protection. The study aimed to answer the following questions: What are community groups and leaders attitudes towards condom use and willingness to promote or provide condoms for dual protection to community members, especially young people? What community structures and resources in urban slum settings could be used to support community level condom promotion for dual protection.

The study was conducted in Nairobi (Kabiro and Kangemi), Mombasa

(MIongwe) in Kenya and Arusha (Unga Limited). Tanzania. Convenience samples of retail shops, hair beauty salons /barbershops video show rooms, bars, guesthouses and nightclubs were selected. A total of 143 establishments were selected and semi-structured interviews were conducted. Over 83 structured Interviews were conducted with male and female groups of youth, community adults and community leaders. Thirty-two focus group discussions were held with women and men community groups. Epi-lnfo computer program was used for data entry and analysis.
Results:

Community group leaders know what condoms are and over 9O% could identify condoms when shown in packets of three. Overall, 84% of the respondents knew the reasons for which condoms are used (to prevent unwanted pregnancy - 95%), to prevent STI, HIV and AIDS - 84%). About 87% of community group leaders support the use of condoms for prevention of pregnancy and ST1, HIV and AIDS and about 90% of them would be willing to distribute Information materials for dual protection. About 85% of community leaders would be wiling to show videos to the youth and about 85% of women and 74% of men would be willing to promote condom use in their communities. Nearly 80% of potential condom outlets (such as bars, guest houses. kiosks and shops) would be willing to make condoms available in their establishments.

It is feasible to use non conventional condom outlets and community structures to promote and distribute male condoms in communities for prevention of unwanted pregnancy and STI, HIVandAIDS. Community based projects could work with these community structures to mitigate the problems of unwanted pregnancy and STI, HIV and AIDS because of their wider reach in the community

The Female Condom Community Intervention Trial (FCCIT) study was conducted on tea, coffee and flower plantations in central and western Kenya between 1998 -1999. It was designed to determine whether the introduction and promotion of female condoms (FCs) would successfully Increase overall condom use and reduce the incidence of STI. Findings from the FCCIT indicated that although the rate of male and female condom use increased substantially, the STI prevalence showed no significant decrease. Some of the questions this study was designed to investigate are: What factors may account for differences between reported levels of condom use and incidence of STI among FCCIT study participants?; what factors are hindering providers from promoting female and male condoms to FP Clients?; and what accounts for differences between the level of condom promotion among clinic staff and outreach staff (depot holders)? These data discrepancies provided the basis for further investigation.

This presentation will investigate the factors influencing the promotion or lack of it among clinic staff and depot holders in order to explain variations in condom distribution.

Qualitative methods were used to explore factors influencing condom use to provide a contextual understanding of sexual activity, the meanings of those relationships, and especially in negotiation for condom use. Timed clinic observations, participant observations, structured In-depth interviews and focus group discussions were conducted. Estate managers, villagers elders {key Informants}, private practitioners, untrained health providers, clinicians, depot holders and plantation workers were interviewed in 2 major tea estates that participated in the FCCIT.

Preliminary findings show that the low performing sites promoted and distributed less condoms because some clinicians felt that promoting condoms was morally wrong. This explains the lack of initiative in providing condoms even when they know that a client needs condoms. Another explanation for low condom distribution was that some clinicians might have also given up on clients who frequently go back to the clinic for treatment of STIs and therefore did not see reason to provide condoms. Some providers were not motivated to promote and distribute condoms; probably because they felt that they were too busy treating clients.

Obtaining more ethnographic information would increase our knowledge about the individual, social, and cultural factors influencing condom rejection and acceptance and can be used to develop strategies to improve condom promotion at service delivery points (SDPs) throughout Kenya and Eastern and southern Africa.

With a total population of about 30 million, over 2 million Kenyan adults and children are estimated to be living with HIV. Though nationwide the Infection rate is 14%, in some areas it is even higher. In Nyanza province on Kenya's, western border, the adult HIV prevalence is estimated at 30%­-40%. Despite the alarming reality of HIV In Kenya, condom use -known to be the only effective way to avoid HIV and other STls among the sexually active - continues to be low.

This study sought to identify, document and explain factors that Influence condom promotion by various categories of STl service providers in order to provide the Ministry of Health with information for interventions to improve condom counseling and distribution.

The study was conducted in an urban (Kisumu) and a rural site (Siaya) In Kenya's Nyanza province. A purposive stratified sample of sites and providers from both the formal and informal health sectors were selected for intensive investigation and STI patients were interviewed individually. Qualitative methods such as in-depth interviews and focus group discussions and structured observations were used to collect data between May 2001 and March 2002. Ten focus group discussions and 143 in- depth interviews were conducted.

Preliminary findings indicate that the mean age of STI patients who participated in structured I observations was 25 years, 52% were male and 48% tamale. There was little or no condom promotion by STI providers in government and municipal facilities. Patients were hardly asked about their risky behavior and providers steered away from discussions on or demonstration of condom use. Pharmacy attendants, unlicensed health providers and traditional healers did not provide any counseling on condoms at all. However, community based distribution agents educated clients on condoms and STIs, provided condoms and made referrals to the formal sector. Providers in the formal sector reported that they were too busy to counsel STl patients in general and specifically, about condoms. The content of condom counseling was inconsistent and varied greatly and many providers said they had not been trained to educate clients on STls and prevention strategies. Patients raised the issue of lack of confidentiality and privacy, lack of free STI drugs led to a decline in the number of patients visiting public facilities. As a result a shift to the informal sector {herbalists. unlicensed providers) was noted while other patients resorted to self-medication.

To be more effective, Interventions must address factors that affect providers’ promotion and provision of condoms and those that push STI patients towards the Informal health sector

It is increasingly feared that teachers are at greater risk for HIV than other professionals of similar education in sub-Saharan Africa. Some factors cited as elevating their risk include their frequent postings and transfers, their comparatively higher and steadier income especially in rural areas (despite the low salaries), and their access to power especially with young female students. Even if teachers were not at higher risk than anyone else, their role in a country's development makes them a special group that deserves unique attention. Significant deaths and illnesses among teachers can erode gains made in educating a labor force, and thereby reverse hard-won economic and developmental achievements. Little is known about what teachers themselves feel about HIV/AIDS, and how they are coping with it in the classrooms and in the schools. Even less is known about the needs of teachers Vis a Vis HIV/AIDS at home and in their personal lives.

In order to learn what teachers think about HIV/AIDS and how they are coping with it at home and at school, informal conversations were held with teachers in 41 primary and secondary schools in two districts in Kenya. A total of 74 teachers evenly split between males and females were involved. The sample also included school principals. Data were collected in March 2002.

Teachers feel they are inadequately informed about HIV/AIDS. Unless they are teaching an HIV-related subject such as family life education, most teachers report that they do not have any unique way of getting HIV/AIDS information when compared to the rest of the population. Teachers also feel at elevated risk of the infection, because they are often requested to deal with emergencies among students that could expose them to bodily fluids. Some teachers also acknowledge that they are at higher risk as a result of the nature of their jobs, higher income, and access to potential sex partners. While a handful know teachers living with HIV, most say they would feel uncomfortable interacting too closely with such a person, especially sharing cups and other utensils. Teachers also say they are afraid of getting tested for HIV, since going for a test acknowledges "self suspicion", in the words of one. As community leaders, they feel VCT is an admission of previous wrongs.

The assumption that teachers are adequately informed about HIV/ AIDS may be mistaken. Programs should address the unique needs of teachers and help them cope with HIV/AIDS both at school and at home. Such programs should address the heavy stigma attached to PLHA, as well as the fear teachers have in getting tested for HIV.

The government of Kenya has declared HIV/AIDS a national disaster and is committed to continuing its spread and attenuating its impact. One of the strategies identified to achieve this goal is condom promotion. Particularly among those population groups that are at the greatest risk of' contracting HIV and other sexually transmitted Infections (STIs), such as sex workers (SWs). The female condom has not been introduced in Kenya's national contraceptive method mix. Since it is a female initiated dual protection method. 1t has been hypothesized that it would fill the gap in protection against STIs among high-risk populations in Kenya. The current FHI/IMPACT SW project in Mombasa provides an opportunity to explore the potential for strengthening a peer education program by introducing the female condom.

To provide information on how the current FHI/IMPACT STl reduction project in Mombasa can be modified to achieve maximum public health benefit by 1) determining the feasibility of introducing the female condom to the current peer education programme; 2) assessing the current SW peer education program; and 3) determining the best way to address men in a female condom intervention with SWs.

Several data collection procedures were used, including participant observation, in-depth interviews, and focus group discussions. Participant observations were conducted in the places where sex workers and their clients hang out, such as bars, discos, traditional brew dens, and guesthouses. In ­depth Interviews were carried out with 20 SWs and 20 partners of SWS to determine the best way of incorporating them in the program. Finally, after receiving an introduction to the female condom and an opportunity to try them for three weeks, focus group discussions were held with approximately 50 SW peer educators regarding their perspectives on the method.

Preliminary findings show that there are opportunities for increased male condom promotion among sex workers and their partners In Mombasa. It also appears to be feasible to introduce the female condom in this population. These results will be validated by a cross sectional survey to be conducted in this population In October. If there is evidence of a condom gap a follow-up intervention study will be designed to empirically test the value of adding the female condom to the condom distribution system. Findings from this formative research will help to inform the design of that study and will bring a broader context of the cultural and economic context of sexual networking among the sex workers .Further findings will be presented at this conference.

HIV prevalence in, Kenya is higher in urban areas (16-17%) compared to rural areas (11-12%). Even in urban areas, the poor tend to suffer a higher burden of the condition (National AIDS Control Council 2000). To mitigate the spread and impact of HIV/AIDS, behavior change proponents promote three main strategies namely abstinence, mutual faithfulness to one partner and condom use. Further, in recognition of women's vulnerability to sexual exploitation their empowerment to negotiate safe sex has been adopted as an important strategy. However, for these strategies to succeed there must be an enabling environment that includes access to condoms, access to health services and sexual privacy. This paper examines the implications of lack of sexual privacy on the sexual lives of slum dwellers in Nairobi.

The data come from a qualitative study that was conducted in four slum areas of Nairobi namely Kibera, Majengo, Kahawa North and Embakasi in January 1999. The main purpose of the study was to assess sexual networking patterns of informal settlements in relation to the people's knowledge on HIV/AIDS and the perceived incidence. Forty focus group discussions. (FGDs) were conducted with groups of both single and married men and women in the age categories 13-17, 18-24, 25-49 and 50+. Also involved were community leaders and service providers. The data were transcribed verbatim and analyzed using NUDIST.

The FGD participants recognized privacy during sex as a big problem mainly because most of the households have single-roomed sleeping arrangements. The coping strategies adopted by parents include "waiting for children to fall asleep, turning the lights off, using curtain materials to separate the sleeping places, playing loud music, postponing sexual activity or sending the other children away". The young people on the other hand have sex at "friend's houses, in the grass/bush, in the toilets/bathrooms, along walls and dark alleys and in abandoned, collapsed or incomplete housing structures". Lack of privacy compromises the ability of the residents to implement safe sex practices, especially use of condoms and abstinence. Sexual activity takes place in the shortest time possible and with minimal noise, which essential makes the use of condoms impracticable. In addition, women are constrained in negotiating safe sex especially if there are children and other kin in the same room. It is also difficult for abstinence to be effective among the youth due to early initiation to sexual activity.

Lack of privacy during sex could be a contributing factor to low condom use and low levels of abstinence among the youth in urban poor areas. Lack of sexual privacy also poses numerous negative psychological and social consequences including embarrassment to parents and children, frustrated sex lives, lack of quality sex, lack of respect between children and their neighbors, and early socialization of children into sex. These factors could also partly explain the linkage between poverty and HIV infection in poor urban areas

There are limited reports on HIV-1 RNA load, CD4+ T-lymphocytes and antibody responses in relation to disease progression in HIV-1 infected untreated children in Africa.