Understanding Gender-Based Violence Service Delivery in CDC-Supported Health Facilities: 15 Sub-Saharan African Countries, 2017-2021

Gender-based violence (GBV) is a complex issue deeply rooted in social structures, making its eradication challenging. GBV increases the risk of HIV transmission and is a barrier to HIV testing, care, and treatment. Quality clinical services for GBV, which includes the provision of HIV postexposure prophylaxis (PEP), vary, and service delivery data are lacking. We describe GBV clinical service delivery in 15 countries supported by the President's Emergency Plan for AIDS Relief (PEPFAR) through the U.S. Centers for Disease Control and Prevention. Through a descriptive statistical analysis of PEPFAR Monitoring, Evaluation, and Reporting (MER) data, we found a 252% increase in individuals receiving GBV clinical services, from 158,691 in 2017 to 558,251 in 2021. PEP completion was lowest (15%) among 15-19-year-olds. Understanding GBV service delivery is important for policy makers, program managers, and providers to guide interventions to improve the quality of service delivery and contribute to HIV epidemic control.

Sexual Violence Trends before and after Rollout of COVID-19 Mitigation Measures, Kenya

COVID-19 mitigation measures such as curfews, lockdowns, and movement restrictions are effective in reducing the transmission of SARS-CoV-2; however, these measures can enable sexual violence. We used data from the Kenya Health Information System and different time-series approaches to model the unintended consequences of COVID-19 mitigation measures on sexual violence trends in Kenya. We found a model-dependent 73%-122% increase in reported sexual violence cases, mostly among persons 10-17 years of age, translating to 35,688 excess sexual violence cases above what would have been expected in the absence of COVID-19-related restrictions. In addition, during lockdown, the percentage of reported rape survivors receiving recommended HIV PEP decreased from 61% to 51% and STI treatment from 72% to 61%. Sexual violence mitigation measures might include establishing comprehensive national sexual violence surveillance systems, enhancing prevention efforts during school closures, and maintaining access to essential comprehensive services for all ages and sexes.

NATIONAL HIV TESTING CAMPAIGNS TO SUPPORT UNAIDS 90-90-90 AGENDA: A LESSON FROM KENYA

Background

HIV diagnosis is the gateway to antiretroviral therapy. However, 20-50% of HIV-infected individuals are unaware of their HIV status, derailing epidemic control.

Objective

To increase awareness of HIV status and enrollment into HIV care & treatment (C&T) services through a national HIV testing services (HTS) rapid results initiative (RRI) campaign in Kenya.

Design

This cross-sectional analysis presents yield of undiagnosed people living with HIV (PLHIV) and their enrollment into HIV C&T resulting from HTS RRI implemented in July-August 2013 as an example of utilizing RRIs to catalyze achievement of UNAIDS targets.

Results

During the campaign 1,462,378 persons received HTS, of whom 220,902 (15%) were children (aged <15 years), 55,088 (7%) couples and 116,126 (8%) key populations. A total of 37,630 (2.6%) HIV+ individuals were identified. Among children who received HTS, 3,244 (1.5%) tested HIV positive, compared to 34,386 (2.8%) among adults. Of the eight regions in Kenya: Nyanza, Rift-valley and Nairobi contributed 73.3% of all HIV+ individuals identified. HTS at health facility settings yielded the highest proportion (69%) of HIV+ and key populations had the highest prevalence (4.8%). Of those infected, 29,851 (79.3%) were enrolled into HIV C&T. Sex, age and setting of HTS were significantly associated with enrollment into HIV C&T (p<0.0001).

Conclusion

National HTS campaigns have the potential of increasing knowledge of HIV status. Targeted provision of HTS at health facility settings, to key populations and high burden geographical regions would narrow the gap of undiagnosed PLHIV towards achieving UNIADS 90-90-90 targets for HIV epidemic control.

Pre-exposure prophylaxis rollout in a national public sector program: the Kenyan case study

Background While advances have been made in HIV prevention and treatment, new HIV infections continue to occur. The introduction of pre-exposure prophylaxis (PrEP) as an additional HIV prevention option for those at high risk of HIV may change the landscape of the HIV epidemic, especially in sub-Saharan Africa, which bears the greatest HIV burden.

METHODS

This paper details Kenya's experience of PrEP rollout as a national public sector program. The process of a national rollout of PrEP guidance, partnerships, challenges, lessons learnt and progress related to national scale up of PrEP in Kenya, as of 2018, is described. National rollout of PrEP was strongly lead by the government, and work was executed through a multidisciplinary, multi-organisation dedicated team. This required reviewing available evidence, providing guidance to health providers, integration into existing logistic and health information systems, robust communication and community engagement. Mapping of the response showed that subnational levels had existing infrastructure but required targeted resources to catalyse PrEP provision. Rollout scenarios were developed and adopted, with prioritisation of 19 counties focusing on high incidence area and high potential PrEP users to maximise impact and minimise costs.

RESULTS

PrEP is now offered in over 900 facilities countrywide. There are currently over 14000 PrEP users 1 year after launching PrEP.

CONCLUSIONS

Kenya becomes the first African country to rollout PrEP as a national program, in the public sector. This case study will provide guidance for low- and middle-income countries planning the rollout of PrEP in response to both generalised and concentrated epidemics.

Application of psychosocial models to Home-Based Testing and Counseling (HBTC) for increased uptake and household coverage in a large informal urban settlement in Kenya

INTRODUCTION

Home Based Testing and Counselling (HBTC) aims at reaching individuals who have low HIV risk perception and experience barriers which prevent them from seeking HIV testing and counseling (HTC) services. Saturating the community with HTC is needed to achieve the ambitious 90-90-90 targets of knowledge of HIV status, ARV treatment and viral suppression. This paper describes the use of health belief model and community participation principles in HBTC to achieve increased household coverage and HTC uptake.

METHODS

This cross sectional survey was done between August 2009 and April 2011 in Kibera slums, Nairobi city. Using three community participation principles; defining and mobilizing the community, involving the community, overcoming barriers and respect to cultural differences and four constructs of the health belief model; risk perception, perceived severity, perceived benefits of changed behavior and perceived barriers; we offered HTC services to the participants. Descriptive statistics were used to describe socio-demographic characteristics, calculate uptake and HIV prevalence.

RESULTS

There were 72,577 individuals enumerated at the start of the program; 75,141 residents were found during service delivery. Of those, 71,925 (95.7%) consented to participate, out of which 71,720 (99.7%) took the HIV test. First time testers were (39%). The HIV prevalence was higher (6.4%) among repeat testers than first time testers (4.0%) with more women (7.4%) testing positive than men (3.6%) and an overall 5.5% slum prevalence.

CONCLUSION

This methodology demonstrates that the use of community participation principles combined with a psychosocial model achieved high HTC uptake, coverage and diagnosed HIV in individuals who believed they are HIV free. This novel approach provides baseline for measuring HTC coverage in a community.

Do clients receiving Home based testing and counselling (HBTC) utilize the HIV prevention messages delivered? A study among residents in an urban informal settlement in Kenya who previously received HBTC

BACKGROUND

Home based HIV testing and counseling (HBTC) increases access to services and is associated with high testing uptake. Alongside testing, individuals are offered HIV prevention messages with an aim of helping them reduce HIV high risk sexual behaviors. This study explored the level of provision and subsequent utilization of HIV prevention messages and associated change in behavior among individuals who had received HBTC previously in an informal settlement.

METHODS

In a mixed method cross sectional study, we interviewed 1257 individuals and conducted 6 focus group discussions (FGD). Multiple correspondence analysis (MCA) was used to construct provision of prevention messages and behavior change indices using STATA 3.0. Pearson's chi-square statistics was used to test for bivariate association between the outcomes and logistic regression analysis was carried out with the behavior change index as the outcome of interest and the predictors considered significant (p<0.1). Thematic content analysis for qualitative data was done using Atlas 3.0.

RESULTS

Out of the 1257participants, 1078 (85.8%) had ever tested for HIV, with 74.2% having tested in the Kibera HBTC program. Nearly all (97.4%) rated HBTC experience as either excellent (62.4%) or good (37%) and would recommend it to a friend. Provision of prevention messages was high among HBTC clients compared to clients from other testing sites; partner reduction counselling (64% versus 52%) and faithfulness (78.3% versus 67%); p=0.001. Self-reported behavior change after HBTC was generally low with condom use at 10.7% and men more likely to practice safer sex (p = 0.002). Trust of the sexual partners and fear of suspicion were the main reasons given for not using condoms. Clients testing HIV positive after previous negative result were 3.4%. The focus group discussions reported multiple sexual partnerships among both HIV negative and positive residents alike.

CONCLUSION

Although prevention messages delivered during HBTC are accepted and appreciated in this community, their utilization is low in both HIV negative and positive individuals. Innovative strategies for change of normative beliefs about sexual behavior are urgently needed.

Factors associated with acceptability of HIV self-testing among health care workers in Kenya

Health care workers (HCWs) in sub-Saharan Africa are at a high risk of HIV infection from both sexual and occupational exposures. However, many do not seek HIV testing. This paper examines the acceptability of an unsupervised facility-based HIV self-testing (HIVST) intervention among HCWs and their partners and factors associated with uptake of HIVST among HCWs. HCWs in seven large Kenyan hospitals were invited to participate in pre-HIVST information sessions during which they were offered HIVST kits to take home for self-testing. A post-intervention survey was conducted among 765 HCWs. Forty-one percent attended the information session; of those, 89% took the HIVST kits and of those, 85% self-tested. Thirty-four percent of surveyed HCWs used the HIVST to test themselves. Of those who took the HIVST kit and had partners, 73% gave the kit to their partner and 86% of them indicated their partner self-tested. Factors positively associated with use of the HIVST on self were being female, being single, and being a HCW from Homa Bay Hospital (located in a high HIV prevalence area). HIVST is acceptable to HCWs and their partners. However, strategies are needed to increase HCWs attendance at pre-implementation information sessions.