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
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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
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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
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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.
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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.
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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:
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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:
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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
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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:
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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
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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.
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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.
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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
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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.
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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.
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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.
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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.
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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)
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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:
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 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.
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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:
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 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

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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
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

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


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
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
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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
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Numbered + Level: 1 + Numbering Style: 1,
2, 3, … + Start at: 1 + Alignment: Left +
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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:


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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
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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
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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
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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
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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
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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
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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
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39
40
41
42
43
SOURCES OF NEW INFECTIONS (KMOT 2009
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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

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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:
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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
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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.

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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

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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
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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
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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)
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Reproductive track immaturity more trauma during sex thus facilitating HIV infection.
47
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May have an asymptomatic and therefore untreated STI facilitating HIV transmission.
Social Cultural Risk Factors
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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.
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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
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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
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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.
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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.
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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
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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.
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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
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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
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Alcohol and other habit forming drugs reduce ability to negotiate for condom use
50
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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
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Widow inheritance facilitates HIV spread
The widow should be “non-sexually” inherited
FSW INJURIES (Kibera 2009)
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“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:
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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
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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
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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?
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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?
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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
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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
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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
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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 :
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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
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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
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Time-bound and measurable deliverables for results for accountability
Results 1
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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
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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.
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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.....,
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Comprehensive prevention, treatment, care and support;
Sustainable livelihoods;
Freedom of association and voice and an enabling policy environment
Prevention
58
Mutopola in Action
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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
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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
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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
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AAIK supports BAMA
Bama supports the women, Eunice included with oxens and plough to increase cultivation and
food production
Support Groups………………
62
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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
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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
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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……
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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
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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……
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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……
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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 ….
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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
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Literacy classes has improved women participation in community development activities in
BAMA villages
Human Rights Awareness…..
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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
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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?
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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
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Phone
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Betty M. Waweru
Mauree M. John
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Melba Katindi
Jennifer Muigai
Naomi MosinyaOgega
Grace Muthui
Jane Wambui
VeronicahThumi
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Esther Gatua
Mary Ndung'u
Gideon Ayodo
Diana Ondato
Elizabeth Aroka
Pamela Njuguna
Wanjala Wafula
Gerald Kimeu
Eunice Odongi
Jacinta Nyachae
Julius Nguku
Anne Mumbi
IfeomaOkonkwo
ZupherAudo
Majory Waweru
Wanjiku Kamau
David Nyaberi
Sari Sapenen
Rosalind Mwangi
Esther Gathiri
Dr. Elizabeth Bukusi
Michael Onyango
HellenMwangi
Rahab Mwaniki
Florence Maguyu
Paul Mwangi
Agatha Mugo
Harriet Kongin
Dr. Joyce Lavussa
Nais Mason
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Prof. Alloys Orago
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86
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Annrita Ikahu
Elizabeth Ngugi
Sobbie Mulindi
Julie Mulindi
Florence Gachanja
Charity Wachira
Carolyne Naomi Wambui
MianoMunene
Susan Anyangu
katieBigmore
Edward Marienga
Diana Madegwa
AminaAbubakar
Rosemary Owoko
Dr. Bathsheba
Rukia Subow
Catherine Mumma
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Pauline Irungu
Maureen Adudans
Patrick Mwai
Halima Yasmin
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