Jerry Okal

Sexual and physical violence against female sex workers in Kenya: a qualitative enquiry

Abstract Few studies in Africa provide detailed descriptions of the vulnerabilities of female sex workers (FSW) to sexual and physical violence, and how this impacts on their HIV risk. This qualitative study documents FSWs experiences of violence in Mombasa and Naivasha, Kenya. Eighty-one FSW who obtained clients from the streets, transportation depots, taverns, discos and residential areas were recruited through local sex workers trained as peer counsellors to participate in eight focus-group discussions. Analysis showed the pervasiveness of sexual and physical violence among FSW, commonly triggered by negotiation around condoms and payment. Pressing financial needs of FSW, gender-power differentials, illegality of trading in sex and cultural subscriptions to mens entitlement for sex sans money underscore much of this violence. Sex workers with more experience had developed skills to avoid threats of violence by identifying potentially violent clients, finding safer working areas and minimising conflict with the police. Addressing violence and concomitant HIV risks and vulnerabilities faced by FSW should be included in Kenyas national HIV/AIDS strategic plan. This study indicates the need for multilevel interventions, including legal reforms so that laws governing sex work promote the health and human rights of sex workers in Kenya.

Social context, sexual risk perceptions and stigma: HIV vulnerability among male sex workers in Mombasa, Kenya

Knowledge about sexual practices and life experiences of men having sex with men in Kenya, and indeed in East Africa, is limited. Although the impact of male same-sex HIV transmission in Africa is increasingly acknowledged, HIV prevention initiatives remain focused largely on heterosexual and mother-to-child transmission. Using data from ten in-depth interviews and three focus group discussions (36 men), this analysis explores social and behavioural determinants of sexual risks among men who sell sex to men in Mombasa, Kenya. Analysis showed a range and variation of men by age and social class. First male same-sex experiences occurred for diverse reasons, including love and pleasure, as part of sexual exploration, economic exchange and coercion. Condom use is erratic and subject to common constraints, including notions of sexual interference and motivations of clients. Low knowledge compounds sexual risk taking, with a widespread belief that the risk of HIV transmission through anal sex is lower than vaginal sex. Traditional family values, stereotypes of abnormality, gender norms and cultural and religious influences underlie intense stigma and discrimination. This information is guiding development of peer education programmes and sensitisation of health providers, addressing unmet HIV prevention needs. Such changes are required throughout Eastern Africa.

Contraceptive needs of female sex workers in Kenya – A cross-sectional study

Background and objectives Female sex workers (FSWs) are thought to be at heightened risk for unintended pregnancy, although sexual and reproductive health interventions reaching these populations are typically focused on the increased risk of sexually transmitted infections. The objective of this study of FSWs in Kenya is to document patterns of contraceptive use and unmet need for contraception. Methods This research surveys a large sample of female sex workers (N = 597) and also uses qualitative data from focus group discussions. Results The reported level of modern contraceptives in our setting was very high. However, like in other studies, we found a great reliance on male condoms, coupled with inconsistent use at last sex, which resulted in a higher potential for unmet need for contraception than the elevated levels of modern contraceptives might suggest. Dual method use was also frequently encountered in this population and the benefits of this practice were clearly outlined by focus group participants. Conclusion These findings suggest that the promotion of dual methods among this population could help meet the broader reproductive health needs of FSWs. Furthermore, this research underscores the necessity of considering consistency of condom use when estimating the unmet or undermet contraceptive needs of this population.

Changes in sexual risk taking with antiretroviral treatment: influence of context and gender norms in Mombasa, Kenya

In-depth interviews were conducted with 23 sexually-active adults receiving antiretroviral treatment (ART) in Mombasa Kenya to understand changes in sexual behaviour after treatment initiation and factors influencing condom use. Advanced HIV disease had previously led to marked decreases in sexual desire and function. After HIV testing, numbers of partners reduced and monogamous relationships began to predominate. Receipt of ART strengthened these changes, while improving sexual health. However, concurrent sexual partnerships continue within polygamous marriage and unprotected sex occurs with regular partners, even those who are HIV-negative. Those who used condoms inconsistently prior to ART often remained inconsistent users thereafter. While disclosure of HIV status appeared to support condom use, this does not always predict protected sex. In addition to classic perceptions about condoms effect on intimacy and trust, traditional gender roles, misconceptions about potential harm from condoms and fertility desires hinder condom use.

Estimates of the size of key populations at risk for HIV infection: men who have sex with men, female sex workers and injecting drug users in Nairobi, Kenya.

Objectives Size estimates of populations at higher risk for HIV infection are needed to help policy makers understand the scope of the epidemic and allocate appropriate resources. Population size estimates of men who have sex with men (MSM), female sex workers (FSW) and intravenous drug users (IDU) are few or non-existent in Nairobi, Kenya. Methods We integrated three population size estimation methods into a behavioural surveillance survey among MSM, FSW and IDU in Nairobi during 2010–2011. These methods included the multiplier method, ‘Wisdom of the Crowds’ and an approach that drew on published literature. The median of the three estimates was hypothesised to be the most plausible size estimate with the other results forming the upper and lower plausible bounds. Data were shared with community representatives and stakeholders to finalise ‘best’ point estimates and plausible bounds based on the data collected in Nairobi, a priori expectations from the global literature and stakeholder input. Results We estimate there are approximately 11 042 MSM with a plausible range of 10 000–22 222, 29 494 FSW with a plausible range of 10 000–54 467 FSW and approximately 6107 IDU and plausibly 5031–10 937 IDU living in Nairobi. Conclusions We employed multiple methods and used a wide range of data sources to estimate the size of three hidden populations in Nairobi, Kenya. These estimates may be useful to advocate for and to plan, implement and evaluate HIV prevention and care programmes for MSM, FSW and IDU. Surveillance activities should consider integrating population size estimation in their protocols.

HIV and STI prevalence and risk factors among male sex workers and other men who have sex with men in Nairobi, Kenya.

Abstract:Previous surveys of men who have sex with men (MSM) in Africa have not adequately profiled HIV status and risk factors by sex work status. MSM in Nairobi, Kenya, were recruited using respondent-driven sampling, completed a behavioral interview, and were tested for HIV and sexually transmitted infections. Overlapping recruitment among 273 male sex workers and 290 other MSM was common. Sex workers were more likely to report receptive anal sex with multiple partners (65.7% versus 18.0%, P < 0.001) and unprotected receptive anal intercourse (40.0% versus 22.8%, P = 0.005). Male sex workers were also more likely to be HIV infected (26.3% versus 12.2%, P = 0.007).

A policy analysis of the implementation of a reproductive health vouchers program in Kenya

BackgroundInnovative financing strategies such as those that integrate supply and demand elements like the output-based approach (OBA) have been implemented to reduce financial barriers to maternal health services. The Kenyan government with support from the German Development Bank (KfW) implemented an OBA voucher program to subsidize priority reproductive health services. Little evidence exists on the experience of implementing such programs in different settings. We describe the implementation process of the Kenyan OBA program and draw implications for scale up.MethodsPolicy analysis using document review and qualitative data from 10 in-depth interviews with facility in-charges and 18 with service providers from the contracted facilities, local administration, health and field managers in Kitui, Kiambu and Kisumu districts as well as Korogocho and Viwandani slums in Nairobi.ResultsThe OBA implementation process was designed in phases providing an opportunity for learning and adapting the lessons to local settings; the design consisted of five components: a defined benefit package, contracting and quality assurance; marketing and distribution of vouchers and claims processing and reimbursement. Key implementation challenges included limited feedback to providers on the outcomes of quality assurance and accreditation and budgetary constraints that limited effective marketing leading to inadequate information to clients on the benefit package. Claims processing and reimbursement was sophisticated but required adherence to time consuming procedures and in some cases private providers complained of low reimbursement rates for services provided.ConclusionsOBA voucher schemes can be implemented successfully in similar settings. For effective scale up, strong partnership will be required between the public and private entities. The government’s role is key and should include provision of adequate funding, stewardship and looking for opportunities to utilize existing platforms to scale up such strategies.

Secrecy, disclosure and accidental discovery: perspectives of diaphragm users in Mombasa, Kenya

The diaphragm is receiving renewed attention as a promising female‐controlled method of preventing HIV and other sexually‐transmitted infections. It is anticipated that female‐controlled technologies will reduce womens biological susceptibility and assist in counteracting their sociocultural vulnerability to HIV. Understanding the subjective experiences of diaphragm users in different settings has the potential to inform the development and promotion of such methods. This paper explores the perspectives of female sex workers and women attending sexual and reproductive health services in Mombasa, Kenya. Data are reported from focus group discussions and in‐depth interviews with women and men, following a prospective study investigating diaphragm continuation rates over six months. Discussions highlighted covert use of the diaphragm, during sex work or with casual partners, and coital independence as favourable attributes. These features were especially pronounced compared with male condoms. Few difficulties with diaphragm use were reported, although its insertion and removal occasionally presented problems. Many women—especially those in long term partnerships—wished to disclose its use but found the disclosure process highly problematic. Accidental discovery often resulted in partner conflict. Although future uptake of the diaphragm may be high in this setting, its use may be limited to certain types of relationships and relationship context.

Exploring the effectiveness of the output-based aid voucher program to increase uptake of gender-based violence recovery services in Kenya: a qualitative evaluation

BackgroundFew studies in Africa have explored in detail the ability of output-based aid (OBA) voucher programs to increase access to gender-based violence recovery (GBVR) services.MethodsA qualitative study was conducted in 2010 and involved: (i) in-depth interviews (IDIs) with health managers, service providers, voucher management agency (VMA) managers and (ii) focus group discussions (FGDs) with voucher users, voucher non-users, voucher distributors and opinion leaders drawn from five program sites in Kenya.ResultsThe findings showed promising prospects for the uptake of OBA GBVR services among target population. However, a number of factors affect the uptake of the services. These include lack of general awareness of the GBVR services vouchers, lack of understanding of the benefit package, immediate financial needs of survivors, as well as stigma and cultural beliefs that undermine reporting of cases or seeking essential medical services. Moreover, accreditation of only hospitals to offer GBVR services undermines access to the services in rural areas. Poor responsiveness from law enforcement agencies and fear of reprisal from perpetrators also undermine treatment options and access to medical services. Low provider knowledge on GBVR services and lack of supplies also affect effective provision and management of GBVR services.ConclusionsThe above findings suggest that there is a need to build the capacity of health care providers and police officers, strengthen the community strategy component of the OBA program to promote the GBVR services voucher, and conduct widespread community education programs aimed at prevention, ensuring survivors know how and where to access services and addressing stigma and cultural barriers.

Emotional and Psychosocial Aspects of Menstrual Poverty in Resource-Poor Settings: A Qualitative Study of the Experiences of Adolescent Girls in an Informal Settlement in Nairobi

We introduce the concept of “menstrual poverty” to categorize the multiple deprivations relating to menstruation in resource-poor settings across the Global South, and we examine how this affects the psychological well-being of adolescent girls in an urban informal settlement in Kenya. We use qualitative data collected through 34 in-depth interviews and 18 focus group discussions with girls, women, and key informants. Menstrual poverty involved practical and psychosocial challenges affecting girls at home and at school. Its emotional impacts included anxiety, embarrassment, fear of stigma, and low mood. Further research is needed on how menstrual poverty affects girls’ psychological and educational outcomes.