This project was implemented with close collaboration with key stakeholders and institutions that are active with women living with HIV health. The project was highly appreciated in the three counties and all the CASCOs, MOH representative, NEPHAK County chairs were part of the team that implemented at the different levels. The project identified a number of challenges faced by women living with HIV when it comes to their sexual reproductive health and rights both at community level and at the facility when they go to access SRH services. This project was implemented in Lamu Isiolo and Migori County which are the priority counties for the Kenya joint Programme on Reproductive health, Maternal and Newborn Child health and Adolescent Health (RMNCAH). According to the Kenya Demographic Health Survey 2014 (KDHS 2014), the three counties. The three counties are among those with the highest maternal mortality and poorest reproductive health indicators. Implementing comprehensive SRHR services to meet the health and rights of women living with HIV in all their diversity requires initiatives that overcome barriers to service uptake, use of reproductive health commodities and continued engagement with key stake holders at the different levels of care and policy formulation.
WOFAK appreciates UNAIDS for funding this project to be piloted in Lamu, Isiolo and Migori County.
Dorothy Onyango (OGW)
WOFAK piloted the WHO checklist in early 2018 and a recommendation was made for the need to scale up sensitization and capacity strengthening on SRHR for WLHIV at the county levels. It further recommended the need to advocate and lobby local stakeholders and county governments to integrate SRHR services for women living with HIV in their plans and strategies to be implemented at different levels of service provision. The SRHR checklist was found to be an appropriate tool to pursue the recommendations made. It is against this background that WOFAK partnering with UNAIDS scaled up this project to sensitize and build capacity of women living with HIV on how to utilize the SRHR checklist in Lamu, Isiolo and Migori County. Women living with HIV in the three counties capacity has been built to identify allies at community and county level and advocate for their rights to SRH at different levels. The women living with HIV in this counties have been empowered to sensitize women living with HIV in their support groups and have one voice in advocacy. Their capacity has been built on how well they can create a allies and lobby for their SRHR at all levels. Part of their action plan is to raise awareness on SRHR violations for community and county responses on specific need identified during field work and in the advocacy training. Women in Kenya are disproportionately affected by HIV and are highly assessable to HIV infection. In 2017, 27 000 women aged 15 and above were newly infected with HIV. Adult women accounted for 860 000 of the 1.5 million people living with HIV in the country. In the same year AIDS related illness remained the leading cause of death among women of reproductive age (15-49 years) at 10000.
Although 83% of women living with HIV in Kenya have access to treatment in 2017, many of them struggle with access to SRHR services, compounded by violation of patients’ privacy and confidentiality, resulting in limited access to family planning services, and delayed uptake of quality treatment and non-adherence of medication. Women living with HIV are more likely to face stigma and discrimination in their home, their community and in health care facilities, and are at increased risk of domestic violence and abandonment by their partners, as well as violence within the community. Lack of awareness of SRHR among women living with HIV and how to demand for the affordable and quality services further compound the problem. In conclusion, SRHR violations experienced by women living with HIV represent human right violations, affecting women’s health and overall public health outcomes, including the ending of AIDS as a public health threat by 2030. In 2017, WHO published the Consolidated guideline on the Sexual and Reproductive Health and Rights (SRHR) of women living with HIV, to support front-line health-care providers, programme managers and public health policy-makers to better address the SRHR of women living with HIV in all their diversity. In 2018, a checklist for Community Engagement to implement the WHO consolidated Guidelines on SRHR of women Living with HIV was developed by Salamander Trust together with women leaders. The objective of the Checklist was to support community activities to guarantee effective implementation of the guidelines at the national level.
In April 2018, Women Fighting AIDS in Kenya (WOFAK) was chosen to pilot the generic checklist for implementation of the WHO Consolidated guidelines. The review process involved a desk review of SRHR policies in Kenya to identify gaps and to determine the extent to which local policies were aligned to the WHO Consolidated guidelines.
The workshop that brought together women living with HIV and representatives in all their diversities deliberated for three days and come up with strong recommendations and succinct advocacy plans for the women to engage in to ensure implementation of the consolidated guidelines at the different levels.
This is the background that WOFAK was funded by UNAIDS to implement this advocacy project in three counties Lamu, Isiolo and Migori targeting County key health stakeholders and women living with HIV.
The specific objectives included of this project include:
- Increased awareness of SRHR among women living with HIV, utilizing the SRHR checklist in.
- Enhanced linkages with the local partners and counties around SRHR of women living with HIV.
- To develop advocacy messages and strategies for strengthening SRHR for women living with HIV.
- Stronger networks of women living with HIV in Isiolo, Lamu and Migori County.
COUNTY BACKGROUND INFORMATION
Lamu county borders Tana River County in the southwest, Garissa County to the north, Republic of Somalia to the northeast and the Indian Ocean to the South. There are 10 wards, 23 locations, and 38 sub-locations in the County. The county is made of cosmopolitan population composed of indigenous communities made of Swahilis, Arabs, Koreni, Boni and Ormas and migrant communities from the rest of the country. The county population as projected in 2012 stands at 112,252 persons composed of 58,641 males and 53,611 females. The main economic activities in the county include crop production, livestock production, fisheries, tourism and mining, most notably quarrying. Among the challenges facing Lamu is population growth owing to migration into Lamu from other parts of the country, fuelled partly by the anticipated opportunities accruing from the Lamu Port South Sudan-Ethiopia Transport (LAPSSET) Corridor. Other challenges include landlessness and poor land management, insufficient social services such as healthcare and education, inadequate supply of piped and fresh water, under-developed infrastructure and food insecurity.
There are 42 health facilities,24 government owned, 3 owned by faith-based organizations, 1 NGO owned and 14 private institutions composed of 3 level five facilities, 5 health centres, 1 nursing home and 33 dispensaries. The county suffers from inadequate personnel with only 4 medical doctors,24 clinical officers,94 nurses,17 public health officers, 5 pharmacists and 30 technical personnel. The average distance to the nearest health centre is approximately 5 kms. With the county’s poor road infrastructure and limited availability of transport services, access to health care is a major challenge. Lamu county has low HIV burden, with prevalence rates at 2.4% however women constitute nearly two-third of all people living with HIV in this county. Furthermore, the county has substantive rates of mother-to child transmission, at 4.7%; affecting Kenya’s strive for validation of elimination of mother to child transmission of HIV and syphilis by 2019.
Isiolo County according to the Kenya National Bureau of Statistics report of 2009 is 143,294. 51% of the population is male while 49% is female. Isiolo County has an estimated prevalence of 3.2% and an estimate of 3139 adults living with HIV. Isiolo County is inhabited by the Turkana, Borana, Somalia and Meru communities, with the Boranas forming the largest portion of the population.
The Somali ex- army officers who participated in the war settled in Isiolo, intermarrying with the local Samburu and Cushitic pastoralists. Scarcity of arable land and pasture is a daily challenge for the people of Isiolo, a phenomena that is witnessed from the constant community conflicts that plague the county. The Borana are nomadic pastoralists, moving from one area to another - within the county and in neighboring counties in search of pasture and water for their goats, camels and cows. The Somali ex- army officers who participated in the war settled in Isiolo, intermarrying with the local Samburu and Cushitic pastoralists. Isiolo County residents are set to benefit from free medical cover following the launch of the universal health coverage being one of the pilot Counties. Isiolo has 52 health facilities, 52 HIV testing sites, 42 PMTCT sites, 16 care and treatment sites, and only 21 functional community units with two partners supporting HIV programs.
Migori stands at a population of 917,170 (2009 population census; annual growth rate estimated at 3.8%) Migori County is located in western Kenya and borders Homa Bay County (North), Kisii County (North E), Narok (South East), Tanzania (West and South) and Lake Victoria to the West. The county also borders Uganda via Migingo Island in Lake Victoria. The population of Migori County according to the 2009 population census was 917,170. Migori County is located in the sugar belt wetlands of Western Kenya and is mostly at the heart of the African tropics. Migori County is the most diverse region of Nyanza after Kisumu. The inhabitants include Suba people, Joluo, Abakuria, Abagusii, Abaluhya, Somalis, Indians, Arabs, and Nubians. The main economic activities include agriculture, fishing, manufacturing and mining. There is some small scale gold mining carried out in the county. Only 15% of Migori County residents have secondary level of education or above. Rongo constituency has the highest share of residents with a secondary level of education or above at 19%. This is 7 percentage points above Kuria East constituency, which has the lowest share and Some 20% of Migori County residents have no formal education. Migori County has four district hospitals and five sub-district hospitals. The most prevalent diseases in the county are malaria, HIV/AIDs, diarrhea, and URTI (urinary tract infections).
The main beneficiaries for this advocacy project were women living with HIV in all their diversity to advocate for their rights at County level and County officials from different departments and local stakeholders such as NGOs, Migori County Assembly Health Committee, RH coordinators, MOH, County HIV & AIDS Coordinator, area chief, CACC, CASCO, KENEPOTE representative and NEPHAK County chair persons for buy in , partnership, collaboration and guidance.
PLANNED ACTIVITIES FOR THE PROJECT PERIOD
Project entry meeting targeting County stakeholders in Lamu Isiolo and Migori County.
Sensitization meeting targeting support groups of Women Living with HIV in Lamu, Isiolo and Migori County to create awareness of the WHO guidelines on SRHR for women living with HIV and select women advocates from the groups to attend the advocacy training.
Pre World AIDS Day stakeholder advocacy meeting targeting Key stakeholders, county officials, women living with HIV, CSOs, FBOs opinion leaders, elders in Lamu, Isiolo and Migori County
Monitoring and Evaluation was conducted to consolidate lessons learned and for accountability purposes (organized back-to-back to activity four) 1 day per county
Advocacy training targeting 30 women living with HIV from Lamu Isiolo and Migori County
- PROGRESS STATUS TOWARDS REALIZATION OF DELIVERABLES AND OUTPUT
Project entry meeting for selected stakeholders was held at Mahrusi hotel in Lamu, Grande Hotel in Isiolo and Calabash hotel in Migori County. The meeting was well attended by county officials, women living with HIV representatives, FBOs opinion leaders, Chiefs, County assembly health committee representative, CASCO, MOH and Local implementing partners .
The aim of this meeting was to have a buy in of the advocacy project in the three Counties, establish County partnerships with Key stakeholders that work closely on health and specifically SRH for women living with HIV and to create awareness of the WHO guidelines for SRH for women living with HIV . The meeting was an opportunity to interact with top County officials and identify allies to the project that will provide support, guidance and provide information that will help the counties to have clear advocacy agendas on SRH for women living with HIV. The MOH and CASCO shared brief reports that showed how poorly the counties were performing in the key SRHR indicators and we discussed what we can do to improve the same as we plan for the next phase of the project. We discussed at length the challenges the health department faces to provide services at the different levels. Integration of SRHR at service provision points was one of the best strategies that the teams agreed upon. All the three Counties had poverty, stigma and discrimination and lack of information and knowledge as one of the barriers that hinders women living with HIV from assessing services.
Sensitization sessions targeting support groups of Women Living with HIV was conducted in the three targeted Counties to create awareness of the checklist on SRHR of women living with HIV. Women from 15 support groups attended the sessions. The facilitators utilized the checklist to sensitize women on their sexual reproductive health and rights both at community and facility. The session were very interactive and reminded us of the group therapies that WOFAK would conduct monthly where women come and shared very personal issues affecting them and solutions could come from the same group. The women shared the challenges they face both at facility and community level. One issue that was very clear is the facts that women in this Counties struggle so much to access SRHR services.
Stigma and discrimination is one of the barriers that women face. Accessing HIV testing, treatment, care and RH services is a challenge for most facilities do not observe patients’ privacy and confidentiality, resulting in for example limited access to family planning services, delayed uptake of quality treatment and non-adherence to care and any other treatment. The three Counties are battling stigma and discrimination in regards to HIV and AIDS. WLHIV have been denied conjugal rights by their spouses when they disclose their status and some have even faced violence from close family members. Women gave out examples of things that happen in the society that make them keep to themselves. A woman from Lamu County shared experience of how she went for an interview and was denied a job. You did everything well but what failed you is the fact that you are HIV positive. Self-stigma is very common for some women considered themselves sick and would seek favors on the basis of being HIV positive. Societal perception/labeling of promiscuity of women living positively with HIV which then hinders disclosure of status to relatives. Some communities still believe that the women are the sole transmitters of HIV and AIDS. This leads to having problems with Self-status acceptance, most women still hide when taking medication or fail to take medication when they feel the environment is not safe. They hide when meeting with community health workers and also when collecting or visiting a health facility to pick medication. Dependency syndrome/poverty of women living with HIV has led to one not sharing their HIV status when tested positive which also fuels HIV infection especially to our Muslim sisters and brothers who are allowed to have 4 wives. WLHIV in still face all forms of GBV. Domestic violence and abandonment by their partners is common in the three Counties. Some of the women are even chased away from their matrimonial homes after sharing their HIV status by their spouse.
Lack of knowledge/platform WLHIV in the three Counties felt that they did not have the capacity to advocate for their rights in the society because they lack the knowledge. They were not able to do anything when their right were violated at service provision points and even in the community. The women were sensitized on the different reporting mechanisms at the facility and at the community. For instance some of the women were not aware that they have a right to sexual enjoyment or even have the right to deciding on when to have a baby.
Most women suffer because of ignorance and not knowing their responsibilities. This sessions therefore equipped WLHIV with the knowledge they required on SRHR and how to handle any cases of violation of their rights.
Pre World AIDS Day stakeholder advocacy meeting was held with county officials, women living with HIV, CSOs, FBOs opinion leaders, MOH, CACCS in Lamu, Isiolo and Migori County to reinforce partnership and advocate for integration of SRHR in all the women clinics. All three Counties had ongoing meetings for WAD and we requested the CASCOs to second two or three women living with HIV to be part of the participants so that they can drive their advocacy issues during the meetings. All the Counties had representation of the women living with HIV that we targeted in the County WAD function.
After field visits in the three priority counties, Lamu, Isiol and Migori for the Kenya Joint Programme on Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCAH), a training on Sexual Reproductive Health Rights was held in Nairobi from the10th -14th December 2018. 30 Women Living with HIV drawn for Lamu, Isiolo and Migori attended the 5 day training and were taken through the advocacy full package and how to advocate for SRH for women living with HIV in their Counties. The women shared their County specific challenges and gaps on SRHR. Most of the challenges shared and discussed were common across the three counties. They were taken through the advocacy process, advocacy characteristics and they were tasked to come up with priority advocacy agenda for County specific advocacy. At the end of the training, the participants developed their county advocacy plans and shared them with the other participants.
- To enhance understanding of critical concepts of Sexual Reproductive Health Rights (SRHR) and linkage with HIV for Women Living with HIV and AIDS in Lamu, Isiolo and Migori County.
- To increase support and strengthen the capacity of women living with HIV to advocate for their Sexual Reproductive Health Rights in Lamu, isiolo and Migori County.
- To develop an action plan to ensure the full implementation of the guideline based on identified issues per county
Methodology employed in the training included : Group work, plenary discussions, Question and Answer session, lectures, presentations and role playing
Participants expectations included: Learn more about WOFAK, to learn about advocacy, to reduce stigma, to understand SRHR, how to empower other women living with HIV to speak out in their respective counties, To know how other counties deal with issues on SRHR.
Challenges facing WLHIV around SRHR . WLHIV face stigma both at community and at the facility and it is common especially in Lamu and Isiolo Counties. This hinders the women to access any form of services including SRHR and HIV treatment. Some facilities don't observe confidentiality and they fear that their HIV status will be shared with community members. Gender based violence, culture and religion, Lack of platforms for WLHIV to air out their grievances, female Genital Mutilation in Isiolo and some parts of Lamu was also mentioned as a RH challenge. Early marriages was also mentioned as a challenge exposing the adolescent girls to UTI and HIV and Lack of family planning information and knowledge on what is available for preference. A presentation on solutions was done by the groups and this is what was highlighted for all the three Counties: Sensitization of the communities, Knowledge of WLHIV on their RH rights should be built, Joining support groups should be encouraged, all expectant mother should be encouraged to visit a health facilities when pregnant and be advised to deliver with the help of health service provider. Support group members should involve and Collaborate with different stakeholders at the different levels.
Basic SRHR of Women Living with HIV was one of the most enjoyed topics with examples and contributions.
- HIV and STI prevention and management
- Gender based violence prevention and support
- Cervical and other reproductive tract prevention and support
- Commodities security and access. E.g. condoms, family planning, nutrition, (include female condom issues)
- SRHR counselling.
- Safe motherhood including MNCH.
- Right to safe abortion
- SRHR intervention of adolescents and young people
After the participants knowledge increased they discussed the gaps under SRHR that were common
- HIV and STI prevention and management . Lack of information on HIV and STIs, Poor adherence and fear for getting tested was mentioned by all the Counties
- Gender based violence prevention and support. People fail to report gender based violence cases, People do not know where to report such cases, Delayed justice or corrupt officers, Lack of knowledge on what to do first once rape occurs, Culture (the belief that a husband shows love to his wife by attacking her)
- Cervical and other reproductive tract prevention and support. Lack of information on available services e.g cancer screening, Lack of cancer screening commodities in facilities, Myths and misconceptions and Fear
- Commodities security and access. E.g. condoms, family planning, nutrition, (include female condom issues) Some men have a negative attitude of using condoms and Low percentage of female condoms in the facilities
- SRHR counseling. Lack of confidentiality from health care providers and Lack of knowledge on such counseling
- Safe motherhood including MNCH. Culture (some communities believe that a pregnant woman should not give birth in a facility) Lack of information on safe motherhood
- Right to safe abortion Culture and religious beliefs and Lack of abortion commodities/facilities
- SRHR intervention of adolescents and young people Lack of youth friendly services
Introducing what advocacy is and the characteristics of advocacy.
These characteristics include: Strategic, Series of actions, Designed to persuade, Targeted, Build alliances, Results in change
Understanding the advocacy process.
- Identify potential issues and the qualities of a good issue for advocacy. A good issue for advocacy is: based on evidence, suitably specific, reasonably attainable in 1-3 years, readily improved
- Identifying key decision makers and influencers
- Noting advocacy opposition and obstacle, and developing mechanisms for addressing opposition to their policy goals.
- Identifying advocacy assets and gaps
- Identifying advocacy partners like powerful organizations and individuals can influence change
- Developing advocacy tactics: by using social media, through community gatekeepers, writing letters to stakeholders
- Develop an advocacy message. One message was developed for the people of Lamu as an example of an advocacy message: Facilities for PMTCT services are inadequate in Lamu County because there are no: (1) Waiting area and reception for WLHIV (2) ARVs and medication are dispensed in the corridors.
As WLHIV we demand that facility infrastructure be improved to ensure pregnant women living with HIV have comprehensive services and confidentiality observed. We call upon the CEC to come up with proper infrastructure and services that will respect the rights of pregnant women living with HIV.
- Evaluate success and failure indicators
The participants were then informed to work on their SRHR advocacy plans for their counties. The advocacy work plan had the following indicators: advocacy issue, goal, activity, time line, resources and indicators for success and failures.
The project was supported by the County government officials and felt privileged to be one of the Counties selected to benefit in this project. The quote below are a good indication of continuity of the projects in the Counties.
The Regional Coordinator for Mombasa, Garrisa and Lamu mentioned that "I will talk to Red Cross so that WOFAK can be given funds to further the good work they have started in this county",
“WOFAK has come in Migori at a time of need where we are in the process of trying to Eliminate Mother to Child Transmission of HIV we are discussing a policy for the next 5years. We stand at 7.3% in EMTCT, we need to go below 5%” Mrs. Eliza Omollo-County HIV and AIDS Coordinator.
The Isiolo CASCO mentioned that space will be given at the Isiolo district hospital to host WOFAK so that we can continue with mentoring the client experts to offer information and support HIV positive clients at the facility and community. With this sentiments from the top County officials the project has the County good will to continue. The group's overarching priorities were (1) Recognition of the correlation between fulfillment of human rights obligation and improvements in health care and outcomes for women; (2) integration of health care and sexual/reproductive health services that ensure that women receive consistent, high-quality services; (3) elimination of government-reinforced stigma and discrimination against women living with HIV; (4) elimination of health disparities based on gender, race, sexual orientation, ethnicity, and class/economic status as a central part of health care reform; and (5) meaningful involvement of people living with HIV in all aspects of decision-making on policies affecting their communities.
- CHALLENGES AND SOLUTIONS
- General apathy among WLHIV. This apathy has been created by some NGOs in the area who get information from them and then disappear creating a feeling of distrust. WOFAK was able to get their buy-in and commitment from stakeholders to support WLHIV) In the three Counties WLHIV travelled from far (sometimes as far as 100 kilometers) to access HIV and SRH services.
- The women agreed to engage in IGAs to raise money and also lobby government to increase service points so as to improve on the health indicators
- WLHIV reported that the greatest challenges facing them are disclosure, stigma and discrimination within families. Recommendations to have community awareness and create demand for services will increase uptake of services and advocate for more service points.
- It was noted that WLHIV in Christian faith are more open about status compared to those in Muslim faith. Support groups at community level will help to empower women to disclose their status and confidently seek RH services.
- Nurses declining to do HTS after the Kwale court case. The Counties are asking partners to sponsor community members who qualify for HTS course to increase the number of HTS counselors
- Nurses strike in this counties also affect service provision and contribute to poor outcomes of health indicators
- Integration HEI/ HIV pregnant women care in MNCH
- Lamu and Isiolo is experiencing very many difficulties on HIV prevention and management compared to other counties this was realized during the training
- County buy-in by stakeholders, general community and WLHIV right from the start is crucial to the success of the program.
- WLHIV have a lot to share related to challenges facing them but do not have forums to do so.
- Each county had its own unique challenges
- The importance of having the right information when getting involve in advocacy.
- The importance of team work
- Objectives for advocacy need to be SMART (Specific, Measurable, Realistic, Attainable, Time Bound).
- The importance of attending cancer screening
- Sexual Reproductive Health Rights of Women Living with HIV should be integrated for full implementation
Download the powerpoint link for GUIDELINE ON THE SEXUAL AND REPRODUCTIVE HEALTH AND RIGHTS OF
WOMEN LIVING WITH HIV here