Implementing a violence prevention and response strategy for key populations in Kenya Parinita Bhattacharjee, Giuliana J. Morales, Timothy M. Kilonzo, Robyn L. Dayton, Reuben T. Musundi, Janet M. Mbole, Serah J. Malaba, Bernard E. Ogwang, Shajy K. Isac, Stephen Moses and Helgar K. Musyoki

HIV and Key Populations in Kenya Kenya has a mixed HIV epidemic Key Populations (KP) in Kenya include Female Sex Workers (FSW), Men who Have Sex with Men (MSM) and People who Inject Drugs (PWID) KP contribute to 33% of all new infections High estimation of KP FSW – 133,675 (76, 654 – 208,711) MSM – 18,460 (9,660-32,886) PWID – 18,327 (12,617 – 23,978) High HIV prevalence among KP NASCOP Kenya. 2013. Kenya Most At Risk Populations Size Estimate Consensus. Final Report. Nairobi: MoH Source: IBBS, 2010; IBBS, 2011 and KAIS 2012

Snap shot of the Kenya KP Programme Led by Ministry of Health (MoH) – National AIDS and STI control Programe (NASCOP) and National AIDS Control Council (NACC) 93 Implementing Partners adopt a combination prevention approach (biomedical, behavioural and structural) to implement KP programme Funding through PEPFAR and Global Fund Technical support through a technical Support Unit within MoH implemented by University of Manitoba with support from BMGF and LINKAGES     FSW MSM PWID Contractual Targets CDC 86955 8208 5789   GF 23010 9858 12127   USAID 45074 16930     Others 21275 10254 1432     176314 45250 19348 Contribution (%)   FSW MSM PWID   CDC 49 18 30   GF 13 22 63   USAID 26 37 0   Others 12 23 7     100 100 100           Coverage vs estimation (%)   133675 18460 18327   CDC 65 44 32   GF 17 53 66   USAID 34 92 0   Others 16 56 8     132 245 106

Violence against key populations in Kenya Physical, sexual and emotional violence against KPs in Kenya is common and frequently perpetrated by sex work clients, police, religious leaders, intimate partners and strangers 22% of FSWs, 14% of MSM and 12% of PWID experienced physical or sexual violence 48% of FSWs, 20% of MSM and 44% of PWID experienced police violence Across populations, violence is fueled by gender inequalities, stigma and discrimination against persons perceived to depart from conventional gender and sexual norms and identities The Kenyan legal system and county by-laws that criminalize behaviours related to sex work, same-sex sexual practices and drug use also legitimize violence, stigma and discrimination against KPs

Two-pronged strategy to address violence against KPs in Kenya Goal Reduce the incidence of violence against KPs Objectives Improve violence reporting by KPs Improve the response to violence for KPs Improve the attitudes of police towards KPs and their rights Violence Response Train IP teams on violence support and creation of a violence response mechanism Create awareness on violence and rights among KPs Develop a network of support services, medical, psychosocial, legal, safe spaces, etc. Document incidents of violence and violence response Violence Prevention Train selected police officers from counties as trainers Sensitize police at the county level regularly Conduct regular advocacy meetings with senior police officers in counties to give updates and build rapport

Data sources and analysis Quarterly program monitoring data reported to NASCOP between October 2013 and September 2017 by 81 implementing partners Data was aggregated annually and analysed using simple trend analysis. Further a chi square test was used to determine whether changes in violence reports and responses were statistically significant Report of violence : A KP disclosing violence — such as sexual assault, physical assault, verbal abuse, discrimination, and arbitrary arrest — to a violence response team member via helpline, to a peer educator during outreach, or to a clinician during a facility visit. Response to violence: A violence response team member, peer educator, or clinician providing first-line support to a KP who reports violence within 24 hours of receiving the report.  

Results: Program reach, reports of violence, and responses to violence by FSWs in Kenya, October 2013 through September 2017 Indicator Oct 2013- Sept 2014 Oct 2014- Sept 2015 Oct 2015- Sept 2016 Oct 2016- Sept 2017 P value Number of FSWs reached 67432 88327 113096 139041   Number of FSW reports of violence 4171 5341 11707 13496 Rate of increase in number of FSWs reached 1.0 1.3 1.7 2.1 Rate of increase in number of FSW reports of violence 2.8 3.2 Percent of FSW reports of violence out of those who were reached 6.2 6.0 10.4 9.7 P<0.001 Percent of responses to FSW reports of violence 53 65 74 84 P<0.0001 Reference year: Oct 2013 – Sept 2014

Results: Program reach, reports of violence, and responses to violence by MSMs in Kenya, October 2013 through September 2017 Indicator Oct 2013- Sept 2014 Oct 2014- Sept 2015 Oct 2015- Sept 2016 Oct 2016- Sept 2017 P Value Number of MSM reached 9118 12106 16680 26972   Number of MSM reports of violence 910 849 1026 1122 Rate of increase in number of MSM reached 1.0 1.3 1.8 3.0 Rate of increase in number of MSM reports of violence 0.9 1.1 1.2 Percent of MSM reports of violence out of those who were reached 10.0 7.0 6.2 4.2 P<0.001 Percent of responses to MSM reports of violence 44 77 86 80 Reference year: Oct 2013 – Sept 2014

Results: Program reach, reports of violence, and responses to violence by PWIDs in Kenya, October 2013 through September 2017 Indicator Oct 2013- Sept 2014 Oct 2014- Sept 2015 Oct 2015- Sept 2016 Oct 2016- Sept 2017 P Value Number of PWID reached 5856 7001 10990 14527   Number of PWID reports of violence 121 533 839 873 Rate of increase in number of PWID reached 1.0 1.2 1.9 2.5 Rate of increase in number of PWID reports of violence 4.4 6.9 7.2 Percent of PWID reports of violence out of those who were reached 2.1 7.6 6.0 P<0.001 Percent of responses to PWID reports of violence 37 48 89 97 Reference year: Oct 2013 – Sept 2014

Conclusion The programmatic data from the national KP programme show that reports of violence relative to individuals reached increased among FSWs and PWID but decreased among MSM proportion of reports of violence that received a response increased among all KP groups Monitoring violence against key populations is important to understand and measure experience of violence and support received. This can facilitate strong violence prevention and response mechanisms and policies in KP programme Even in an criminalised environment, national government can take leadership in successfully addressing violence against key populations in partnership with stakeholders

Thank You Acknowledgement KP programme Implementing Partners in Kenya All the peer educators and outreach workers from KP communities who provide support to KP victims of violence and build their confidence to report violence Key Populations Technical Support Unit (TSU) Partners for Health and Development in Kenya (PHDA) Bill & Melinda Gates Foundation (BMGF) U.S. Agency for International Development (USAID) LINKAGES project implemented by FHI 360 Thank You