Women and HIV: Challenges and Opportunities - Kenya Dr. Jemima Kamano Associate Program Manager, AMPATH Lecturer and Consultant Physician, Moi University School of Medicine and Moi Teaching and Referral Hospital

Map of Kenya Kenyan Statistics Country population: 44,351,000 people Women population: 50.11% Life expectancy: 61 years GDP per capita is US $1800, i.e. 82% lower than the world’s average. Population below poverty line: 45.9% Prevalence of HIV: 5.6% Prevalence of HIV in women: 6.9% Prevalence of HIV in men: 4.4%

AMPATH Academia and Government partnership Started in 2001 in response to HIV Restructured in 2009 to address population health Currently taking care of 60,000 HIV positive patients, of whom 68% are women

Gladys Married to a philandering husband at age of 21 Not employed and no special skills Husband, sole breadwinner, denied her permission to ever take a HIV test Diagnosed HIV positive at ANC – 4 th child Disclosed status, beaten and abandoned by husband, family and in-laws No income, 4 children, and expected to attend clinic, exclusively breastfeed, and eat healthy Worst fear through all of this was: “what if my children are also infected?” Gladys giving a talk in one of the motivational sessions to patients in the psychosocial support group. Gladys at her workstation at AMPATH.

Jane Jane, 45 years old. HIV positive on ART for the last 15 years. Widowed at 29 years, and raised her 4 children alone. First born daughter got an early pregnancy from the sex for fish trade at age 12. Jane recently had a minor stroke and was then diagnosed hypertensive – treatment unaffordable. Jane has never had a pap smear, yet her two sisters have both been diagnosed with cervical cancer. She has lived in fear of any kind of screening. Recently regained hope after joining a support and GISE group and now able to afford hypertension care since its integration in CCC.

Esther Esther: 18 year old orphan. Born with HIV and started ARVs as a child. Grew up with step family, endured lots of abuse about having been promiscuous like her mother. Due to the abuse, lost hope early and had very poor adherence in early teenage years – failed first line. Now in college, on second line, biggest challenge: disclosure to peers, dating with HIV. Her words: “I do fear what will happen when my second line finally fails, so I do all in my power to keep it working. But when the time comes, I know AMPATH will find a way for me, you already kept me for 18 years, and now am full of life and have so much to live for.”

Challenges Women socio-economically and culturally disempowered and more stigmatized. Limited access to healthcare: Health systems underfunded, static and geared to diseases rather than populations. Limited access to capital, skills: Silo programs at national level and in healthcare Little community involvement in funding and in planning. Continued risky sexual behavior among especially younger women with continued spread and low access to screening. Without community screening, higher rates of MTCT in community despite falling rates in hospitals. HIV mortality rates still high, and resistance rates increasing. Aging population with HIV hence increased NCDs that are now contributing immensely to the health burden but remain unaddressed.

Opportunities Population health approach: Find, Link, Treat and Retain (FLTR): Early case and risk finding and intervention = control. Integrated care task shifted/shared to the lowest primary care level; Care package that’s community centered. LACE (Legal Aid Centre of Eldoret). Population health supported by Zuri Health Insurance and AMPATH coordinated microfinance groups.

Expected outcomes from microfinance groups Group caring for themselves – Improved linkage; target > 80% – Retention in care; target > 95% – Improved drug compliance/adherence – Improved quality of life – Cost reductions – patients & program Economic gains for the group from activities OVERALL: Reduction in community VL & HIV incidence --– HIV pandemic control

Membership Family Preservation Initiative Total of over 10,000 members ever enrolled in GISE 83.33% female members 75.01% attendance rate to group meetings 98.8% retention rate 13.3% average membership growth rate

Conclusion Era of HAART may have brought new hope, but deeper socio-economic and systems issues still need to be solved. Funding ≠ Access ≠ Utilization Nothing can put women down forever, they always will bounce back and stronger. Investing in women, the only way to ensure population health.

Acknowledgements PEPFAR and USAID Abbott AbbVie Eli Lilly and Company Grand Challenges Canada AMPATH Consortium Kenya MOH The great people of Western Kenya

Thank you