Female Sex Workers Cohorts Dr. Joshua Kimani University of Manitoba & Nairobi Research Group

HIV/AIDS in Kenya- Contextual issues Estimated Population- 35 m (GDP – USD 530) 1.4 m Kenyans estimated to be living with HIV National HIV Prevalence 2003: Kenya Demographic HS- 7% -Surveillance % Negative impact on all sectors of the society 50% to 70% of Medical hospital beds occupancy is linked to HIV (Out of pocket financing being the norm) Reversed previous health gains: life expectancy 62 to 46 years About individuals are currently on ART up from about in 2004 With the support from PEPFAR and Global Fund;-Antiretroviral therapy and HIV palliative care became part of the MOH standard of care in 2005

UoM/UoN Research Group- Nairobi, Kenya Worked closely with female sex workers since 1985 Initial program started in response to a GUD (Chancroid) outbreak in Nairobi around 1982 Oldest clinic based at the Majengo slums of Nairobi, while Korogocho and Kibera are the two less known cohorts The three cohorts -targets low socio-economic Female sex workers Average of 5 sex partners /day with a high rate of partner change Marginalized and vulnerable population All at high risk of HIV transmission and acquisition

Shanty Towns - Nairobi

Program Goals Provision of a standardized care package and counseling support that assures prevention of STIs/ HIV Conducting epidemiological and immuno- biology research studies among the female sex workers Advocacy for sex worker ’ s issues Linkages to programs that offer social support and possible exit strategies

Majengo Sex Workers Cohort Initial group of female sex workers were mobilized and recruited into the cohort in 1985 ?Oldest cohort – in Africa Open cohort with over 3000 participants enrolled to date Twice yearly resurveys is a unique tradition started in 1985 and maintained today About 700 on active follow- up during a single resurvey Contributed a wealth of information on HIV natural history and resistance to date May provide a natural model of HIV immunity NB: Over 95% of those who need ARVs on medication now

Majengo Sex workers Clinic

Majengo Cohort: Success factors Sex workers involvement in programming from the outset Peer led outreach and cohort cohesion program Emphasis on ‘informed consent’ at baseline Basic attitude of service providers assuring confidentiality Continuous exchange of information through individual, mini and yearly baraza’s STI screening and management linked to the monthly follow-ups and biannual resurveys Use of cell phones ‘sms’ to remind individuals about their appointments and to take medications

Majengo Cohort: Success factors Free condoms, information, promotion and demonstrations on use Above average comprehensive standard of care offered over the years compared to what's available in MOH clinics HIV basic care and ARV services provided since 2005 as part of the standard of care On site ARV/TB and care services Continuous presence in the area over two decades Groups success in fund raising

Mini – “Baraza”

Korogocho Sex Workers Cohort Established in 1998 Korogocho;- a poor slum – N/E of the CBD Targets low socio-economic sex workers Open cohort with 500 participants enrolled to date HPV work has been the main research activity but funding has been problematic Peer led networks and mini baraza ’ s used to maintain cohort cohesion Use of cellphone- ‘ sms ’ reminders on follow-ups and drugs adherence The ongoing ARV roll out has rekindled follow-up rates in a big way On site HIV ARV / TB and Care services

Kibera Sex Workers Cohort Established in 1997 near Kibera slums Kibera is the ?largest shanty town in Africa Estimated population 1 million people We target low socio-economic female sex workers Mobilized 1500 sex workers with 889 recruited into the trial Trial - A double blind Azithromycin prophylaxis trial for STI and HIV control Study conducted between Cohort members not in active follow from 2002 but in touch through peers and cell phone numbers where possible A dedicated nurse counselor still on site to date for consultations Peer led networks still used to maintain contacts with most sex workers Linkages to the ongoing ARV roll out has rekindled interest and follow- up rates high Cohort members can be re-mobilized within a short time for other studies using the peer leaders

Challenges Sex work is criminalized in Kenya No budgetary allocation for STI prevention for vulnerable populations Number of sex workers in most urban centers unknown Fluidity in sex work and population highly mobile ‘ Informed consent ’ process problematic due to the low level of education Age of consent is 18 in Kenya yet many sex workers are below that age Rampant substance abuse (Alcohol) Drugs for classical STIs not covered by PEPFAR

Challenges High expectations especially on socio – support among study participants High maintenance of cohorts Donor or funding agencies fatigue Sustainability questions High cost of air-time for mobile telephony Coordination at the MOH level lacking – NASCOP and NACC confusion … No policy or guidelines on way forward beyond PEPFAR supported ARV roll out program by MOH and stakeholders Fragile public health system (Post election violence) Weak and inefficient ethics review committee Experiences not generalizable between clinical trials scenario and cohort studies

Thank You