Evaluating an intervention of post rape care services in Public Health Settings: A case of Kenya Nduku Kilonzo, PhD Liverpool VCT, Care & Treatment (LVCT) GBV taskforce – Interagency Gender Working Group November 8 th 2007

LVCT … our Mission To use our research results and our technical resources to inform HIV/AIDS policy formulation in Kenya and beyond and to build the capacity of government, private and civil society organizations to provide quality prevention, care and treatment services to those at risk of infection, infected or affected by HIV, with special attention given to those with greatest vulnerability to infection and those with special service needs. To use our research results and our technical resources to inform HIV/AIDS policy formulation in Kenya and beyond and to build the capacity of government, private and civil society organizations to provide quality prevention, care and treatment services to those at risk of infection, infected or affected by HIV, with special attention given to those with greatest vulnerability to infection and those with special service needs. 2 Kenyan NGO since 2002, 190 staff, regional presence – Botswana, Cote de Ivoire, South Sudan Kenyan NGO since 2002, 190 staff, regional presence – Botswana, Cote de Ivoire, South Sudan

Why post rape care? Beautiful country! 32M – population 16% F reporting SV in preceding year (KDHS 2003) 9%: 5% HIV prevalence – women: men additional impetus... health workers reports & SV clients in VCT

operational research study - 3 districts (Nairobi, Malindi, Thika) situation analysis - – perceptions of rape/sexual violence in Kenya (18 FGDs age & gender dissagregated; 2 CSWs) – situation & priorities for post rape care services (36 key informant interviews with health providers – clinicians, counselors; policy makers, police) intervention – develop & implement a standard of care evaluation – uptake, delivery & acceptability of services 4

5 findings – on perceptions... fuzzy boundaries force, coercion & consent l ets say I have a boyfriend and am against the act, but you can be forced. He will come at night when he knows I am there because he want to do …, and to make me to give him. He knows if he rapes me, I will be disappointed and when others get to know, they will reject and laugh at me saying I was raped – so I will give in (adolescent female, 16yrs, Thika)

findings health provider difficulties – initiate risk reduction for survivors – gender & age challenges in examination of survivors – health provider perceptions of SV service delivery level – inconsistent services: EC, STI/ HIV prevention (PEP); counseling – trauma; HIV testing; PEP adherence 6

7 findings policy level – no regulatory framework & standards – no coordination, documentation limited capacities – human, technical, financial high user costs – cards, fees

8 Intervention process – participatory action approaches stakeholder consultations – DHMTs consensus on delivering the standard of care records/documentation – mutually defined outcomes targeted health provider training & investigated personal values towards SV – clinicians/nurses/laboratory personnel & trauma counselors

Survivor CASUALTY Emergency management PEP/EC, physical examination, documentation Counseling (primarily at VCT) Trauma/crisis, HIV testing, PEP adherence; preparation for Justice system Laboratory HIV testing, blood monitoring (Hb) specimen analysis HIV care clinics: PEP management & STIs, Clinical monitoring, Data collection: demographics, HIV PEP uptake, HIV outcomes Refer to STI clinic if not provided at CCC on-going follow up 4/52 Delivering the standard of care

Evaluation – uptake, delivery & acceptability of the intervention uptake - survivors taking up services delivery – data from routine records – data collection from casualty, lab, HIV care clinic, pharmacy – described coverage, quality of clinical evaluation, clinical management, counselling & PEP delivery acceptability – knowledge, perceptions, ownership 10

Study limitations data challenges – no baseline data – health facility data only – no research targeted data collection – counselling data scanty – no systems SV against children, men not explicitly explored specificity of the intervention 11

12 findings - uptake of services 3 HFs (Thika; Malindi; Rachuonyo) – n=295/386 median age – 16.5 IQR (9,25) age range of cohort (16 months – 102 years) 88% female (Malindi – 24% males) 56% children (<18years) children more likely to know perpetrator/s (OR 6.2; p=0)

13 findings - delivery: quality of clinical management (n=292) of the cohort eligible females - 88% got emergency contraception 74% - lab services 73% - STI prophylaxis 56% - physical examination & documentation 50% counselling; 50% information

- 51% PEP completion - 16% loset in client flow pathway - those counseled more likely to complete PEP (OR 2.7; p=0.004) - 1 sero-conversion – 7yr old, female

findings - acceptability … am certainly now more confident filling in the P3 forms. Nothing is missed and court presentations are a lot easier and concise. I think this kind of thing should be taught in medical school, including the counselling and attitude change stuff … it s very good for stigma reduction as well …. Particularly as most of the patients are women (medical officer) 15

16 achievements informing policy – national guidelines – PRC as part of RH policy – training manuals for clinicians & counsellors – medico-legal linkages – PRC1 form national indicators – KNASP II – M & E – PEP/PRC indicators – PRC – performance indicator in the SWAp – DRH business plan - PRC indicators practice – scale-up to 16 PRC sites, >2,000 survivors seen

17 baseline for future PRC evaluation, but new programming challenges... medico-legal linkages & psychosocial care – common indicators btwn health and CJS PEP – baseline data on adherence, HIV outcomes – indicators for social support characteristics – documentation & follow up systems costing studies – cost study done but, – cost effectiveness of intervention, – costing per-contact HIV/pregnancy/STI transmission, chronic exposures

18 lessons & opportunities documentation - critical to inform programming data - essential for policy & practice utilization of local health systems lessons from HIV programming for GBV – results framework with defined indicators – mutual agreement of outcomes linking service delivery & policy to research

19 Acknowledgements Division of Reproductive Health in Kenya All LVCT staff & programmes Trocaire DfID/Futures