Rahab Mwaniki, NEPHAK AIDS 2010, Vienna Advancing the Sexual and Reproductive Health and Human Rights of People Living with HIV in Kenya, Nigeria and Zambia NZP+

SRHR Guidance Package Developed through a consultative process by partnership of international organisations (GNP+, ICW, Young Positives, EngenderHealth, IPPF, UNAIDS) Provides recommendations to global stakeholders in the areas of health, policy and advocacy on what should be done to support and advance SRHR of PLHIV.

Summary recommendations People living with HIV have the right to healthy, satisfying sex lives, and need laws to protect these rights and appropriate services to ensure their sexual and reproductive health is guaranteed Decision makers and service providers must recognize that PLHIV enter into relationships, have sex and have children. Ensuring that they do these things safely is key to maintaining their own health, and that of their partners, families and public health in general.

Implementation at country level HIV Leadership through Accountability Programme aims to gather evidence base data on developed tools for the purpose of advocacy to influence policy and service change. Supported by DFID’s Governance and Transparency Fund (GTF) Programme, in partnership with GNP+ and World AIDS Campaign “HIV Leadership Through Accountability “ programme tools -PLHIV Stigma Index -GIPA Report Card -Global Criminalization Scan -Human Rights Count! -SRHR of PLHIV

Background NEPHAK, NEPWHAN and NZP+ conducted studies to further develop their understanding of SRHR experiences and needs of three key populations:  Nigeria:Sero-discordant couples  Zambia:Young adolescents living with HIV  Kenya: HIV positive women and their partners

Methodology Led by national PLHIV networks, supported by GNP+ Identify key populations for further research Conduct focus group discussions Develop evidence-gathering tools (eg through questionnaire developed from the FGD ) Conduct interviews with people living with HIV Conduct interviews with service providers and policymakers and partners of people living with HIV Collate and analyse data Develop report Implement advocacy strategy

NEPHAK HIV positive women and their partners about their experiences of PMTCT in Nairobi, Kenya

Kenya Quotes from focus groups: “Talking of sex is difficult as a result of self stigma. The most disturbing thing is self stigma. Secondly getting someone to discuss your sexual needs with is difficult. You feel free with someone who is open, a medical/social work person who is also positive and very, very open”. (Female FGD participant)

Kenya - Participants A total of 53 people were interviewed in Nairobi province regarding 4 PMTCT services: Client exit interviews to establish satisfaction (44) Clients consisted of 36 women and 8 men Interviews of health care service providers (4) Interviews of policy makers within Ministry of Medical Services and Ministry of Public Health and Sanitation (MoPHS) (2) Interviews of District Health Management Teams (DHMTs) Ministry of Medical Services (MoMS) and Ministry of Public Health and Sanitation (MoPHS) (3) Focus group discussions with 6-8 PLHIV were held to triangulate the info gathered from in-depth interviews with clients and health care service providers.

Kenya - 1 Service Provision Waiting time at the public facility rated at btw 3 – 4 hours with service time of between 15 – 20 minutes 9 of the clients responded that they can’t refer anyone for PMTCT because of stigma and discrimination. They would rather one decide voluntarily. On average, PMTCT mothers have a total of 2-4 infant feeding counseling sessions during pregnancy and after delivery A lot is being done on PMTCT but not all of it is documented. Male involvement is low and little efforts are being made by the public facilities to improve it.

Kenya - 2 Health systems 38 out of the 53 respondents reported gaps in staffing which contribute to long waiting hours at the health facilities. All the health care service providers recorded having received some training in HIV/PMTCT and ART use. Auxiliary staff are not too informed on HIV related issues so not handling clients well eg. Comments such as ‘the HIV place is in block D’. Government facilities are well equipped and try to integrate HIV services to their general services e.g. FP/HIV/PMTCT. But lack a directory on referral, there is no feedback mechanism to ensure the referred client accesses services and is satisfied. Integration of PMTCT into existing public health systems is slow

Kenya - 3 Policy Policy awareness: – Service providers – All the 4 health care service providers interviewed were aware of the existence of the guidelines with 50% of them reporting constant use/referral to some of the guidelines (VCT, ARV and PMTCT). – Clients – 17% of the clients interviewed reported awareness VCT, PMTCT and ART guidelines. – Health Management Teams and policy makers – All were aware and had participated in the development of policy documents and guidelines

Kenya - 4 Policy - 2 All the 4 service providers reported implementation of 2 or more of the policies with a slight variation between public and private facilities. 100% of the respondents recorded knowledge of human rights. But, over 65% overwhelmingly responded that the rights of PLHIV are not respected evidenced by high stigma and discrimination level in the community including health facilities. “I can not refer anyone here for PMTCT because, even the person conducting counseling already has a negative opinion about PLHIV, that we got infected because we were promiscuous.”

Way Forward Launch of the Positive Health Dignity and Prevention guidelines. Disseminate the research finding to key stakeholders and communities. Advocate for access to treatment by positive mothers and their partners. Plans are underway to fundraise and implement the research in a rural set-up.

Acknowledgements We would like to thank: All people living with HIV who participated in the studies and contributed to the process Kenya: Lovena Akinyi, Rahab Mwaniki Nigeria: Godwin Emmanuel, Peter Nweke Zambia: Francis Mangani, Kenly Sikwese GNP+: Georgina Caswell, Marsel Kuzyakov, Chris Mallouris, Gavin Reid UNFPA and DFID for supporting the networks and the studies