1. GENDER ISSUES IN SCALING UP COUNSELLING AND TESTING FOR HIV XVII International AIDS Conference 2008, Mexico City Nduku Kilonzo, PhD, Liverpool VCT, Care & Treatment (LVCT) Kenya 1

2. Presentation outline Background Background – Gendered dimensions of HIV in Kenya – HIV counseling and testing in Kenya History & assumptions History & assumptions Current status & models Current status & models Impact of new approaches on uptake of CT Impact of new approaches on uptake of CT Gender issues and concerns emerging Gender issues and concerns emerging Opportunities for responding Opportunities for responding Recommendations Recommendations 2

3. HIV and gender in Kenya – the #’s HIV prevalence (KAIS ‘07) HIV prevalence (KAIS ‘07) – Females – 9.2%; Males 5.8% – Females 15-24yrs 4X more likely to be infected – Increasing HIV prevalence in rural Kenya 70% of general popn, 84% of female popn 70% of general popn, 84% of female popn – Women’s lower education co-related to HIV infection – Rate of new infections – higher among men – 45% discordance among married couples – Polygamous unions – more likely to be HIV infected (11% vs 7%) 3

4. Gender & HIV in Kenya – beyond the #’s Sexual practice and behaviour Sexual practice and behaviour – Based on perceptions of masculinity & femininity – Framed within socio-cultural norms Women are less likely to have access to VCT than males (NASCOP ’05) Women are less likely to have access to VCT than males (NASCOP ’05) Males – more decision making power in sexual relations (Erulkar 2005) Males – more decision making power in sexual relations (Erulkar 2005) Blurred boundaries - consent, coercion & force with -ve implications for seeking HIV services (Kilonzo et. al, 08) Blurred boundaries - consent, coercion & force with -ve implications for seeking HIV services (Kilonzo et. al, 08) Perceptions of low/no risk among married women (KDHS 2003) Perceptions of low/no risk among married women (KDHS 2003) ‘my partner’s results are mine’ (Njeri 08 – unpublished) – reason for not testing by both women & men ‘my partner’s results are mine’ (Njeri 08 – unpublished) – reason for not testing by both women & men 4

5. 5 Background of VCT Knowledge of HIV status – ’80’s & 90’s.. Knowledge of HIV status – ’80’s & 90’s.. – Protect stigmatized persons – confidentiality – Human rights vs public health approach- consent – Support coping (no treatment) – counselling HIV counseling and testing HIV counseling and testing – Responsibility for prevention on individuals VCT models - western located with different contexts VCT models - western located with different contexts – individualized health care & sexual decision making power – Monogamy based

6. Kenya’s HIV - CT history Liverpool VCT, Care & Treatment (LVCT) Liverpool VCT, Care & Treatment (LVCT) – Started 3 VCT sites – 1998 – national standards development – Services Quality Assurance system – Social mobilization campaign > 1,000 VCT sites in 2007 > 1,000 VCT sites in 2007 LVCT - HCT services - >940,000 people LVCT - HCT services - >940,000 people New approaches – 2006 onwards New approaches – 2006 onwards – Mobile VCT, Provider Initiated CT, Community Based HIV testing and counseling Kenya committed to universal access to counseling and testing – GOAL: 80% knowledge of HIV status by 2010 Kenya committed to universal access to counseling and testing – GOAL: 80% knowledge of HIV status by 2010 6

7. SO, WHAT HAVE THESE NEW APPROACHES MEANT FOR UPTAKE OF CT SERVICES? Knowledge of HIV status Necessary for Care & Treatment Necessary for Care & Treatment A RIGHT FOR ALL A RIGHT FOR ALL primary to PREVENTION - ?? primary to PREVENTION - ?? 7

8. - Increase in uptake of HIV testing by women – linked to new testing approaches - Increase in uptake of HIV testing by women – linked to new testing approaches 8

9. LVCT HIV counseling and testing data - June 2007 – June 2008 LVCT HIV counseling and testing data - June 2007 – June 2008 Women’s uptake – higher than males Women’s uptake – higher than males 9

10. AND WHAT GENDER ISSUES EMERGE FOR COUNSELLING AND TESTING IN THE CONTEXT OF THESE APPROACHES FOR PREVENTION, FOR TREATMENT AND CARE? 10

11. Models of HCT Individualized approaches – counselling, risk reduction, testing & forward planning Individualized approaches – counselling, risk reduction, testing & forward planning – Sexual practice – socially defined (who can have sex with whom, where, when and how), – Multiple partners largely sanctioned – Limited sexual decision making power among women Conceptualizing ‘risk’ – moral framework? based on monogamy? what is ‘high’ risk? Conceptualizing ‘risk’ – moral framework? based on monogamy? what is ‘high’ risk? - Polygamy is accepted - Understandings of ‘risk’ by gender (married women perceive themselves as low risk in Kenya DHS’ 03) - Assumptions of consensual sex 11

12. HIV CT Models Assumptions of heterogeneity in women’s/men’s populations - ‘one size CT fits all’ Assumptions of heterogeneity in women’s/men’s populations - ‘one size CT fits all’ – Messaging for CT & HIV prevention not gender dissagregated – No targeted prevention messaging for women by age, disease burden – HIV risk (e.g alcohol consumption) not engaged Referral services following CT – gender blind Referral services following CT – gender blind – Gender impacts on health seeking, access, ability and desire to uptake as individual & by family & retention in health systems (report on social determinants of Health_ 12

13. Current definitions - ‘Couples’ Focus on ‘couples’ as monogamous Focus on ‘couples’ as monogamous – Polygamy & extended relations basis for family & problem solving – ‘Serial monogamy’ – knowledge of ‘couple’ HIV status at each point of engagement – Women’s agency to engage in these relationships has been documented – Youth (boys & girls) – a left out group in the ‘couples’ discussion Current definition of ‘couples’ problematic 13

14. ‘CONSENT’ Consent for what? information, testing, results to self and/or partner? Who asks consent from whom? M/F? Consent for what? information, testing, results to self and/or partner? Who asks consent from whom? M/F? Consent in health provider-client relations (Molyneux ‘06) Consent in health provider-client relations (Molyneux ‘06) – Contextual – who asks, potential consequences/ benefits, male/female understandings difer Perceptions of consent - by health providers, general populations and human rights advocates? Perceptions of consent - by health providers, general populations and human rights advocates? – Lessons learnt – anonymous vs confidential VCT? – CT in varied context - reproductive health (PMTCT), medical management (PITC), self determined (VCT), or supply driven services (CBHCT) – different standards? 14

15. Disclosure Disclosure of sexual practice/consequences is socially constructed – gender and age lines Disclosure of sexual practice/consequences is socially constructed – gender and age lines – What can be disclosed to whom by women & men Intended disclosure higher than actual Intended disclosure higher than actual Supported disclosure – highly contested issue Supported disclosure – highly contested issue – Fear of the consequences of disclosure esp women – Experiences of violence documented (Maman ’01, 2) – Women largely supported (Kilewo ‘01; Maman ’01) Additional concerns for disclosure Additional concerns for disclosure – Children – Extended families challenging for women 15

16. Data on married couples that are HIV +ve **Pathways, motivations of actual HIV status disclosure by gender are unknown **knowledge of partner HIV status – primary to engaging sexual discussions among couples 16

17. HOW DO WE RESPOND TO THESE ISSUES TO STRENGTHEN ACCESS TO KNOWLEDGE OF HIV STATUS? WHAT OPPORTUNITIES EXIST? HOW CAN THEY BE UTILIZED TO OPTIMIZE ON SHORT AND LONG-TERM OBJECTIVES OF CT? 17

18. 18 The question can no longer be whether to scale up counseling and testing, it can only be, how do we make this scale up gender responsive Proportion of HIV infected Kenyan’s in need of CTX

19. Gender responsive HIV CT - forward directions… Re-engaging counseling - Gender responsive counseling Re-engaging counseling - Gender responsive counseling – Opportunity to facilitate sexual discussions among couples & families – Offer supported disclosure & partner notification - options to support negotiation of knowledge of partner status – Used to harness ‘family & community risk reduction planning’ rather than individuals Re-define ‘risk’ & focus social mobiliization on ‘knowledge of self status and that of sexual partner – status is not shared’ Re-define ‘risk’ & focus social mobiliization on ‘knowledge of self status and that of sexual partner – status is not shared’ 19

20. Gender responsive HIV CT Develop gender audits for HIV CT services & lobby for inclusion as minimum package for scale up of HTC Develop gender audits for HIV CT services & lobby for inclusion as minimum package for scale up of HTC – Evaluate responsiveness of CT programming at programme start through scale up – Develop service QA that is explores the needs and implications for women and men Gender targeted messaging for prevention is essential with a focus on gendered heterogeneities & on youth Gender targeted messaging for prevention is essential with a focus on gendered heterogeneities & on youth Re-focus on male uptake of HIV counseling and testing Re-focus on male uptake of HIV counseling and testing Scale up services that provide CT for couples & families Scale up services that provide CT for couples & families 20

21. Acknowledgements LVCT colleagues LVCT colleagues Ministry of Health Ministry of Health National AIDS Control Council National AIDS Control Council PEPFAR/CDC - Kenya PEPFAR/CDC - Kenya 21