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Peer educators promoting oral pre-exposure prophylaxis (PrEP)

 Peer educators promoting oral pre-exposure prophylaxis (PrEP)

By Daniel Kyalo and Geoffrey Njenga

Nairobi, Kenya – You cannot talk about the successful implementation of PrEP in Riruta Health Centre without mentioning Julia, Mary, Diana, and Magdalene. The four have a lot in common, they are single mothers, active sex workers and are peer educators linked to Riruta.

Harassment by customers, condom bursts and contracting STI’s was the order of the day for the four. PrEP couldn’t come at a better time as they were constantly worried of getting HIV and they were tired of being on PEP due to condom bursts.

Having been on PrEP for the last two years, they have seen the benefits and were motivated to become strong advocates of PrEP as they desired to see their fellow sex workers healthy and worry-free from the fear of contracting HIV and leaving behind their children.  “I have seen many people infected with HIV, others have died as a result of it and many children orphaned, it makes me sad knowing they could have taken PrEP to prevent HIV. This motivated me greatly to become a peer educator” says Magdalene.

The number of sex workers in Nairobi County is estimated to be 29,494 and they are among key populations that contribute a third of all new HIV infections in Kenya. The HIV prevalence rates among sex workers is 29.3% yet they have the least access to prevention, care, and treatment services because their behaviors are often stigmatized. By using peer educators to reach out to hot spots with information on HIV prevention a positive attitude by service providers at Riruta and a combination of services such as family planning, cervical cancer screening, STI treatment, condom, lubricant supply and counselling, female sex workers feel at ease going for PrEP services at Riruta, a public health facility.

The four are among 428 peer educators sensitized by Jilinde on HIV prevention methods including PrEP, condom negotiation/use and how to identify those at risk and in need of PrEP. They create awareness of PrEP at the hotspots and in the community linking those at risk of HIV infection to Jilinde supported sites for PrEP services. They have reached 9,256 female sex workers with PrEP messages.

Reaching sex workers is not always easy, the four peer educators confess. Most sex workers don’t want to take a daily pill they would prefer to take just one pill that protects them for an extended period of time. “Sometimes we get abused during outreaches and following up clients on PrEP for refills is not easy as most of them are mobile” says Julia. These challenges have been addressed by correcting the myths with correct information and ensuring a strong referral system.

“PrEP is not for sex workers only, it’s for anybody who is at risk of HIV infection. “Anybody can take it as long as they are at ongoing risk. “says Mary

Riruta Health Centre is a shining example that, if sex workers are trained as peer educators, facilitated to do their work and a nice rapport between them and the health workers is ensured, public health facilities can increase PrEP uptake and reduce HIV transmission.

 

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Reducing Stigma by Health Providers

Reducing Stigma by Health Providers

By Geoffrey Njenga

Nairobi,Kenya – It was a bright Wednesday morning; the sky was clear and the sun was slowly baking the grounds of Kenyatta University which was dotted with tents from different organisations. The students were marking International Condom Day on February 13th 2018. HIV services were being offered by different organisations in a bid to avert the increasing numbers of new HIV infections among youth and encourage condom use. Approximately 29% of all new HIV infections in Kenya are among adolescents and youth. Thirty percent of new HIV infections in adults are among youth below 24 years. Young women aged 15 – 24 years post the highest number of HIV infections and contribute 21% of all new infections in Kenya. Jilinde a Jhpiego led project is rolling out PrEP in Kenya as part of the combination prevention package and on this day, Jilinde was on site offering HIV testing and PrEP services.

 

For Elizabeth, a clinician at Mathare North Health Centre in Nairobi, this day was different than the ones she had done before as it involved students. As she was busy offering HIV testing and PrEP services a group of young men aged 19 came to the tent set up by Jilinde requesting for PrEP services. PrEP, a pill taken daily has proven to be an effective way of preventing HIV. It is used in combination with other HIV prevention strategies.

 

The young men were referred to Elizabeth who was more than happy to offer the services until her colleague mentioned that they are Men who have sex with Men (MSM).

 

For the first 10 seconds her face stuck in an incredulous expression, unblinking stare, she was desperately trying to make sense of it all, she was rendered speechless unable to comprehend what she had just been told. She sat there with the client as if paralyzed from the neck up. It was Elizabeth’s first encounter with MSM’s in her 8-year career in providing health services. “My thoughts were blocked. I dint know where to start or how to talk to the clients, since I was not prepared how to handle them. It was tough for me to handle them at first.” says Elizabeth.

 

The young men quickly noticed the shock in Elizabeth’s face and felt uneasy and were not willing to disclose why they were at high risk of HIV infection and in need of PrEP. “I judged them based on their sexual orientation because I did not understand why they had to be MSM at that young age”. Says Elizabeth.

 

Instead of focusing on offering PrEP services, Elizabeth was hard at work convincing them to reconsider their sexual orientation and asked inappropriate questions. For the young men they felt stigmatized by a health worker who should be helping them.  Finally, the MSM’s were able to get the services they came for however they felt they did not receive quality services.

 

Many key populations  who will potentially benefit from PrEP face barriers to healthcare through discrimination and stigmatisation. Healthcare providers, including clinical staff, and counsellors should be provided with the competencies to provide quality PrEP services.

 

Jilinde organized a PrEP sensitization training on key population sensitivity, clinical guidelines, counselling, and attitudes to promote uptake and retention of PrEP by creating a non-stigmatizing and supportive environment for key populations. Elizabeth together with other health care workers went through this training and were equipped with the knowledge, attitude, and skills to provide effective PrEP services to different people.

 

For Elizabeth, the training has enabled her provide better PrEP quality services and even helped her reach out to more key populations at high risk and in need of PrEP. “The training has enabled me to be better prepared and more relaxed even if it’s key population coming for services. I am confident of handling them respectfully.” says Elizabeth.

 

Since the incident she has offered PrEP services to an older MSM couple and was able to handle them well and follow up with them during their monthly revisits. She is now able to reach out to key populations at risk and encourage them to take up PrEP as part of combination prevention package to ensure holistic care.

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Bridge to Scale Project at IAS

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Jhpiego’s Daniel Were represented the Kenyan oral PrEP scale-up project at a WHO-sponsored satellite session during the 9th International AIDS Society Conference on HIV Science in Paris. Co-presenters included U.S. Global AIDS Coordinator Ambassador Deborah Birx; Rachel Baggaley of the HIV department at WHO; Yogan Pillay of the National Department of Health, South Africa; South African epidemiologist Quarraisha Abdool Karim; Sheena McCormack, a clinical epidemiologist at UCL; and Jean-Michelle Molina, an infectious disease specialist at the University of Paris Diderot. Moderating the session was Dr. Wafaa El-Sadr, founder and director of ICAP.

Oral Pre-Exposure Prophylaxis (PrEP) for an AIDS-Free Generation

A single pill taken daily to prevent HIV

Oral PrEP Works!

A daily dose is more than 90% effective in preventing HIV.

The World Health Organization (WHO) recommends oral PrEP to anyone at substantial risk for becoming infected with HIV and includes PrEP on the Essential Medicines List. A dozen clinical trials have proven that taking oral PrEP as prescribed prevents HIV.

*Fonner VA, Dalglish SL, Kennedy CE, et al. 2016. Effectiveness and safety of oral HIV pre-exposure prophylaxis for all populations. AIDS. 30(12):1973–1983. doi: 10.1097/QAD.0000000000001145.

 

Who Needs Oral PrEP?

Anyone who is HIV-negative and at substantial risk of becoming infected with HIV

Examples of those who may particularly benefit from PrEP include:

  • adolescent girls and young women in areas where HIV is common
  • HIV-negative men or women in a relationship with an HIV-positive person
  • men who have sex with men
  • sex workers
  • those with behavioral risks that make it easier to get HIV

Bridge-to-Scale in Kenya

One of the largest national oral PrEP programs

Scale-up of routine oral PrEP services to over 22,000 people at risk for HIV

A global learning laboratory for governments and stakeholders considering oral PrEP policy and programs

Support from the Bill & Melinda Gates Foundation

The Jhpiego Difference

Trusted relationships with governments and international stakeholders

Close collaboration with WHO to make oral PrEP web-based training available to clinicians and pharmacists

Proven experience scaling up large and challenging interventions

Prior experience translating science to public health practice that is affordable, effective and sustainable.

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With PrEP, I am Covered

July 25, 2017

Geoffrey Njenga and Catherine Ndungu

Cynthia, 25, a sex worker in Nairobi’s Kengemi informal settlement, with her first dose of PrEP, an HIV-prevention medication. Photo: Juozas Cernius.

Photo: Juozas Cernius.

Pre-exposure prophylaxis offers peace of mind to people at continuous risk of HIV infection

Nairobi, Kenya—In the outskirts of Nairobi is the sprawling Kangemi informal settlements. The slum is bustling with people; some cooking outside their shacks, others burning charcoal to sell or busying themselves with their food stalls. The sky is overcast and the air is cold. At the hall hired for the day’s outreach, bedsheets serve as makeshift partitions. This outreach is unique: Here, for the first time in Kenya, eligible clients will have access to pre-exposure prophylaxis (PrEP).

PrEP is a pill taken once daily by HIV-negative people who are at continuous risk for HIV infection. In Kenya, Jhpiego—through the Jilinde project—is scaling up the use of PrEP into a large-scale public health response. Over 20,000 people at continuous risk of HIV infection will receive oral PrEP, which will be integrated within existing HIV combination prevention services.

Today’s outreach gives clients access to HIV testing and counseling services, anti-retroviral therapy and PrEP. Among those getting their first dose of PrEp is Cynthia, a warm and candid 25-year-old sex worker.

Born and raised in Nairobi, Cynthia was introduced to sex work as a teen, after the birth of her daughter. “My father deserted us and my mother struggled to take care of my siblings and I,” she explains. At 15, she dropped out of school to look for a job so she could feed her baby. When no opportunities arose, her cousin, a sex worker, told her how she could earn earn between 2,000-3,000 KES per night (the equivalent of about $20 to $30), and $5,000 KES ($50) on weekends. Most of the clients are men 35 and older, from wealthy neighborhoods surrounding Kangemi slum.

Too good to be true?

Conventional protection isn’t always easy or even possible, Cynthia says: “Sometimes, clients pay extra for condom-less sex and sometimes a condom bursts.” She has also been forced to have sex with policemen to buy her freedom when arrested.

When Cynthia first heard about PrEP from a Jilinde-trained peer educator, it sounded like a scam, too good to be true. “My first thought was, there is no cure for HIV, so how could there then be a pill that prevents HIV?” Only when she saw PrEP in the media did she begin to believe it was a real drug and seek more information.

The Jilinde project is scaling up the use of PrEP in Kenya within existing combination prevention services to people like Cynthia who are at high risk of HIV. More than two million people acquire HIV infection globally every year. In Kenya, in 2015, 71,034 people aged above 15 years and 6,613 aged 0-14 years got infected with HIV. This translates to 77, 648 Kenyans requiring lifelong antiretroviral treatment to keep them alive and prevent further transmission of HIV.

The Jilinde project is set to demonstrate the incredible potential of PrEP by generating evidence that population-level PrEP interventions are feasible and effective in low-and middle-income countries which bear the brunt of the world’s HIV burden.

For Cynthia and so many others like her, the time for PrEP is now.

“I don’t like the sex work and hope that one day I can start my own food business,” she says. “But for now, PrEP gives me peace of mind because I know that I can keep HIV at bay.”

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Taking Control of my health

By Geoffrey Njenga

Kwale, Kenya – As darkness sets in, the coastal town of Ukunda becomes alive as music blares from the clubs announcing the start of another colorful night. Scantily dressed young women and men are on the prowl looking for men and women who will pay for sex. Among them is 23 year old Duncan Thomas or Dan as he is fondly called by family and friends. He is a male sex worker  and his ultimate price is white men who will pay twice as much as his local clients. He sleeps with 4 men a day each paying Ksh 4,000 about $40 on a good day. Some men refuse to use a condom however Dan is at peace as he knows he is protected thanks to the Pre-Exposure Prophylaxis (PrEP) pill he is taking daily.

 

In the early days of the HIV epidemic in Kenya, there were few ways of preventing an individual from contracting HIV.  However Kenya has come a long way in HIV prevention with the latest addition being Oral PrEP- a pill prescribed to HIV-negative individuals at high-risk of infection. Jhpiego—through the Jilinde project —is ensuring PrEP is integrated within current HIV prevention services by creating demand for PrEP, identifying eligible users through HIV testing, enrolling new users, and supporting continued use as long as individuals remain at risk.

Stolen childhood

Dan was just 3 years old when he was orphaned. He was brought up by his sister in Ukunda and life was not easy. At the age of 13, Dan was taken in by a well-off family but little did he know that this would be the start of his journey as a man who has sex with men commonly referred to as MSM.

One of the family members was an MSM and he started enticing him and sleeping with him. He was only 14. “I only agreed to his advances because he was paying my secondary school fees and I was doing well in school.” Dan says. In 2013, Dan parted ways with his male partner and he started selling his body on the famed beaches and clubs of Diani to both tourists and locals to make ends meet. He was very afraid of contracting HIV as he did not have an alternative. “In order to make ends meet, I used to sleep with different men every day some without protection and I was very scared of getting HIV” Dan says

 Curious about PrEP

While surfing the web, Dan came across PrEP on MSM dating sites like Planet Romeo and Grinder. He got curious about this drug that could prevent him from contracting HIV. He researched more on it and he was yearning to know where he would get it in Ukunda. By chance he bumped into a Jilinde trained peer educator who gave him the correct information and referred him to a clinician at Ukunda Drop in Center who answered all his questions on PrEP.

For effective delivery of oral PrEP in Kenya, Jilinde has built the competence and confidence of health care providers to deliver PrEP and give correct information to counter the rumours and misinformation about PrEP. Whole site orientations conducted by the project has ensured health care workers and support staff are knowledgeable about PrEP and can provide appropriate referrals to clients.

Dan says he had received a lot of conflicting information on PrEP and he was glad he found someone who could give him accurate information. After his questions were satisfactorily answered, Dan enrolled on PrEP and he has been on it for three months.

“I am HIV negative and I love PrEP because it has helped me regain control of my health. I know I am safe and won’t be at risk of HIV infection” Duncan says.

According to the National HIV estimates, Kenya has seen a sharp decline in HIV incidence among adults aged 15-49 from 0.41% in 2010 to 0.27 in 2015 possibly due to the scale up of various prevention programmes. In terms of absolute numbers, the new HIV infections among all adults aged 15+ years declined from 83,097 in 2010 to 77, 648 in 2015, a 7% decline in the number of new annual HIV infections at national level. The government believes oral PrEP together with other HIV prevention methods will play a big role in reducing these numbers even further.

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Creating PrEP Demand

Urembo Wednesday: Creating Demand For PrEP

By Geoffrey Njenga

Nairobi, Kenya- Walking up the stairs to the 3rd floor of the wellness center run by Bar Hostess Empowerment and Support programme, my ears are tickled with the sound of warm music and my nostrils are hit with the scent of acetone and fingernail polish. I arrive at the reception and there are young beautiful ladies chatting and watching music videos as they wait for their turn to be pampered in an adjacent room.

Every Wednesday BHESP with support from Jilinde hosts Urembo Wednesday where sex workers get a chance to try something new with their nails, change their look and get pampered. However, there is a twist to this event. Not only do the girls get pampered they also get health talks on HIV prevention methods like condoms, Post Exposure Prophylaxis (PEP), and the latest HIV prevention method Pre-Exposure Prophylaxis (PrEP)- a pill taken daily to prevent HIV infection for those at high risk. This is one of the many events that Jilinde in partnership with Civil Society Organizations (CSO’s) is using to create demand for PrEP and health services in general.

The receptionist greets me with a friendly “hello” and a smile. “I am here to meet Mercy the Prevention Manager” I say with a smile. “Please have a seat” she tells me. She retreats into one of the offices and comes back to tell me Mercy will be with me shortly as she is wrapping up another meeting.

I decide to make new friends in the meantime and I started charting with Gladys a 23-year-old bubbly sex worker and an outreach worker at BHESP. “Why are you here today?” I inquire. “I am here to help with the event and to get myself pampered” she replies. “For you to be a successful sex worker you have to be attractive and be good looking” she continues. She invites me to the room where the action is happening and I am met with young women getting their nails done. In one corner of the room manicurists are busy tending to their clients, in another, there is a condom demonstration happening, there is also a station for snacks for the clients. I notice a health talk going on as they are being pampered. There are posters on the wall reminding clients the need to maintain a negative HIV status and use PrEP daily.

After 10 minutes, Mercy comes to where I am and pulls me aside. “Welcome to our Drop in Centre. This is a safe space for female sex workers where they not only get health services but also a space where they can come to catch up with their peers and relax” she says. As we continue talking I find out Urembo Wednesday came about after consultation with the sex workers as a way of creating demand for health services among sex workers and particularly PrEP.  “You see Wednesday is ladies’ night and what better way to get your mojo on than to pass by the wellness center and get pampered before proceeding to your hotspot” she says.

Urembo Wednesday is usually a hit with the sex workers and its one of the demand creation approach they are using together with Jilinde to ensure sex workers and those at high risk of HIV infection are reached with PrEP information and are able to take PrEP to prevent HIV infection.

After talking to Mercy, I walk back to Gladys who was getting her nails done. She had chosen different colors for each of her nails. “I have been on PrEP for 1 year 2 months now and I am satisfied with its protection. I can’t imagine living with HIV” she says. As I walk out of the wellness center I meet more ladies arriving at the facility to get their dose of beauty.

 

 

 

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