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 8th 2007

LVCT… our Mission”

To use our To use our research resultsresearch results and our technical and our technical resources to inform HIV/AIDS policy formulation in resources to inform HIV/AIDS policy formulation in

Kenya and beyond and to build the capacity of Kenya and beyond and to build the capacity of government, private and civil society organizations to government, private and civil society organizations to

provide provide quality quality prevention, care and treatment prevention, care and treatment services to those at risk of infection, infected or services to those at risk of infection, infected or

affected by HIV,affected by HIV, with special attention given to with special attention given to those with greatest vulnerability to infection and those with greatest vulnerability to infection and

those with special service needs.those with special service needs.

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Kenyan NGO since 2002, 190 staff, regional presence Kenyan NGO since 2002, 190 staff, regional presence – Botswana, Cote d’e Ivoire, South Sudan– Botswana, Cote d’e 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

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findings – on perceptions...

fuzzy boundaries ‘force, coercion & consent’

“lets 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

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findings

policy level– no regulatory framework & standards– no coordination , documentation

limited capacities – human, technical, financial high user costs – cards, fees

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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

CASUALTYEmergency 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

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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 

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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)

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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

Late presentation14%

Lost to referral11%

HIV+ at baseline5%

No to HIV test11%

Continued PEP59%

Delivery: Quality of PEP delivery (n=292)

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)

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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

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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

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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

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Acknowledgements

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