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 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.
Kenyan NGO since 2002, 190 staff, regional presence
– Botswana, Cote d’e Ivoire, South Sudan
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Why post rape care?
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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)
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situation analysis –
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intervention
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develop & implement a standard of care
evaluation
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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)
uptake, delivery & acceptability of services
findings – on perceptions...
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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)
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findings
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health provider difficulties
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service delivery level
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initiate risk reduction for survivors
gender & age challenges in examination of survivors
health provider perceptions of SV
inconsistent services: EC, STI/ HIV prevention (PEP);
counseling – trauma; HIV testing; PEP adherence
findings
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policy level
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no regulatory framework & standards
no coordination , documentation
limited capacities – human, technical, financial
high user costs – cards, fees
Intervention process – participatory
action approaches
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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
Delivering the standard of care
Survivor
CASUALTY
Emergency management
PEP/EC, physical examination,
documentation
Counseling (primarily at VCT)
Laboratory
HIV testing, blood monitoring (Hb)
specimen analysis
Trauma/crisis, HIV testing,
PEP adherence; preparation for
Justice system
on-going follow up 4/52
HIV care clinics: PEP management & STIs,
Refer to STI clinic
if not provided at CCC
Clinical monitoring, Data collection: demographics,
HIV PEP uptake, HIV outcomes
Evaluation – uptake, delivery &
acceptability of the intervention
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uptake - survivors taking up services
delivery – data from routine records
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acceptability
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data collection from casualty, lab, HIV care clinic,
pharmacy
described coverage, quality of clinical evaluation,
clinical management, counselling & PEP delivery
knowledge, perceptions, ownership
Study limitations
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data challenges
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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
findings - uptake of services
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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)
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
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Delivery: Quality of PEP delivery (n=292)
Late presentation
14%
Lost to referral
11%
Continued PEP
59%
HIV+ at baseline
5%
No to HIV test
11%
- 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)
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achievements
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informing policy
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national indicators
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national guidelines
PRC as part of RH policy
training manuals for clinicians & counsellors
medico-legal linkages – PRC1 form
KNASP II – M & E – PEP/PRC indicators
PRC – performance indicator in the SWAp
DRH business plan - PRC indicators
practice
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scale-up to 16 PRC sites, >2,000 survivors seen
baseline for future PRC evaluation,
but new programming challenges...
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medico-legal linkages & psychosocial care
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PEP
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baseline data on adherence, HIV outcomes
indicators for social support characteristics
documentation & follow up systems
costing studies – cost study done but,
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common indicators btwn health and CJS
cost effectiveness of intervention,
costing per-contact HIV/pregnancy/STI transmission,
chronic exposures
lessons & opportunities
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documentation - critical to inform programming
data - essential for policy & practice
utilization of local health systems
lessons from HIV programming for GBV
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results framework with defined indicators
mutual agreement of outcomes
linking service delivery & policy to research
Acknowledgements
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Division of Reproductive Health in Kenya
All LVCT staff & programmes
Trocaire
DfID/Futures