Power and poverty: A participatory study on the complexities of HIV and intimate partner violence in an informal urban settlement in Nairobi, Kenya.

People in informal urban settlements in Kenya face multiple inequalities, yet researchers investigate issues such as HIV or intimate partner violence (IPV) in isolation, targeting single populations and focusing on individual behaviour, without involving informal settlement dwellers. We formed a study team of researchers (n = 4) and lay investigators (n = 11) from an informal settlement in Nairobi, Kenya to understand the power dynamics in the informal urban settlement that influence vulnerability to IPV and HIV among women and men from key populations in this context. We facilitated participatory workshops with 56 women and 32 men from different marginalised groups and interviewed 10 key informants. We used a participatory data analysis approach. Our findings suggest the IPV and HIV nexus is rooted in the daily struggle for cash and survival in the informal urban settlement where lucrative livelihoods are scarce and a few gatekeepers regulate access to opportunities. Power is gendered and used to exercise control over people and resources. Common coping strategies applied to mitigate against the effects of poverty and powerlessness amplify vulnerabilities to HIV and IPV. These complex power relations create and sustain an environment conducive to IPV and HIV. Prevention interventions thus need to address underlying structural drivers, uphold human rights, create safe environments, and promote participation to maximise and sustain the positive effects of biomedical, behavioural, and empowerment strategies.

Intra-Urban Variation of Intimate Partner Violence Against Women and Men in Kenya: Evidence from the 2014 Kenya Demographic and Health Survey.

Although urban areas are diverse and urban inequities are well documented, surveys commonly differentiate intimate partner violence (IPV) rates only by urban versus rural residence. This study compared rates of current IPV victimization among women and men by urban residence (informal and formal settlements). Data from the 2014 Kenya Demographic and Health Survey, consisting of an ever-married sample of 1,613 women (age 15-49 years) and 1,321 men (age 15-54 years), were analyzed. Multilevel logistic regression was applied to female and male data separately to quantify the associations between residence and any current IPV while controlling for regional variation and other factors. Results show gendered patterns of intra-urban variation in IPV occurrence, with the greatest burden of IPV identified among women in informal settlements (across all types of violence). Unadjusted analyses suggest residing in informal settlements is associated with any current IPV against women, but not men, compared with their counterparts in formal urban settlements. This correlation is not statistically significant when adjusting for women's education level in multivariate analysis. In addition, reporting father beat mother, use of current physical violence against partner, partner's alcohol use, and marital status are associated with any current IPV against women and men. IPV gets marginal attention in urban violence and urban health research, and our results highlight the importance of spatially disaggregate IPV data-beyond the rural-urban divide-to inform policy and programming. Future research may utilize intersectional and syndemic approaches to investigate the complexity of IPV and clustering with other forms of violence and other health issues in different urban settings, especially among marginalized residents in informal urban settings.

Experiences and Perpetration of Recent Intimate Partner Violence Among Women and Men Living in an Informal Settlement in Nairobi, Kenya: A Secondary Data Analysis.

Evidence suggests an overlap between intimate partner violence (IPV) experience and perpetration. However, few studies in sub-Saharan Africa have investigated experience and perpetration of IPV among women and men within the same community. This study reports prevalence of past-year IPV experience and perpetration among women and men living in an informal settlement in Nairobi, Kenya, and factors associated with IPV. Data analyzed for this study involved a geographically distributed random sample of 273 women and 429 men who participated in a community survey. We approximated prevalence of IPV experience and perpetration and used logistic regression for estimating associations between individual-level factors and IPV. Women and men experienced similar levels of IPV, but a significantly higher proportion of men reported physical and sexual IPV perpetration. Witnessing violence between parents in childhood was associated with women's physical and sexual, and men's sexual IPV experience; and with women perpetrating emotional, and men perpetrating sexual IPV. Less equitable gender attitudes were associated with men's perpetration of physical IPV. More equitable gender knowledge was associated with women's experience of sexual IPV, and with men perpetrating IPV. Perceived skills to challenge gender inequitable practices were negatively associated with men perpetrating sexual IPV. In conclusion, we found IPV experience and perpetration were highly correlated, and that, contrary to commonly reported gender gaps, men and women experienced similar rates of IPV. We make suggestions for future research, including on IPV prevention interventions in areas with such IPV prevalence that would be beneficial for women and men and future generations.

The use of case advocates to manage child survivors of sexual violence in public health facilities in Kenya: A qualitative study exploring the perceptions of child survivors, care givers and health care providers.

BACKGROUND: The uptake of and retention in health services by child survivors of violence (CSV) is a growing challenge, especially in sub-Saharan Africa. While lay health workers have been used in several settings to improve access to health services, there is limited literature on the use of such workers to support services for CSV. OBJECTIVE: To explore the acceptability of using trained lay health workers (case advocates) to provide basic information and escort CSV to various referral points within two public health facilities in Kenya. PARTICIPANTS: The following participants were enrolled after giving their consent: CSV 14-18 years of age presenting for services along with their caregivers during the study; caregivers above age 18; and healthcare providers (HCPs) providing services for sexual violence at the two study sites. METHODS: In-depth interviews (14 with CSV and 27 with caregivers) and four focus group discussions (with 30 HCPs) were conducted. Data were transcribed in MSWord and analysed using a grounded theory analytical approach. RESULTS: Caregivers and CSV reported that the case advocates were useful in fast-tracking access to services, easing CSV movement through health facilities and helping CSV communicate their issues. HCPs reported improved timeliness and completeness of services due to the involvement of the case advocates. CONCLUSION: The use of case advocates to support CSV is acceptable to children, caregivers and HCPs. Task-sharing between case advocates and HCPs has the potential to improve the uptake of the various services offered to CSV, especially in resource-limited settings.

A Cross-sectional Study to Compare Hepatitis B Immunity in HIV-infected and HIV-uninfected Kenyan Children After Primary Hepatitis B Immunization.

To evaluate protective antibody levels against hepatitis B surface antigen in HIV-infected and HIV-uninfected Kenyan children, this study enrolled 531 children. In the HIV-infected group, only 18.3% had protective hepatitis B surface antigen compared with 74.4% in the HIV-uninfected group (P < 0.0001). Perhaps HIV-infected children should be immunized differently.

Addressing the dual health epidemics of HIV and sexual abuse among children and adolescents in Kenya: uptake of HIV counseling and post-exposure prophylaxis.

PURPOSE: Child sexual abuse and HIV are key health challenges in Kenya. In 2015, LVCT Health conducted a study aimed at assessing the quality of HIV-related services offered to child survivors of sexual violence in public health facilities. MATERIALS AND METHODS: A qualitative data collection approach was utilized. Qualitative data were collected through in-depth interviews with 31 providers. Quantitative methods included a retrospective review of 164 records of child survivors of rape who had accessed services 6 months prior to the commencement of the study. SPSS Version 22 was used in the descriptive analysis of the medical records. Client exit interviews and observation data were analyzed using MS Excel. In-depth interviews were analyzed using a thematic analytical approach. RESULTS: Twenty-seven percent (n=164) survivors were documented to have received the first dose of postexposure prophylaxis (PEP). Providers did not conduct HIV pre- and posttest counseling for the survivors. There were no longitudinal follow-up mechanisms to ensure child survivors initiated on PEP adhered to the treatment plan. Less than 30% of survivors returned to the facility for PEP adherence counseling and follow-up HIV testing. Twenty providers cited capacity gaps in undertaking HIV risk assessment for child survivors. Limited availability of PEP is a barrier to HIV prevention, as most departments only offer services between 8 am and 5 pm. HIV tests were only available on weekdays before 5 pm. PEP being out of stock remains a barrier to HIV prevention. CONCLUSION: Existing post-rape care services are not adequately structured to facilitate delivery of quality HIV-related services to child survivors. Health provider capacity in the management of children remains weak due to lack of skill-based training on the dynamics of responding to the needs of child survivors. There is a need for standard operating procedures and training modules on the prevention of HIV in the context of child sexual abuse.

Prevalence and correlates of treatment failure among Kenyan children hospitalised with severe community-acquired pneumonia: a prospective study of the clinical effectiveness of WHO pneumonia case management guidelines.

OBJECTIVE: To determine the extent and pattern of treatment failure (TF) among children hospitalised with community-acquired pneumonia at a large tertiary hospital in Kenya. METHODS: We followed up children aged 2-59 months with WHO-defined severe pneumonia (SP) and very severe pneumonia (VSP) for up to 5 days for TF using two definitions: (i) documentation of pre-defined clinical signs resulting in change of treatment (ii) primary clinician's decision to change treatment with or without documentation of the same pre-defined clinical signs. RESULTS: We enrolled 385 children. The risk of TF varied between 1.8% (95% CI 0.4-5.1) and 12.4% (95% CI 7.9-18.4) for SP and 21.4% (95% CI 15.9-27) and 39.3% (95% CI 32.5-46.4) for VSP depending on the definition applied. Higher rates were associated with early changes in therapy by clinician in the absence of an obvious clinical rationale. Non-adherence to treatment guidelines was observed for 70/169 (41.4%) and 67/201 (33.3%) of children with SP and VSP, respectively. Among children with SP, adherence to treatment guidelines was associated with the presence of wheeze on initial assessment (P = 0.02), while clinician non-adherence to guideline-recommended treatments for VSP tended to occur in children with altered consciousness (P < 0.001). Using propensity score matching to account for imbalance in the distribution of baseline clinical characteristics among children with VSP revealed no difference in TF between those treated with the guideline-recommended regimen vs. more costly broad-spectrum alternatives [risk difference 0.37 (95% CI -0.84 to 0.51)]. CONCLUSION: Before revising current pneumonia case management guidelines, standardised definitions of TF and appropriate studies of treatment effectiveness of alternative regimens are required.