Transcript Majengo Cohort: Success factors

Female Sex Workers Cohorts
Dr. Joshua Kimani
University of Manitoba &
Nairobi Research Group
HIV/AIDS in Kenya- Contextual issues
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Estimated Population- 35 m (GDP – USD 530)
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1.4 m Kenyans estimated to be living with HIV
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National HIV Prevalence 2003: Kenya Demographic HS- 7%
-Surveillance 2007- 5.6%
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Negative impact on all sectors of the society
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50% to 70% of Medical hospital beds occupancy is linked to HIV
(Out of pocket financing being the norm)
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Reversed previous health gains: life expectancy 62 to 46 years
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About 200000 individuals are currently on ART up from about 10000 in 2004
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With the support from PEPFAR and Global Fund;-Antiretroviral therapy and HIV
palliative care became part of the MOH standard of care in 2005
UoM/UoN Research Group- Nairobi, Kenya
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Worked closely with female sex workers since 1985
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Initial program started in response to a GUD (Chancroid) outbreak in
Nairobi around 1982
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Oldest clinic based at the Majengo slums of Nairobi, while Korogocho
and Kibera are the two less known cohorts
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The three cohorts -targets low socio-economic Female sex workers
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Average of 5 sex partners /day with a high rate of partner change
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Marginalized and vulnerable population
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All at high risk of HIV transmission and acquisition
Shanty Towns - Nairobi
Program Goals
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Provision of a standardized care package and
counseling support that assures prevention of
STIs/ HIV
 Conducting epidemiological and immunobiology research studies among the female
sex workers
 Advocacy for sex worker’s issues
 Linkages to programs that offer social support
and possible exit strategies
Majengo Sex Workers Cohort
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Initial group of female sex workers were mobilized and recruited
into the cohort in 1985
?Oldest cohort – in Africa
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Open cohort with over 3000 participants enrolled to date
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Twice yearly resurveys is a unique tradition started in 1985 and
maintained today
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About 700 on active follow- up during a single resurvey
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Contributed a wealth of information on HIV natural history and
resistance to date
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May provide a natural model of HIV immunity
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NB: Over 95% of those who need ARVs on medication now
Majengo Sex workers Clinic
Majengo Cohort: Success factors
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Sex workers involvement in programming from the
outset
 Peer led outreach and cohort cohesion program
 Emphasis on ‘informed consent’ at baseline
 Basic attitude of service providers assuring
confidentiality
 Continuous exchange of information through
individual, mini and yearly baraza’s
 STI screening and management linked to the
monthly follow-ups and biannual resurveys
 Use of cell phones ‘sms’ to remind individuals about
their appointments and to take medications
Majengo Cohort: Success factors
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Free condoms, information, promotion and
demonstrations on use
Above average comprehensive standard of
care offered over the years compared to
what's available in MOH clinics
HIV basic care and ARV services provided
since 2005 as part of the standard of care
On site ARV/TB and care services
Continuous presence in the area over two
decades
Groups success in fund raising
Mini – “Baraza”
Korogocho Sex Workers Cohort
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Established in 1998
Korogocho;- a poor slum – N/E of the CBD
Targets low socio-economic sex workers
Open cohort with 500 participants enrolled to date
HPV work has been the main research activity but funding has
been problematic
Peer led networks and mini baraza’s used to maintain cohort
cohesion
Use of cellphone- ‘sms’ reminders on follow-ups and drugs
adherence
The ongoing ARV roll out has rekindled follow-up rates in a big
way
On site HIV ARV / TB and Care services
Kibera Sex Workers Cohort
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Established in 1997 near Kibera slums
Kibera is the ?largest shanty town in Africa
Estimated population 1 million people
We target low socio-economic female sex workers
Mobilized 1500 sex workers with 889 recruited into the trial
Trial - A double blind Azithromycin prophylaxis trial for STI and HIV
control
Study conducted between 1998 -2002
Cohort members not in active follow from 2002 but in touch through
peers and cell phone numbers where possible
A dedicated nurse counselor still on site to date for consultations
Peer led networks still used to maintain contacts with most sex workers
Linkages to the ongoing ARV roll out has rekindled interest and followup rates high
Cohort members can be re-mobilized within a short time for other
studies using the peer leaders
Challenges
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Sex work is criminalized in Kenya
 No budgetary allocation for STI prevention for
vulnerable populations
 Number of sex workers in most urban centers
unknown
 Fluidity in sex work and population highly mobile
 ‘Informed consent’ process problematic due to the
low level of education
 Age of consent is 18 in Kenya yet many sex workers
are below that age
 Rampant substance abuse (Alcohol)
 Drugs for classical STIs not covered by PEPFAR
Challenges
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High expectations especially on socio –support among study
participants
High maintenance of cohorts
Donor or funding agencies fatigue
Sustainability questions
High cost of air-time for mobile telephony
Coordination at the MOH level lacking – NASCOP and NACC
confusion…
No policy or guidelines on way forward beyond PEPFAR
supported ARV roll out program by MOH and stakeholders
Fragile public health system (Post election violence)
Weak and inefficient ethics review committee
Experiences not generalizable between clinical trials scenario
and cohort studies
Thank You