«by Hannah Patterson BS, Ohio University, 2009 Submitted to the Graduate Faculty of Behavioral and Community Health Sciences Graduate School of Public ...»
HIV/AIDS IN THE SLUMS OF KENYA: INTERVENING THROUGH EFFECTIVELY
BS, Ohio University, 2009
Submitted to the Graduate Faculty of
Behavioral and Community Health Sciences
Graduate School of Public Health in partial fulfillment
of the requirements for the degree of
Master of Public Health
University of Pittsburgh
UNIVERSITY OF PITTSBURGHGraduate School of Public Health This thesis was presented by Hannah Patterson It was defended on November 28, 2011 and approved by Thesis Advisor Martha Ann Terry, PhD, MA Assistant Professor Behavioral and Community Health Sciences Graduate School of Public Health, University of Pittsburgh Committee Member Clareann H. Bunker, PhD, MPH Associate Professor Epidemiology Graduate School of Public Health, University of Pittsburgh Committee Member Christopher R. Keane, ScD, MPH Assistant Professor Behavioral and Community Health Sciences Graduate School of Public Health, University of Pittsburgh ii Copyright © by Hannah Patterson 2011 iii
HIV/AIDS IN THE SLUMS OF KENYA: INTERVENING THROUGH
EFFECTIVELY UTILIZING VOLUNTEERS
2.0 HIV/AIDS IN SUB-SAHARAN AFRICA
2.1. History of HIV/AIDS in Kenya
2.2 The Current HIV/AIDS Situation in Kenya
2.2.1 Women and HIV/AIDS
3.0 THE FOCUS ON SLUMS
3.1.1 HIV/AIDS in Kibera.
3.1.2 The Barriers to HIV/AIDS Prevention in Kibera
4.0 STATE, VOLUNTARY, AND PRIVATE SECTOR PARTNERSHIPS.............17 5.0 INTERNATIONAL VOLUNTEERING
5.1 International volunteering in Kenya
6.0 FADHILI COMMUNITY PARTICIPANT OBSERVATION REASEARCH...26
7.1 Volunteers Addressing Barriers to HIV Prevention
8.2 Future Research
8.3 Implications for Global Health
APPENDIX: HIV/AIDS MANUAL
I would like to extend my deepest gratitude to every member of Fadhili Community for embracing me as a part of your family and allowing me to share in your tireless work to improve the lives of those suffering from HIV/AIDS in Kenya. Asante sana.
Since its emergence, HIV/AIDS has disrupted and destroyed millions of lives throughout the world. Sub-Saharan Africa is the region of the world where this devastation has been the most severe. For decades, the global community has responded to the HIV/AIDS epidemic in sub-Saharan Africa through donations, innovations, and human service. In fact, international volunteerism focusing on HIV/AIDS is extremely popular among young people and has become an integral piece in the fight against HIV/AIDS. Kenya has embraced international volunteerism as a part of its vast tourism industry and attempted to utilize the hundreds of international volunteers in order to combat HIV/AIDS. International volunteers are often inclined to focus their efforts on the neediest areas of Kenya, such as the slums.
This paper focuses on Fadhili Community, a Kenyan organization that fosters partnerships between international volunteers and HIV/AIDS programs throughout the country.
The author travelled to Kenya in order to examine both sides of the volunteer process, the HIV/AIDS programs and the volunteers. The objectives of this research study were to assess current volunteer HIV/AIDS programs, determine gaps in knowledge and skills prevalent among volunteers, and develop an HIV/AIDS training manual for incoming volunteers. Based on emergent themes from the HIV/AIDS programs‘ expectations and limited knowledge and skills from volunteers, the HIV/AIDS manual is now utilized by Fadhili Community and its
effectiveness and viability of HIV/AIDS programs within Kenyan slums.
In the following pages, the author discusses both the history and current state of HIV/AIDS in sub-Saharan Africa with a focus on Kenya. Chapter 3 highlights the need for a special focus on slums, particularly Kibera. Chapter 4 discusses private, state, and voluntary partnerships as they relate to HIV/AIDS programming. In Chapter 5, the author discusses international volunteering and its increased popularity within Kenya. Chapter 6 explains the participant observation research in Kenya and outlines the objectives, methods, and results of this research. In Chapter 7, the author addresses the research limitations and makes recommendations for future research. Finally, Chapter 8 offers a conclusion from the research and discusses the implications for global health.
Sub-Saharan Africa is a term used to classify all African nations that are located either partially or fully south of the Sahara dessert. The population of this region is over 900,000 million (UNAIDS, 2010). There are only six nations in Africa not classified as sub-Saharan.
Sub-Saharan Africa is home to 22.5 million people living with HIV/AIDS (PLWHA) as of 2009.
This is nearly two thirds of the global total of PLWHA (UNAIDS, 2010). The notable spread of HIV started in sub-Saharan Africa in the late 1970s, as indicated by most of the available epidemiological data (UNAIDS, 2003). The first case of what was later identified as AIDS was officially reported in Africa in 1982 (Kates & Carbaugh, 2006).
Kenya, nestled in the heart of Sub-Saharan Africa, has a population of 39 million and is one of the regions hit hardest by the HIV/AIDS epidemic. As the HIV epidemic spread across sub-Saharan Africa and into Kenya, 26 cases of AIDS were reported between 1983 and 1985 (NASCOP & Ministry of Health, 2006). The first group affected was sex workers, according to the Bureau of Hygiene and Tropical Diseases (1986). By 1987, a total of 287 cases had been reported. In subsequent years, adult HIV prevalence rose from 5.1% in 1990 to 13.4% in 2000
Unlike its neighbors, Kenya historically has not responded as aggressively to the epidemic in terms of condom promotion, education, and preventative measures. The government‘s response to the epidemic was delayed and muddled. It was not until 1999 that Kenyan President Daniel Arap Moi declared AIDS a national disaster and called for the creation of a National AIDS Control Council (AIDS Analysis Africa, 2000). The prevalence rate has been declining steadily since 2000 from 13.4% in 2000 to 6.9% in 2006, likely a result of increased awareness and preventative interventions (NASCOP & Ministry of Health, 2006). Another notable cause for the decline in HIV prevalence between 2000 and 2006 is the large number of people dying from AIDS in Kenya. In 2001 alone, an estimated 190,000 people died from AIDS (Central Intelligence Agency, 2011).
Currently, Kenya has an estimated 1.5 million PLWHA: 180,000 of them are children (UNAIDS, 2010). The adult HIV prevalence rate is 6.3%, which is 5.2% higher than the overall global HIV adult prevalence rate of 1.1% (Kates & Carbaugh, 2006). Among young people (15Kenya‘s HIV prevalence rate is 2.9% (UNICEF, 2010).
The HIV epidemic in Kenya is categorized as generalized, which means that HIV affects people across all sectors of the population. Of course, HIV does not affect all groups equally. Its effects depend on gender, education, location, age, and many other factors. Some groups in Kenya are disproportionately affected by HIV/AIDS and these include commercial sex workers,
border mobile populations (Kefa, 2011). It is difficult to identify the effect that HIV has had on Kenya‘s homosexual population, as homosexuality is illegal in Kenya and is punishable by law up to 14 years in prison (Human Rights Watch, 2010). Therefore, accurate data on this marginalized group are unavailable.
Women in Kenya are disproportionately affected by HIV. In particular, young women are victims of an apparent disparity. As of 2009, young males had an HIV prevalence rate of 1.8%, whereas females had an HIV prevalence rate of 4.1% (UNICEF, 2010). This rate is more than double that for males, as males have a higher rate of comprehensive HIV knowledge (55% males, 48% females).
Women, especially those under 24, are much more likely to experience high rates of violent sexual contact than men. According to the 2003 Kenya Demographic Health Survey, 13% of women aged 20-29 years had experienced sexual violence in the previous year (Government of Kenya, 2004). In fact, nearly half of Kenyan women report being victims of sexual violence. Victims of violent sexual encounters are particularly vulnerable to HIV transmission during the act because of genital trauma, multiple perpetrators, and the associated risk of STIs (Royce et al., 1997). This is a likely contributor to higher rates of HIV in this population.
Rape of young women is common in Kenya. Widespread myths about sex with virgins perpetuate the rape of young women countrywide. In a 2003 National Survey, nearly one quarter
positive men in Kenya believe that sexual intercourse with a virgin will reduce their viral load, and this belief contributes to the occurrence of incest between fathers and daughters (AmuyunzuNyamongo, Okeng'o, Wagura, & Mwenzwa, 2007). Another common scenario in Kenya is young mothers sending out their very young daughters (age five and above) to work in prostitution, in an effort to raise money to assist with the cost of HIV medication as well as food and other necessities for the family (Kefa, 2011). Females in Kenya from very young ages are placed in compromising situations that increase their likelihood to acquire HIV.
Recently, Kenya experienced an intense period of post-election violence following the 2007 presidential elections. During this time period, women were at a much higher risk for gender based sexual violence than in times of peace. Amongst the turmoil of post-electoral violence, women were victims of rape, gang rape, attempted assault, sexual slavery, and sexual exploitation. Over 650 cases of gender based sexual violence were reported at Nairobi Women‘s Hospital during the crisis (Siebert, 2009). This large number, combined with the large number of cases that went unreported, highlights the burden of gender based sexual violence contributing to HIV prevalence in Kenya.
The annual population growth rate in Kenya between 2000 and 2009 was 2.9%, which places it 29th globally. Considering this and the total fertility rate of 4.9 children per woman, Kenya has a large number of people and limited physical space (UNICEF, 2010). Approximately 35% of Kenya‘s population lives in urban areas and more than half of urban residents are living in slums (UN-Habitat 2007). It is expected that the percentage of the population living in urban areas will increase by 50% by 2015, and as a result, the nation is facing the pressure of increased urbanization (UN-Habitat 2007).
Approximately 50% of Kenyans live below the poverty line, living on less than $1/day (Central Intelligence Agency, 2011). Residents of slum areas are in this category. Slums are characterized by severe overcrowding in low quality housing and a lack of general infrastructure including sanitation, drainage, and a clean water supply. Slum residents have deplorable housing conditions. Structures are made of corrugated iron sheets that serve as both the walls and roof.
There is usually no permanent flooring in place. When it rains, the floors turn to mud, and the structural integrity of the home is compromised. Most residents lack secure tenure in their housing (UN-Habitat, 2011). Landlords are ever-changing and corruption abounds among them.
Residents can be forced from their homes at any time, without explanation (UN-Habitat, 2011).
Clean water is limited and most residents do not have access to it. Without this, residents are at a high risk for waterborne diseases (Mulama, 2007). Sanitation issues are extensive in
place lack the capacity to serve the large population and its waste (UN-Habitat, 2011). Poor sanitation and population congestion contribute to negative health outcomes for slum residents.