Final Report for the
AIDSCAP Program in Kenya: Executive Summary

This report comprehensively summarizes the FHI/AIDSCAP program in Kenya (1992-1997). The report lists program accomplishments, constraints and outcomes, as well as supplying information on lessons learned and recommendations.

Kenya, a country with an estimated population of 27.6 million, has seen a rapid rise in the spread of HIV. By the early 1990s, HIV seroprevalence rates were increasingly affecting a wide section of the population. Prevalence rates in the adult population were estimated to be 3.1% in 1990, and then rose on average 1% per year, to 8% in 1996. In urban areas, the prevalence is one out of every eight adults and there are areas where the prevalence is already 20-30%. 200,000 cases of AIDS have been diagnosed and it is estimated that 1.2 million people have HIV. Seventy-five percent of cases occur between the ages of 20-45, with the peak ages for AIDS cases being 25-29 for females and 30-34 for males. Young women in the age group 15-24 are twice as likely to be infected as males. The epidemic as yet shows no indication that it has reached its peak. STDs constitute about 15% of outpatient consultations in government health facilities and this proportion is thought to be higher in the private health sector.

Until the recent World Bank loan was assumed by the Government of Kenya, external donors funded most of Kenya's AIDS prevention efforts. USAID, one of the largest and most consistent donors, had supported AIDS prevention activities since 1989 under the AIDSTECH project. AIDS prevention activities were expanded when, in September 1992, Kenya was designated a priority country under the AIDSCAP program. Activities began in 1993 with four transitional subprojects, and major activities were launched in early 1994.

The goal of the AIDSCAP program was to reduce the incidence of sexually transmitted HIV. The purpose was to reduce high-risk behavior in target populations in selected sites. This would be addressed through an integrated strategy combining interventions in behavior change, improved STD case management, and condom promotion. The total budget funded from USAID/Kenya was $4.6 million. $1,800,000 was provided under the Cooperative Agreement, which, in September 1994, was changed to a Delivery Order, with a budget of $2,796,182. In addition, USAID/Washington provided core funding support for projects in behavioral research, women and AIDS, work with the churches through MAP International, and Rapid Response activities.

The primary target populations were men and women in the formal workplace; clients seeking services for sexually transmitted disease (STD); family planning clients; and students at institutions of higher education. Interventions were targeted to reach these populations in three urban areas: Nairobi, Mombasa, and Eldoret, primarily through interpersonal peer education and training for health care providers. National interventions provided a supportive framework for these intensive prevention activities, through promotion of policy dialogue, support for mass media, behavioral and operations research, and capacity building and sustainability activities.

At the close of the AIDSCAP program, quantitative evidence of significant amounts of behavior change has yet to emerge, either from the general population data available from the Kenya Demographic and Health Survey (KDHS) or from smaller studies of populations targeted by direct interventions. Knowledge of AIDS and of prevention methods is high, but behavior change has lagged behind. However, the KDHS results show that the number of men using condoms regularly more than doubled between 1989 and 1993 (from 3% to 7%), while the percentage of men who have used a condom at least once increased from 17 to 27% during the same period. The 1993 KDHS asked respondents who reported having had sex in the past six months if they had used a condom with any partner: 20% of men and 6% of women said yes. In AIDSCAP's 1995 study of workplace populations exposed to peer education, 52% of men and 54% of women with non-regular partners reported condom use at last sex act. Although the KDHS and the worksite population samples are certainly not comparable, the differences in the results suggest that exposure to interventions is having the intended effect.

Statistics from both public and private condom distribution systems also indicate that condom use is growing. Condoms distributed by the public sector increased from 9 million in 1989 to 45 million in 1994 and those distributed by USAID's social marketing program from 40,000 a month in 1989 to 500,000 a month in 1995.

Qualitative data from AIDSCAP subprojects suggest that people believe that Kenyans are reducing partners, remaining abstinent, and/or using condoms more now than in the past. The perception exists despite the fact that participants also describe instances where people they know refuse to use condoms, and continue to have unprotected sex with multiple partners. However, the perception "in the streets" seems to be that social norms are changing and that the interventions from AIDSCAP and other donors have helped to push that change along. The challenge remains to document statistically the degree of change we know is happening among people receiving intensive interventions.

The years of the AIDSCAP project have, however, seen a change in public and private acceptance of the impact of the epidemic. Prior to the early 1990s there was official denial that AIDS represented a serious threat to the Kenyan people. This was replaced in the early 1990s by silence from policymakers on the issue, though outspoken hostility to condoms and family life education for youth was still expressed by some religious leaders. 1996 saw the publication and approval by Parliament of the Government of Kenya (GOK)'s Sessional Paper on AIDS, giving official recognition to the need for a national policy on the epidemic. Media coverage of HIV/AIDS issues has also substantially increased: when AIDSCAP began funding the AIDS WATCH column, it provided virtually the only regular coverage of AIDS issues; these are now far more frequently and accurately addressed in the media.

Although these changes cannot be attributed only and directly to AIDSCAP's work, AIDSCAP's policy and media interventions contributed to this increasing openness, and can be considered one of the Kenya AIDSCAP country program's major successes. The book, AIDS in Kenya: Socioeconomic Impact and Policy Implications, published in 1996, played a role in directing attention to the impact of AIDS on society. Shortly following the launch of the book, at which the Vice President of Kenya was the keynote speaker, President Moi referred to AIDS for the first time in a national address. AIDSCAP supported MAP's work to facilitate policy dialogue on AIDS issues among church leaders, which resulted in two joint statements on the churches' position on AIDS appearing in the press, signed by the representatives of the leading church umbrella organizations, including the Catholic Secretariat. AIDSCAP also funded the Kenya AIDS NGOs Consortium (KANCO) in an innovative project to increase the understanding among and contributions of grassroots NGOs to the policy process. This intervention resulted in a listing by NGOs of priority issues, the production of three advocacy papers, and the establishment of KANCO branches to continue coordinating NGO priorities and activities at the district level.

Whenever possible, AIDSCAP selected either umbrella NGOs or NGOs that had an existing network of linked organizations to implement AIDSCAP subprojects. MAP, for example, was linked with a network of church groups and has, through AIDSCAP, supported the growth of local branches of the Kenya Christian AIDS Network. KANCO also established local branches as part of the AIDSCAP program. In the peer education and STD case management training projects, AIDSCAP worked through Family Planning Private Sector (FPPS), which enabled the interventions to reach worksites and colleges supported by the existing network of FPPS private sector clinics. Because of this institutional base, it is expected that many of the AIDSCAP interventions will continue to affect their communities even though funding has ended.

AIDSCAP/Kenya also contributed significantly to the pool of information and materials dealing with AIDS prevention — another series of interventions that will have long-lasting effects. KANCO's Resource Centre, nonexistent in 1993, grew from its start in mid-1994 to become a source of information with over 800 resources, Internet access and a Web site, that is visited by approximately 250 inquiries per month and has distributed over 14,000 materials to NGOs, plus an additional 48,000 on behalf of PATH. PATH's in-service training for NGOs in materials development not only increased the technical skills of participants from 20 NGOs, but resulted in 8 materials, two of which were subsequently reprinted by the National AIDS/STD Control Programme (NASCOP). The World AIDS Day youth drama festival organized by Artnet Waves, grew from a small event with 15 competing groups, to become a regionally based series of training and outreach activities with community groups, in which over 175 groups are now participating.

Overall, AIDSCAP/Kenya trained 3,754 persons, educated an estimated 49,200 persons and reached an estimated 2.8 million people. The program distributed 311,200 materials and an estimated 985,300 condoms. Thirty new materials (including policy papers, books, videos, posters, newsletters, and curricula) were produced as a result of the project. Two national AIDS prevention networks were established, each with over twenty branches. A total of 561 providers (including 64 supervisors) were trained in improved STD case management; and 310 episodes of a weekly radio program (62 in five languages) and over 100 weekly newspaper columns were produced. In addition, Kenya participated in a major international research study on counseling and testing, and a international qualitative study to test the acceptability of the female condom among women and their partners.

Among the main lessons learned and recommendations for the future are the following:

• Volunteer peer education works, for both worksite and student populations. However, the programs depend on maintaining both institutional support (from managers and college administrators) and peer educators' motivation. Some means of providing an ongoing link with an outside institution for in-service training and provision of fresh IEC materials is highly desirable.
• Training in syndromic case management of STDs results in improved quality of service delivery. However, it is difficult to attract private practitioners, who are often the first to be consulted by clients, to attend these training courses. There is an urgent need to find acceptable ways to extend the training to more private health providers.
• Working with the churches has proved to be highly successful. Sensitive subjects such as condom use can be addressed with religious communities provided the implementing organization facilitates discussion rather than dictates solutions.
• Despite the fact that AIDS is now a widespread epidemic affecting most Kenyans and that awareness and knowledge of prevention methods is high, the evidence for significant behavior change has yet to be convincingly documented quantitatively. National surveys of general population samples cannot be expected to show large amounts of behavior change in the short periods of time usually covered by funding cycles. Faster behavior change will more likely be observed within population subgroups targeted with comprehensive reinforcing interventions that include a focus on subjective and interpersonal barriers to change and on realistic assessment of personal risk.
• Better ways to measure stages of change in targeted groups need to be found. While the internationally accepted Prevention Indicators (PIs) provide standardized measures to track long-term trends in behavior change at the national level, the use of target-group based cross-sectional surveys over shorter periods of time should be explored, in order to track change in intervention areas.
• Youth, particularly young women, are increasingly at risk in Kenya, yet services for youth are still under-supplied and family life education remains a controversial subject. It is vital that future AIDS prevention programs focus intensively on this age group.
• Discrimination, crisis counseling, and insurance issues were increasingly mentioned by peer educators at the worksite and by NGOs as priority policy issues. Policy guidelines on these issues and access to counseling and health services will become more necessary as the number of AIDS cases increases.