Running Head: HIV/AIDS Intervention Through Churches in Kibera, KENYA1 HIV/AIDS Intervention Through

Running Head: HIV/AIDS Intervention Through Churches in Kibera, KENYA1

HIV/AIDS Intervention Through Churches in Kibera, KENYA8

HIV/AIDS Intervention Through Churches in
Kibera Slums, Nairobi, Kenya

Proposal

August 10, 2020

Submitted by:

[DEIDENTIFIED NAME]

[DEIDENTIFIED EMAIL]

In Partial Fulfillment of the Requirements for the

Master of Public Health Degree

Milken Institute School of Public Health

The George Washington University

Background

The HIV/AIDS pandemic is disproportionately concentrated in Sub-Saharan Africa, which accounts for more than 71% of the global burden of infection even though <10% of the world’s population live here (James et al, 2018). The East and Southern regions of Africa are the hardest hit, where – in 2019 – about 730,000 new HIV infections occurred, just under half of the global total. Kenya, nestled in East Africa, has the joint third-highest HIV epidemic in the world alongside Tanzania with about 1.6 million people living with HIV (UNAIDS, 2019). The country has witnessed tremendous progress in the reduction of new HIV infections over the past decade. However, new HIV infections in major cities such as Nairobi and Mombasa have markedly increased by more than 50%. This high HIV incidence in urban areas is largely fueled by the high infection rates in the overcrowded urban informal settlements, also known as slums, where more than half of the country’s 27.5% urban population reside (Ministry of Health/National AIDS Control Council, 2016; World Bank, 2019).

A study by Muhula et al (2016) found that the urban slum settlements have a significantly higher HIV prevalence at 12% compared to just 6.5% and 5.1% in urban non-slum and rural areas respectively. The Kibera slum area in Nairobi, Kenya, the largest urban slum in Africa, constitutes a high-risk environment for HIV due to high levels of poverty, alcohol and substance consumption, poor education, cultural and religious beliefs, underlying social issues like stigma and discrimination, gender roles, and also environmental issues that exacerbate HIV transmission. The outlook in urban slums is quite dire.

Churches are growing rapidly in Kenya and increasingly influencing people’s lives. Kenyans have a deeply religious and spiritual orientation, and most people’s lives are touched by religion. The main religion is Christianity (85.5%) with Islam (10.9%) being second but mostly concentrated along the coastal regions of the country. As such, even though there is a lack of concrete data regarding the impact of churches on health care, they provide a key platform in combating HIV due to their unique reach and presence within communities. However, their potential has been underutilized (Puffer et al, 2016; Eriksson et al, 2014).

Program Objectives

This program aims to reduce the vulnerability of adolescents and young adults (both married and single) in Kibera slums to HIV infection by using churches to establish a multi-dimensional intervention to educate and prevent them from acquiring HIV.

Health Objective: Reduce new HIV infections among adolescents and young people (both married and single) in Kibera slums by 15% within 3 years of program implementation.

Behavioral Objectives:

To increase participation in church-based HIV prevention activities among target population by 40% within 18 months of program implementation.

To increase engagement in safe sex protocols among target population by 50% within 18 months of program implementation.

To increase seeking of HIV prevention care among target population by 35% within 18 months of program implementation.

Immediate Objectives:

To increase instrumental support for engagement in safer sex practices among target population in Kibera slums by 60% within 12 months of program implementation.

To increase emotional support for prevention seeking behaviors among the target population in Kibera slums by 45% within 12 months of program implementation.

To increase informational support on HIV transmission and risk reduction strategies among target population in Kibera slums by 50% within 12 months of intervention.

To increase appraisal support among target population in Kibera slums by 75% within 12 months of program implementation by increasing their awareness of social factors that perpetuate the spread of HIV.

Methods

Literature Review

A literature review will be conducted using electronic databases: Google Scholar, PubMed/Medline, Scopus, Grey Literature Report, Global Health, and African Index Medicus (AIM). Search terms will include HIV and AIDS, risk factors, slums, urban, low socio-economic status (SES), social support, social behaviors, religion and HIV. The literature search will include evidence-based peer-reviewed studies published in English-language and HIV/AIDS programming that have been implemented in Africa or other continents with similar low-income countries. Articles published in languages other than English will be excluded in addition to conference abstracts which generally do not provide enough information to asses a study’s validity.

The intervention will draw upon lessons from relevant evidence-based HIV/AIDS programs such as “Stepping Stones”, “Sister-to-Sister” and “Shuga” (Kenyan Ministry of Health, 2017). The first program is a life skills training program that targets young people living in informal settlements using combined structural and behavioral intervention to decrease gender inequalities and increase livelihood security thereby reducing intimate partner violence (IPV) and HIV risk (Gibbs et al., 2017). The second program is delivered through female health care workers and peer educators and aims to eliminate or reduce risk behaviors and prevent HIV and STI infections among women ages 18-45 years through increasing self-efficacy and condom negotiation. Finally, the last program is a multi-media behavior change communication intervention that targets youth out of school between ages 15-24 years with the following key themes: personal risk perception, correct and consistent condom use, sexual concurrency, sexual agency, reduction of stigma and discrimination towards people living with HIV (PLHIV), transactional sex, gender-based violence (GBV) and parent/child communication (Booker, Miller, & Ngure, 2016).

PRECEDE/PROCEED Planning Model

Using Green & Kreuter’s PRECEDE/PROCEED planning model (2004), this program delivered through local churches—strong and established social structures—will use participatory approach to integrate peer education programs and direct skills training of HIV prevention in order to raise awareness and emphasize long-term prevention of HIV/AIDS among adolescents and young adults in Kibera. The program’s theory of change posits that the proximal impact of the program would be decreased HIV incidence among adolescents and young adults in Kibera by enhancing social support and HIV prevention-related skills, all of which would improve long-term outcomes related to the target populations’ HIV risk behaviors (Glanz, Rimer & Viswanath, 2015).

Social Assessment of the Problem

Kibera slums, situated 7 km Southwest of Nairobi – Kenya’s capital city – is one of the largest informal settlements in the world. It harbors about 250,000 people living on approximately 2.5 square kilometers (600 acres) of government owned land. The slum is made up of a number of densely populated villages, including Gatwekera, Kianda, Kisumu Ndogo, Lindi, Laini Saba, Silanga/Undugu, Makina, Mashimoni, and Soweto, with a railway line crossing through the slum almost dividing it into two (see Appendix A for map of Kibera). The average shacks in Kibera are about 12ft x 12ft in size and are built with mud walls, corrugated tin roofs with dirt or concrete floors. These shacks cost about KES 700 per month (£7) to rent and often house up to 8 or more people with many sleeping on the floor. The average resident of Kibera lives on less than $1.00 a day, and unemployment rate is nearly 50% (Kenya National Bureau of Statistics, 2019; Kibera UK, 2020).

Kibera is lacking in basic infrastructure and underserved by other socio-economic amenities like electricity, water and sanitation services. Residents have limited access to quality health services since there are no government health clinics or hospitals in the area. Although Kibera is an extremely poor suburb, it happens to have a high and rigorous investment in education which makes it one of the slums with the highest level of hope. There are government schools in the area and also non-informal schools run by local residents but registered with the government schools for examinations. In addition, there a number of charitable schools run by churches and individual donors that also take care of the children’s’ basic needs and provide meals at school for most the children to keep them in school (Kenya National Bureau of Statistics, 2019; Kibera UK, 2020).

Epidemiologic Assessment of the Problem

The HIV incidence among adolescents and young adults in Kenya is high. In 2015, more than half (51%) of all new infections were among adolescents and young people (aged 15-24 years), a rapid increase from 29% in 2013. Young women are almost twice as likely to acquire HIV as their male counterparts. They post the highest number of HIV infections accounting for 33% of the total number of new infections (23,312) in 2015, compared to young men who accounted for just 16% of all new HIV infections (12,464) (Kenyan Ministry of Health/National AIDS Control Council, 2016). This program seeks to address some of these key risk factors that contribute to the high incidence of HIV among the target population in Kibera. Refer to Appendix B for a visual illustration of the conceptual model of the program.

Behavioral Risks:

HIV behavioral risk factors related to adolescents and young adults involve their individual and relational factors. These factors are closely linked to having multiple sex partners, age-disparate sex, early sexual debut, transactional sex, limited personalized risk perception, and inconsistent condom use, all of which contribute to the spread of HIV (Idele et al, 2014; Stoebenau et al, 2016; Becker et al, 2018)

Biological Risks:

Similar to behavioral factors, these also have both the individual and relational dimension aspects. Adolescents and young adults’ acquisition of HIV can be influenced by their own biological susceptibility and/or the biological factors related to their partners. According to Baggaley et al (2018), the biological susceptibility of women and girls increases their HIV transmission risk during vaginal sex compared to men due to a number of factors such as increased expression of HIV co-receptors in cervical cells compared to foreskin cells, large surface area of the vagina compared to that of the penis, high levels of activation of the immune cells in the female genital tract, vaginal lining, increased mucosal HIV exposure time, potential for micro-abrasions and tears of the vagina or cervix, and high concentration of HIV in semen than vaginal fluids. The low prevalence of male circumcision is associated with high HIV prevalence in Sub-Saharan Africa (Hines et al, 2017). Finally, the presence of other sexually transmitted infections and reproductive tract infections among adolescents and young adults or their partners is likely to increase HIV transmission (Johnson, & Lewis, 2008).

Environmental Risks:

Kibera residents are extremely poor and live in very inhumane and disconcerting surroundings with severe lack of clean water supply, proper sanitation, housing, health services, and solid waste management facilities (Kibera UK, 2020; Kenya National Bureau of Statistics, 2019). These conditions trap residents into mass poverty consequently increasing their risk of engaging in risky sexual behavior for economic survival which in turn predisposes them to contagious diseases, gender-based violence, and child sexual abuse (Gibbs et al, 2017; Mojola, & Wamoyi, 2019). Additionally, studies have found that adolescents and young adults who have been orphan experience a higher risk of engaging in more risky sexual behavior and HIV infection. And barriers to accessing sexual and reproductive health (SRH) services also limit their ability to access information, counselling and prevention tools (such as condoms, contraception, HIV testing and other services) contributing to the HIV incidence problem among these population (Idele et al, 2014; Mojola, & Wamoyi, 2019).

Educational and Ecological Assessment

Predisposing Factors:

Even though awareness of HIV/AIDS in Kenya is high, comprehensive knowledge is still low among the urban young population (Kenya Ministry of Health/NACC, 2016). Societal attitudes towards HIV/AIDS and perceptions about teaching adolescents and young adults about HIV and sexual health remains controversial in Kenya. According to the Kenya National Bureau of Statistics (2015), an estimated 40% of adults are against educating young people about condoms, for example, with many citing the fear of encouraging them to have sex as a reason. Similarly, about 50% of adolescents do not know their HIV status while 44% have never heard of family planning methods (Kenyan Ministry of Health, 2017). Finally, gender inequality and social dynamics that accept concurrent relationships contribute to generating larger sexual networks. And the cultural concepts of masculinity and unequal power dynamics encourage men/husbands to expect or demand their conjugal rights and influence women’s negotiation skills (Shannon et al, 2012; Harrison et al, 2015).

Reinforcing Factors:

Stigma and discrimination are still ubiquitous, undeniable, and embedded in the social norms of Kenya and many African countries. A common belief among people is the view that having HIV/AIDS is God’s condemnation for engaging in sin or immorality (Gyimah et al, 2013). Given the high religiosity in Kenya, faith communities should be at the frontline of the response to the HIV epidemic. Yet it can be argued that churches have played both supportive (expressing clearer norms on abstinence, being faithful, delayed sexual activity, etc.) or detrimental roles in the fight against HIV/AIDS. By asserting moral ground and moral authority over premarital sexual transgressions they provide standards to judge/guide behavior which can deter people from seeking vital HIV services, some churches discourage open discussion around sex and/or denial of existence of HIV/AIDS, and they also hinder certain HIV prevention interventions given their religious stance on contraceptive use. Poverty and economic dependency in Kibera, compromises the power of adolescents and young adults to negotiate for appropriate reproductive health decisions and safer sexual relations leading to coerced sex, decreased power in relationships, and decreased access to education and services (Kenyan Ministry of Health, 2017). In addition, a systematic review and meta-analysis study found that peer pressure, lack of education, and social media platforms can influence risky sexual behavior among adolescents and young adults (Muche et al, 2017).

Enabling Factors:

Reducing HIV incidence among adolescent and young adults requires accelerated uptake of the standard package of health services yet perceived low risk of infection and poor linkage to care in Kibera hinders uptake of HIV counselling and testing services, condom use uptake and antiretroviral drug coverage (Kenya Ministry of Health/NACC, 2016; Kenya National Bureau of Statistics, 2019). Lack of good governance and proper leadership, combined with the tribalism that pervades Kenyan politics, in Kibera has worsened the situation (Kenyan Ministry of Health, 2017). Also, the lack of availability and accessibility of resources such as life skills training, mentoring programs, and other health-related skills can facilitate a behavior’s occurrence.

Summary and Synthesis of Need

Although HIV prevalence has continued to decline in Kenya since 2007, HIV remains a major public health challenge due to increase in number of new infections especially among the urban young population which is particularly worrying given the burgeoning youth population. There is an important window of opportunity to halt the potential for millions more infections by strengthening primary prevention efforts (Kenyan Ministry of Health, 2017; UN World Population Review, 2020). For this reason, religious organizations hold potential as community-based settings for primary prevention interventions in low-resource settings targeting urban slum residents who should be regarded as a priority population to reverse the spread of HIV in Kenya.

Proposed Program Description & Theoretical Approach

The HIV/AIDS epidemic continues to exert a disproportionate effect on adolescents and young people in Kenya who continue to engage in risky sexual behaviors due to a number of underlying social and cultural factors (Ministry of Health/National AIDS Control Council, 2016). All of the biological, behavioral and environmental risk factors impacting transmission of HIV in Kibera are important, however, not all are easily changeable. The risk factors will be divided into “more” and “less” changeable categories and the program will prioritize determinants that fall in the more important, more changeable quadrant of the decision matrix.

The proposed program will draw on Social Support Theory (SST) to support its various components. The SST emphasizes the structural and functional aspects of social relationships, and recognizes that social support, an important interpersonal factor, can influence health behaviors (Glanz, Rimer & Viswanath, 2015).

References

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Appendix A: Map of Kibera

Figure 1. Retrieved from https://www.kibera.org.uk/maps/

Figure 2. Retrieved from http://mapkiberaproject.yolasite.com/maps-and-statistics.php

Appendix B: Conceptual Model