Alcohol harm reduction intervention among female sex workers in Mombasa, Kenya Preliminary 6-month follow-up data Presented by Peter Mwarogo FHI360 Meeting of the University of Nairobi STD/AIDS Collaborative Group January 25, 2013

Alcohol Use Disorders in Kenya and among Female Sex Workers NACADA 2012 Rapid Assessment Survey Substance Abuse and Dependency: DSM IV tr Criteria About 5.8% of Kenyans are abusing alcohol while another 5.5% are dependent on alcohol use; [11.3 % of 20,000,000 [15-64 years olds]: Abusers: 1,160,000 Dependent: 1,100,000 Total who need counseling interventions: 2,260,000 Kenyans

FSW and AUD AUD among FSW possibly between 70 to 90%? NASCOP Mapping 2012 Estimated number of FSW in Kenya: 140, ,000 NASCOP: MARPS Book Report 2012 The most common location for meeting clients was at bars (77%) and at the roadside (29%) areas

FHI360/ICRH/SAPTA Study Objective To investigate whether FSWs at drop-in centers in Mombasa, Kenya, who report harmful or hazardous alcohol intake and participate in a brief alcohol intervention, will reduce their alcohol use and incidence of STIs, HIV, and sexual violence, as well as increase their condom use.

Study Design Recruited FSWs through USAID APHIA Plus, Mombasa 818 participants enrolled March-October 2011 Participants randomized to 6-month alcohol intervention, or 6-month nutrition intervention Data collection at baseline, 6 month, and 12 month follow-up – Clinical testing for HIV, trichomoniasis, gonorrhea, chlamydia – Behavioral survey on alcohol, condom use, physical and sexual violence 6-month follow-up rate: 86% (n=701) 12-month follow-up rate: 87% (n=710)

Study Sample Characteristics at Baseline Intervention N(%) 411 (50.2) Control N(%) 407 (49.8) TOTAL N(%) 818 Age (years) (39.7) 124 (30.2) 65 (15.8) 59 (14.4) 153 (37.6) 131 (32.2) 65 (16.0) 58 (14.3) 316 (38.6) 255 (31.2) 130 (15.9) 117 (14.3) Education Never attended school Primary school, any Secondary school, any Post-secondary school, any 12 (2.9) 212 (51.6) 149 (36.3) 38 (9.2) 21 (5.2) 204 (50.1) 146 (35.9) 36 (8.8) 33 (4.0) 416 (50.9) 295 (36.1) 74 (9.0) Religion Christian Muslim None 296 (72.0) 115 (28.0) 0 (0.0) 296 (72.7) 109 (26.8) 2 (0.5) 592 (72.4) 224 (27.4) 2 (0.2) Marital status Never married Currently married Separated, divorced, widowed 187 (46.1) 14 (3.4) 205 (49.5) 190 (47.1) 14 (3.5) 199 (49.4) 377 (46.6) 28 (3.5) 404 (49.9) HIV Positive83 (20.2)83 (20.4)166 (20.3)

Alcohol Use at 6 Months Intervention N(%) 347 (49.5) Control N(%) 354 (50.5) TOTAL N(%) 701 Alcohol use in last 30 days Every day At least once per week Less than once per week Never 12 (3.5) 124 (35.7) 25 (7.2) 186 (53.6) 34 (9.6) 207 (58.5) 20 (5.6) 93 (26.3) 46 (6.6) 331 (47.2) 45 (6.4) 279 (39.8) Sex while feeling drunk in last 30 days Most of the time Sometimes Rarely Never 10 (3.8) 48 (18.3) 38 (14.5) 166 (63.4) 33 (10.6) 99 (31.8) 67 (21.5) 112 (36.0) 43 (7.5) 147 (25.7) 105 (18.3) 278 (48.5) Binge drinking (3+ drinks on one occasion) Most of the time Sometimes Rarely Never 25 (7.2) 34 (9.8) 33 (9.5) 255 (73.5) 142 (40.1) 60 (16.9) 34 (9.6) 118 (33.3) 167 (23.8) 94 (13.4) 67 (9.6) 373 (53.2) Any binge drinking (5+ drinks) before sex with client 1 21 (8.1)76 (24.7)97 (17.1) Any binge drinking (5+ drinks) before sex with nonpaying partner 2 9 (4.2)36 (14.7)45 (9.8) 1 For women who reported sex with client in last 30 days 2 For women with non-paying partners 1 Women who had sex with client in last 30 days 2 Women with non-paying partner

STIs at 6 Months Intervention N(%) 347 (49.5) Control N(%) 354 (50.5) TOTAL N(%) 701 Any incident STI (trichomoniasis, gonorrhea, chlamydia, HIV)* 33 (9.6)30 (8.5)63 (9.0) HIV seroconversion from baseline1 (0.4)0 (0.0)1 (0.2) *Trichomoniasis diagnosed by wet prep, gonorrhea and chlamydia diagnosed by PCR, HIV diagnosed using Kenya Ministry of Public Health and Sanitation guidelines for HIV testing

Condom Use at 6 Months Intervention N(%) 347 (49.5) Control N(%) 354 (50.5) TOTAL N(%) 701 Condom use last time with client323 (93.1)337 (95.2)660 (94.2) Condom use “all the time” with client in last 30 days (65.5)212 (69.1)381 (67.4) Condom use last time with nonpaying partner Yes No Don’t Know Does not have non-paying partner 141 (40.6) 133 (38.3) 0 (0.0) 73 (21.0) 163 (46.0) 112 (31.6) 1 (0.3) 78 (22.0) 304 (43.4) 245 (35.0) 1 (0.1) 151 (21.5) Condom use “all the time” with nonpaying partner in last 30 days 1 92 (38.7)115 (44.6)207 (41.7) 1 Note: Analyses restricted to women reporting sex in last 30 days with partner type

Sexual and Physical Violence at 6 Months Intervention N(%) 347 (49.5) Control N(%) 354 (50.5) TOTAL N(%) 701 Forced sex by client in last 30 days one or more times 45 (17.4)65 (21.1)110 (19.4) Forced sex by nonpaying partner in last 30 days one or more times 72 (26.5)75 (27.5)147 (27.0) Beaten/physically abused by client in last 30 days one or more times 16 (4.6)16 (4.5)32 (4.6) Threatened/verbally abused by client in last 30 days one or more times 72 (20.7)107 (30.3)179 (25.6) Robbed/not paid by client in last 30 days one or more times 59 (17.0)82 (23.2)141 (20.1) Beaten/physically abused by non-paying partner in last 30 days one or more times 40 (14.7)57 (20.9)97 (17.8)

Key Observations Participants are young, have little education, are predominantly Christian, and many are separated/divorced – Intervention and control groups have similar demographic characteristics Alcohol use at 6 months was reported be lower in intervention than control group, regarding: – Alcohol use in past 30 days – Sex while feeling drunk in past 30 days – Binge drinking 3+ drinks; Binge drinking 5+ drinks before sex Low rates of incident STIs and HIV seroconversion from baseline to 6 month follow-up Condom use is high with paying clients and lower with non-paying partners Physical and sexual violence by clients and partners is common

Acknowledgement Kelly L'Engle, FHI360 Nzioki Kingola,ICRH William Sinkele, SAPTA Reach Out Trust, Mombasa USAID APHIA Plus Nairobi-Coast Project in Mombasa

Additional Comments: Dr. Sinkele Intervention was based on the WHO manuals for AUDIT interventions Evidence based: using motivational interviewing AUDIT: 1-7 Low Risk Drinking 8-15 Hazardous Drinking Harmful Drinking 20< Dependent Drinking (Alcoholism) Some other authors recommend lower scores for dependency: for women

Sinkele: Comments Prior to the study implementation: Dr. Sinkele trained the research team, including the three nurse- counselors in a five day training on: effects of alcohol; effects of alcohol on women; the relationship of alcohol and HIV and AIDS, especially the impact on ART; and motivational interviewing. We also adjusted the AUDIT so that it was more localized in language: both in English and Kiswahili. We had focus group discussions with a number of female sex workers to understand their ideas on drinking, what they considered low risk drinking and why their drank.

Sinkele: Comments For the alcohol intervention: these were individual counseling sessions lasting normally 15 to 20 minutes each session. They meet with the nurse once a month over 6 months. After the six month intervention, the nurses reported that many of the women reduced or stopped their drinking: they reported that they felt better, friends/family members reported they looked healthier, were taking better care of their children, and

Sinkele: Comments During the six months implementation, Dr. Sinkele oversaw clinical supervision and gave additional training of the nurse-counselors which assisted them to deal more effectively with the skills and gain more knowledge on various motivational interventions. Two challenging groups: those who had scored close to low risk drinking and felt no reason to reduce their drinking or those who could not reduced their drinking because of the influence of drinking friends.

Sinkele: Comments While for this study only individual counseling sessions were used, the program could be adapted for a group approach. This intervention could be adapted: 1) for use with MSM/MSW 2) for use in HIV CCCs for alcohol using/abusing PLWHAs

Sinkele: Comments Women who scored 20 and above were screened out of the study and given counseling by women addiction counselors. However, most failed to show up for more than one counseling session. Need for a manualized evidence based counseling approach for those who are alcohol dependent Dr. Sinkele and Mr. Evans Oloo, head of training at SAPTA, are finalizing on 12 psychoeducational lessons for alcohol/drugs/HIV risk reduction that can be delivered by substance abuse or HIV peer educators or in HIV and ART CCC. Ready by July.

Sinkele: Comments Asanteni sana SAPTA: