Baseline Polling Booth Survey

Ministry of Health National Aids and STI Control Program NASCOP

Baseline Polling Booth Surveys among Male and Female Sex Workers in Nairobi and Mombasa NASCOP Learning Sites

Baseline Polling Booth Surveys among Male and Female Sex Workers in Nairobi and Mombasa NASCOP Learning Sites.

Editor : Brooks Anderson Design and layout : Anariko Ikweri/IKAN Media Productions Year of publication : 2014 Suggested citation: Odek W, Bhattacharjee P, Anthony J, Njiraini M, Kimani G, Musimbi J, Musyoki H, Githuka G, Ramesh BM, Isac S, Baseline Polling Booth Surveys among Male and Female Sex Workers in Nairobi and Mombasa NASCOP Learning Sites, NASCOP, 2014.

Research team The research team included Dr. Willis Odek, Parinita Bhattacharjee, John Anthony, Margret Njiraini, Gloria Gakii Kimani, Janet Musimbi, Helgar Musyoki, Dr. George Githuka, Dr. BM Ramesh and Dr. Shajy Isac.

Acknowledgement We thank űű Dr. William Maina, Head, Directorate of Preventive and Promotive Health Services, Government of Kenya, for his support and guidance űű Dr. Stephen Moses and Dr. James Blanchard for their technical support in the project űű All the sex workers who participated in the study and all the peer educators and outreach workers in Nairobi and Mombasa who supported the study űű Redemtor Atieno for managing the designing and printing process Support This study was conducted with funding support from the World Bank and the Bill & Melinda Gates Foundation.

Technical Support was provided by the Centre for Global Public Health (CGPH), University of Manitoba. The study was conducted in collaboration with Sex Workers Outreach Project (SWOP) in Nairobi and the International Centre for Reproductive Health Kenya (ICRHK), Mombasa. We also thank Kenya Sex Workers Alliance (KESWA) and Bar Hostess Empowerment and Support Programme (BHESP) for their partnership in the NASCOP Learning Sites. Thanks to PEPFAR for supporting the Nairobi Learning Sites.

The views expressed herein are those of the authors and do not reflect the official policy or position of the World Bank, the Bill & Melinda Gates Foundation, or PEPFAR.

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Baseline Polling Booth Surveys among Male and Female Sex Workers in Nairobi and Mombasa NASCOP Learning Sites

Table of Contents Acknowledgement............................................................................................................................................................i Figures.............................................................................................................................................................................iv Summary.........................................................................................................................................................................vi 1. Background ..................................................................................................................................................................1 2. Rationale for Outcomes Assessment .........................................................................................................................2 3. Outcomes Assessment Methodology..........................................................................................................................3 3.1. Polling Booth Survey (PBS)...............................................................................................................................3 3.2. Sampling............................................................................................................................................................4 3.3. Steps in Conducting PBS...................................................................................................................................5 3.4. Data Analysis.....................................................................................................................................................6 3.5. Ethical Considerations......................................................................................................................................7 3.6. Field Team and Logistical Arrangements.........................................................................................................7 4. Results Part I: Female Sex Workers.............................................................................................................................8 4.1 Age.......................................................................................................................................................................8 4.2. Condom Use.......................................................................................................................................................8 4.3. Condom Breakage/Burst.................................................................................................................................10 4.4. Barriers to Condom Use..................................................................................................................................11 4.5. Sexual Practices among FSWs........................................................................................................................12 4.6. HIV Testing and Treatment............................................................................................................................13 4.7. Structural Factors...........................................................................................................................................15 4.8. Knowledge of Sexually Transmitted Infections (STIs) .............................................................................18 4.9. Sexually Transmitted Infections.....................................................................................................................19 4.10. Attendance at Drop-In Centres.....................................................................................................................21 4.11. Highlights of FSW Findings.........................................................................................................................22 5. Results Part II: Male Sex Workers............................................................................................................................23 5.1. Participants' Mean Age...................................................................................................................................23 5.2. Sexual Practices among MSWs.......................................................................................................................23 5.3. Condom Use....................................................................................................................................................25 5.4. Condom Breakage/Burst................................................................................................................................27 5.5. Barriers to Condom Use..................................................................................................................................27 5.6. HIV Testing.....................................................................................................................................................28

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Baseline Polling Booth Surveys among Male and Female Sex Workers in Nairobi and Mombasa NASCOP Learning Sites

5.7. HIV Treatment................................................................................................................................................29 5.8. Structural Factors...........................................................................................................................................30 5.9. Sexually Transmitted Infections.....................................................................................................................31 5.10. Attendance at Drop-In Centres....................................................................................................................32 5.11. Highlights of MSW Findings...........................................................................................................................33 6. Summary and Programmatic Implications..............................................................................................................34 Appendix 1: Polling Booth Survey Questionnaire – Female Sex Workers..................................................................36 Appendix 2: Polling Booth Survey Questionnaire – Male Sex Workers......................................................................37 Appendix 3: Polling Booth Survey Reporting Form.....................................................................................................38 Appendix 4: Polling Booth Survey Tallying Form.........................................................................................................39 Appendix 5: Sampling Information..............................................................................................................................40 References......................................................................................................................................................................45

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Baseline Polling Booth Surveys among Male and Female Sex Workers in Nairobi and Mombasa NASCOP Learning Sites

Figures Figure 1: A polling booth session in progress...............................................................................................................................................6 Figure 2: Participants’ mean age, by area and sex work spot type, FSWs, Nairobi and Mombasa, 2013.................................................8 Figure 3: Consistency of condom use, FSWs, Nairobi and Mombasa, 2013……………….......……............................... .............................9 Figure 4: Consistency of condom use, FSWs, Nairobi, 2013……………………………………..…....................................................................9 Figure 5: Consistency of condom use, FSWs, Mombasa, 2013……………………………........…..................................................................10 Figure 6: Condom breakage/burst the last time a condom was used, FSWs, Nairobi and Mombasa, 2013……………..........................10 Figure 7: Condom breakage/burst, by spot type, FSWs, Nairobi and Mombasa, 2013…............….........................................................11 Figure 8: Barriers to condom use, by sex work spot type, FSWs, Nairobi, 2013 ……................……........................................................11 Figure 9: Barriers to condom use, by sex work spot type, FSWs, Mombasa, 2013……............................................................................12 Figure 10: Reported anal sex, by sex work spot type, FSWs, Nairobi and Mombasa, 2013....................................................................13 Figure 11: Percentage tested for HIV in the past three months, by area, FSWs, Nairobi and Mombasa, 2013………...........................14 Figure 12: HIV testing in the past three months, by spot type, FSWs, Nairobi and Mombasa, 2013...................................................14 Figure 13: HIV treatment, by area, FSWs, Nairobi and Mombasa, 2013……….....................…................................................................15 Figure 14: HIV treatment, by spot type, FSWs, Nairobi and Mombasa, 2013……….....……………..........................................................15 Figure 15: Percentage reporting experience of violence, by area, FSWs, Nairobi and Mombasa, 2013.................................................16 Figure 16: Reported experience of violence, by spot type, FSWs, Nairobi and Mombasa, 2013……......................................................16 Figure 17: FSW participation in groups, by area, Nairobi and Mombasa….…...........................................................................................17 Figure 18: FSW participation in groups, by spot type, Nairobi and Mombasa, 2013…………..…….........................................................17 Figure 19: HIV-related knowledge, FSWs, Nairobi, 2013……………………………….………….....................................................................18 Figure 20: HIV-related knowledge, FSWs, Mombasa, 2013…………………………….…………....................................................................19 Figure 21: Experience of and treatment for sexually transmitted infections, by area, FSWs, Nairobi and Mombasa, 2013…………...20 Figure 22: Self-reported STIs, by spot type, FSWs, Nairobi and Mombasa, 2013………………...............................................................20 Figure 23: Percentage visited drop-in centres within the last three months, by area, FSWs, Nairobi and Mombasa, 2013……………..21 Figure 24: Percentage visited drop-in centres within the last three months, by spot type, FSWs, Nairobi and Mombasa, 2013…………22 Figure 25: Mean age of MSW participants, Nairobi and Mombasa, 2013……………………………............................................................23 Figure 26: Self-reported anal sex, by area, MSWs, Nairobi and Mombasa, 2013..................………........................................................23 Figure 27: Self-reported anal sex, by spot type, MSWs, Nairobi and Mombasa, 2013…………….............................................................24 Figure 28: Self-reported involvement in sex work and paying for sex with men, MSWs, Nairobi and Mombasa, 2013……………………24 Figure 29: Other sexual partner types, MSWs, Nairobi and Mombasa, 2013.........................................................................................25 Figure 30: Consistency of condom use, MSWs, Nairobi and Mombasa, 2013.........................................................................................25 Figure 31: Consistency of condom use, by area and sexual partner type, MSWs, 2013..........................................................................26 Figure 32: Consistency of condom use, by spot and sexual partner type, MSWs, 2013.........................................................................26 Figure 33: Condom breakage/burst at last usage, by area, MSWs, Nairobi and Mombasa, 2013...........................................................27 Figure 34: Condom breakage/burst at last usage, by spot type, MSWs, Nairobi and Mombasa, 2013...................................................27 Figure 35: Barriers to condom use, by spot type, MSWs, Nairobi and Mombasa, 2013..........................................................................28

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Baseline Polling Booth Surveys among Male and Female Sex Workers in Nairobi and Mombasa NASCOP Learning Sites

Figure 36: HIV testing in the past six months, by area, MSWs, Nairobi and Mombasa, 2013...............................................................28 Figure 37: HIV testing in the past six months, by spot type, MSWs, Nairobi and Mombasa, 2013......................................................29 Figure 38: HIV treatment, by area, MSWs, Nairobi and Mombasa, 2013................................................................................................29 Figure 39: HIV treatment, by spot type, MSWs, Nairobi and Mombasa, 2013........................................................................................30 Figure 40: Reported violence, by spot type, MSWs, Nairobi and Mombasa, 2013...................................................................................30 Figure 41: Participation in support groups, by area, MSWs, Nairobi and Mombasa..............................................................................31 Figure 42: Participation in support groups, by spot type, MSWs, Nairobi and Mombasa......................................................................31 Figure 43: Self-reported STI, by spot type, MSWs, Nairobi and Mombasa, 2013....................................................................................32 Figure 44: Attendance at drop-in centres in past three months, by area, MSWs, Nairobi and Mombasa, 2013...................................32 Figure 45: Attendance at drop-in centres in past three months, by spot type, MSWs, Nairobi and Mombasa, 2013...........................33

Tables Table 1: Calculated and attained FSW and MSW study sample, Nairobi and Mombasa.............................................5

Tables in the Appendix Table 1: Sampling for FSW polling booth survey, Starehe, 2013.................................................................................40 Table 2: Sampling for FSW polling booth survey, Westlands, 2013............................................................................41 Table 3a: Sampling for FSW polling booth survey, Mvita, 2013..................................................................................42 Table 3b: Sampling for FSW polling booth survey, Kisauni, 2013...............................................................................42 Table 4: Sampling for MSW/MSM polling booth survey, Westlands and Starehe, 2013............................................43 Table 5: Sampling for MSW/MSM polling booth survey, Mvita and Kisauni, 2013...................................................44

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Baseline Polling Booth Surveys among Male and Female Sex Workers in Nairobi and Mombasa NASCOP Learning Sites

Summary Background The National AIDS & STI Control Programme in Kenya (NASCOP), through the Technical Working Group for Most-at-Risk Populations (MARPs TWG), in 2012 selected the Sex Workers Outreach Programme (SWOP), implemented in Nairobi by the University of Manitoba and the University of Nairobi, and the International Centre for Reproductive Health Kenya (ICRHK) in Mombasa as national Learning Sites for sex work programmes.

Both Learning Sites serve female sex workers (FSWs) and male sex workers (MSWs). The Learning Site initiative aims to optimise the design, implementation, evaluation, and impact of targeted HIV prevention among FSWs and MSWs. The initiative builds on existing local structures, services, and programmes to engage communities and more comprehensively address the specific needs of sex workers. The Nairobi Learning Site covers Starehe and Westlands areas while the Mombasa Learning Site covers Kisauni and Mvita areas. Both Starehe and Mvita encompass the central business districts of the respective cities. To facilitate assessment of behavioural outcomes of the Learning Site initiative, a baseline survey was conducted among representative samples of FSWs and MSWs in the identified sites in Nairobi and Mombasa. The baseline survey among FSWs in Starehe area, Nairobi, was conducted from February 4 to 12, 2013, while surveys among FSWs and MSWs in the other sites were conducted from August 26 to September 27, 2013.

Methodology The baseline survey was conducted using a group interview methodology known as polling booth survey (PBS).

Polling booth survey is an anonymous and unlinked group interview method that has been shown to reduce biases in reporting of sexual behaviour, which are common with face-to-face interviews and self-administered questionnaires. The survey was conducted among a representative sample of 824 and 693 (total 1,517) FSWs in Nairobi and Mombasa, respectively; the MSW sample size was 301 in Nairobi and 261 in Mombasa (total 562).

Results Over two-thirds (68%) of FSWs in Mombasa and 59 per cent of those in Nairobi reported having a regular, nonpaying sexual partner. Similarly, among MSWs in both sites, 60 per cent reported having a regular, non-paying male sexual partner, and 40 per cent had a live-in/regular female sexual partner.

Condom use at last sex was high among FSWs, at 88 per cent in Nairobi and 84 per cent in Mombasa. However, consistency of condom use was a problem, as about 40 per cent of FSW participants in both sites reported having had sex without a condom with a casual, paying client at least once within one month preceding the survey. Also, nearly half of the FSWs in both sites reported having not used a condom the last time they had sex with a regular, non-paying partner.

Condom use among MSWs was even lower, with only 54 per cent of participants in Mombasa and 45 per cent of those in Nairobi reporting condom use at last sex with a casual, paying client. In addition, about a third of MSWs in both sites reported not using a condom with a casual, paying client at least once within one month preceding the survey. Coupled with inconsistent use was the problem of incorrect condom use, with 20 per cent of MSWs in both sites, and 33 per cent and 25 per cent of FSWs in Nairobi and Mombasa, respectively, reporting condom breakage at last usage.

Over 70 per cent of MSWs in both Nairobi and Mombasa and 73 per cent of FSWs in Nairobi had undergone an HIV test within the past six months; the proportion of FSWs tested for HIV in Mombasa over the past three months was 62 per cent. Sixteen and 12 per cent of FSWs in Nairobi and Mombasa, respectively, were on antiretroviral (ARV) medication; corresponding figures for MSWs were 23 per cent and 15 per cent.

Incidents of violence among FSWs were more common in Nairobi (27% and 53% reporting sexual and physical violence, respectively) than in Mombasa (17% and 30% reporting sexual and physical violence, respectively).

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Baseline Polling Booth Surveys among Male and Female Sex Workers in Nairobi and Mombasa NASCOP Learning Sites

Incidents of sexual violence were reported by 18 and 26 per cent of MSWs in Nairobi and Mombasa, respectively, and physical violence was reported by about 23 per cent of MSWs in Nairobi and Mombasa.

About 16 per cent of MSWs in both sites and 27 and 23 per cent of FSWs in Nairobi and Mombasa, respectively, reported experiencing symptoms of an STI at the time of the survey. Attendance within the previous three months at drop-in centres that provide STI treatment was reported by 52 per cent of FSWs in Nairobi as compared to 29 per cent in Mombasa, and by about half of the MSWs in both sites.

Some area-level differences were notable. Among FSWs, Starehe recorded the highest level of condom use at last sex with a casual, paying client but also the highest level of inconsistent condom use, with nearly half (45%) of respondents from this site, as compared to 33–38 per cent in the other sites, reporting not having used a condom with a casual, paying client at least once in the previous one month. As compared to other areas, Starehe recorded higher proportions of FSWs who had experienced sexual violence (29% versus 16–25% in other areas) and physical violence (61% vis-à-vis 29–45% in other areas), in the past six months. Also, Starehe had the highest proportion of FSWs who were experiencing symptoms of an STI at the time of the study (31% compared to 22–24% in the other areas).

Among MSWs, compared to other areas Starehe recorded the lowest proportion of MSWs who used condoms when they last received pay for sex (35% against 48–61% in the other areas). However, Starehe had the highest proportion of MSWs who had been tested for HIV in the previous six months (84% versus 66–76% in the other areas) and the highest proportion of MSWs belonging to support groups (60% against 42–51% in the other areas).

Programmatic Implications Results from this baseline survey indicate the need to strengthen outreach and education among both FSWs and MSWs to improve their access to condoms and utilisation of STI and other HIV prevention, treatment, care, and support services at the drop-in centres. The results also highlight the importance of tackling violence as part of a comprehensive HIV intervention among both male and female sex workers.

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Baseline Polling Booth Surveys among Male and Female Sex Workers in Nairobi and Mombasa NASCOP Learning Sites

1. Background HIV prevalence in Kenya is currently estimated at 5.6 per cent in the general adult population (aged 15–64 years), based on the most recent Kenya AIDS Indicator Survey (KAIS).1 However, rates of HIV prevalence vary by demographic groups and geographic areas. HIV prevalence is higher among women (6.9%) than men (4.4%). The highest HIV prevalence rates in the country are in Nyanza region (15.1%), followed by Nairobi (4.9%), Western (4.7%), and Coastal (4.3%) regions. Adults in Kenya’s urban areas have been found to have higher HIV prevalence (6.5%) than adults in rural areas (5.1%). Due to sampling constraints, general population-based surveys, such as KAIS, may not provide accurate data on HIV prevalence among populations most at risk for HIV, including female sex workers (FSWs), men who have sex with men (MSM), men who sell sex to men (male sex workers or MSWs), and people who use drugs (PWUD). Previous studies have found higher than national average HIV prevalence rates among these populations. For instance, pooled HIV prevalence data suggest that three decades into the HIV response, nearly half (45.1%—range 44%–46.2%)2 of FSWs in Kenya are infected with HIV, compared to 6.9 per cent of the general female population aged 15–64 years. Also, nearly one-fifth (18.2%) of MSM in Kenya are estimated to be living with HIV.3 According to estimates from a Modes of Transmission (MoT) analysis,4 FSWs and MSM contribute up to 15 per cent of all new HIV infections in Kenya, though this may underestimate upstream sources of infection among those in steady relationships.

Both FSWs and MSM are vulnerable to HIV and other sexually transmitted infections (STIs) not only because of their individual risk behaviours but also due to broader societal and community factors, including cultural norms, stigma, and a prohibitive legal environment. Sex between men is a criminal offence in Kenya, attracting up to 14 years imprisonment for those who are convicted. Also, the sale of sex by women is criminalised. Coupled with high stigma attached to sex between men, the stringent legal environment can hamper access to HIV services among MSM. In addition, limited training and preparation of healthcare providers on the needs of both FSWs and MSM means that these sub-populations may not receive appropriate HIV prevention, care, and support services.

Accurate information on HIV-risk behaviours, and access to and utilisation of HIV services are critical for male and female sex workers in Kenya.

As part of the efforts to strengthen HIV responses among populations most at risk, Kenya’s National AIDS & STI Control Programme (NASCOP), through the Technical Working Group for Most-at-Risk Populations (MARPs TWG), selected the Sex Workers Outreach Programme (SWOP), implemented in Nairobi by the University of Manitoba and the University of Nairobi, and the International Centre for Reproductive Health Kenya (ICRHK) in Mombasa to serve as national Learning Sites for targeted HIV prevention programmes among male and female sex workers.

The Learning Site initiative aims to optimise the design, implementation, evaluation, and impact of targeted HIV prevention among male and female sex workers. This initiative is not a separate project but aims to enhance the programming in existing interventions in line with the national guidelines and provide an opportunity for MARPs programme implementers to build their skills, competencies, and abilities.

The Nairobi Learning Site covers Starehe and Westlands areas, which jointly account for 35 per cent and 73 per cent of the FSW and MSW populations in the city, respectively, based on a geographical mapping study conducted in 2011/2012.5 The Mombasa Learning Site covers Kisauni, a large residential and commercial area, and Mvita, which encompasses the central business district. The two areas covered by the Mombasa Learning Site account for 63 per cent and 77 per cent of the FSW and MSW populations in the city, respectively.

To facilitate assessment of behavioural outcomes of the Learning Site initiative, a baseline survey was conducted among representative samples of FSWs and MSWs in Nairobi and Mombasa. This report presents results of the baseline survey. The baseline survey among FSWs in Starehe area, Nairobi, was conducted from February 4 to 12, 2013, while assessments among FSWs and MSWs in the other areas were conducted from August 26 to September 27, 2013. The survey methodology is described in detail in the report.

Baseline Polling Booth Surveys among Male and Female Sex Workers in Nairobi and Mombasa NASCOP Learning Sites

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2. Rationale for Outcomes Assessment To achieve the greatest efficiency and impact, HIV prevention strategies at a national or sub-national level should be tailored to the local epidemic. The Programme Science approach provides a framework that closes the gap between science and programmes by addressing complex public health choices and tradeoffs to ensure appropriate focus on selected geographic areas, high priority groups, a right mix of interventions, optimal delivery mechanisms and options, real-time monitoring, and tactical and strategic adaptations. The Program Science Initiative, led by the World Bank and the Centre for Global Public Health (CGPH) at the University of Manitoba, is defined as the systematic application of theoretical and empirical scientific knowledge to improve the design, implementation, and evaluation of public health programmes.6 Monitoring and evaluation (M&E) are integral to the Programme Science approach. M&E are concerned with efficiency, effectiveness, and impact of interventions. Efficiency focuses on the application of resources (people, money, skills, and time) to achieve programme goals and objectives. Effectiveness is concerned with the extent to which programme activities bring about desired changes in the lives of the people and communities targeted.

Impact relates to the long-term results from a concerted response to a problem, for example, reduced levels of HIV incidence at the national or sub-national level, over a given period of time. A monitoring and evaluation framework is designed to help provide data or evidence that programme activities are meeting objectives of efficiency and effectiveness and contributing towards impact. Monitoring helps to establish what is being and/or has been done, while evaluation examines what has been achieved.7 The common M&E framework considers developmental change as a chain of interrelated components, consisting of inputs, processes, outputs, outcomes, and impacts. Inputs include a variety of resources (e.g., staff, skills, equipment) that are brought to bear on a programme. These inputs are transformed into outputs through activities undertaken or services delivered. The transformation of inputs into outputs entails a process that requires attention to quality, unit costs, access, and coverage of services. M&E focusing on inputs, the process of their transformation, and outputs is also referred to as process monitoring, in contrast to outcomes/effectiveness and impact evaluation.8 Effectiveness or outcome and impact evaluation often require targeted studies conducted at the beginning and repeated after a considerable period of programme implementation, sometimes with a control or comparison group.

An outcome evaluation or assessment seeks to determine if, and by how much, programme activities are achieving their intended effects in the target population. An outcomes evaluation or assessment needs to answer two key questions: a) Are the desired outcomes being observed in the target population? and b) Are the observed changes likely to be the result of the programme or intervention?9 Outcomes evaluation for MARPs programmes typically collects data on knowledge, attitudes, practices, or behaviour, and structural influences on the same over time.10

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Baseline Polling Booth Surveys among Male and Female Sex Workers in Nairobi and Mombasa NASCOP Learning Sites

3. Outcomes Assessment Methodology Key design considerations for an outcomes assessment include a sampling strategy (including both sample size calculation and sample selection procedures), periodicity of data collection, and data collection and analysis methods. To be representative, sampling should be based on probability sampling techniques that provide an equal chance to all programme participants meeting defined criteria to be included in the outcomes assessment study. The periodicity of data collection can vary, but at the minimum should provide baseline indicators and postintervention or follow-up indicators to facilitate the assessment of changes that are likely to have resulted from the intervention. As regards data collection, a variety of methods exist, which include face-to-face interviews, selfcompleted questionnaires, computer-assisted self-interviewing (CASI), and other innovative approaches, such as polling booth survey (PBS). PBS, described further below, was used for the baseline assessment within the Nairobi and Mombasa Learning Sites. The Learning Site behavioural outcome indicators are highlighted in the box below.

Learning Site Outcome Indicators űű Percentage of sex workers reporting the use of condoms in last sex act with a casual paying client űű Percentage of sex workers reporting sex without condom with any client in last one month űű Percentage of sex workers reporting condom breakage or slippage in last sex űű Percentage of sex workers with an STI űű Percentage of sex workers tested for HIV in the last three months űű Percentage of sex workers who can refuse a client if a condom is not used űű Percentage of sex workers who report experience of any form of violence in last six months űű Percentage of sex workers who are part of groups/alliance/community-based organisation (CBO) űű Percentage of sex workers who know their HIV status űű Percentage of sex workers who identify that use of condoms can prevent HIV űű Percentage of sex workers who dispel major misconceptions about HIV transmission

3.1. Polling Booth Survey Accurate and reliable data on knowledge, behaviours, and practices influencing HIV transmission and acquisition are critical for effective HIV-prevention programme design and implementation but are often difficult to obtain due to the sensitivity surrounding sexual behaviour. Accurate reporting of sexual behaviour is heavily influenced by personal and contextual barriers, such as predisposition to self-disclosure, poor recall, perceptions of confidentiality, and social desirability bias.11 For this reason, survey methods that offer a greater level of privacy for respondents and assure anonymity of their response are more likely to elicit comparatively accurate data.12 Polling booth survey is such a survey method that seeks to overcome biases in reporting of sexual behaviour in face-to-face interviews and self-administered questionnaires.

Polling booth survey is a group interview method whereby individuals give their responses through a ballot box. The individual responses are anonymous and unlinked. The anonymity is intended to assure participants of confidentiality of their responses, thereby encouraging accurate responses to sensitive and intimate questions.

Participants are selected using a probability sampling procedure and organised into small homogenous groups of 10–15 people per session. Participants may be stratified by other factors of interest, such as type of sex work or age. Being a group interview, questions need to be kept few, short, and simple and dichotomised for ease of response. The method is not individualised, and therefore is not suitable for analysing correlates of sexual behaviour. Studies that have employed this method have confirmed its advantages over face-to-face interviews and self-administered questionnaires for eliciting sensitive sexual behaviour information.13,14 (See Appendix 1 and 2 for the PBS questionnaires).

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3.2. Sampling 3.2.1. Sample Size Determination Sampling for PBS follows standard probability sampling procedures used in surveys. Sampling for the PBS in Nairobi and Mombasa built upon population size estimates for these areas derived from a geographical mapping and population size estimation study in 2011/2012. The required sample size in each programme site was calculated using Cochran’s formula for sampling for proportions,15 shown below.

Equation 1 In the formula, no is the sample size, Z2 corresponds to the desired confidence interval (95%), e2 is the desired level of precision, p is the estimated proportion of an attribute in the population (e.g., condom use with clients), and q is 1-p.

For small populations (less than 10,000), the sample calculated using the above formula is adjusted using the equation below.

Equation 2 Where, n is the sample size and N is the population size.

The parameters used for calculating the sample size for each population group (FSW and MSW) in each geographic area of Nairobi (Starehe and Westlands) and Mombasa (Kisauni and Mvita) included the following: the level of precision (e) was set at ±5%, confidence interval at 95%, and baseline indicator at 50%.

The sampling procedure in each area proceeded in three stages. In the first stage, the required sample size was calculated for each population group based on the total estimated population from the geographical mapping study. In the second stage, the calculated sample was apportioned to each spot type in proportion to the estimated FSW or MSW population in those spots. For this purpose, population estimates that had been revalidated by the programmes more recently were used. The number of spots selected in each spot strata was determined by the following factors: űű the distribution of MSWs and FSWs in each area by spot type; űű the target to have approximately 12-15 FSWs or MSWs per PBS session; and űű the target to select approximately five or more MSWs or FSWs per spot.

In the final stage, the required number of MSWs and FSWs per spot was selected using a systematic random sampling method based on the list of MSWs and FSWs that was prepared by peer educators at the spots.

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Baseline Polling Booth Surveys among Male and Female Sex Workers in Nairobi and Mombasa NASCOP Learning Sites

Table 1 summarises the calculated and attained sample sizes for FSWs and MSWs in each of the four programme sites. Overall response rate was 102 per cent for both population groups. Detailed information used for sampling is provided in Appendix 5.

Table 1: Calculated and attained FSW and MSW study sample, Nairobi and Mombasa AREA

Starehe - Nairobi Westlands - Nairobi Kisauni - Mombasa Mvita - Mombasa Total

FSW Sample Calculated 425 372 352 342 1,491

Attained 420 404 359 334 1,517

Response Rate 99% 109% 102% 98% 102%

MSW Sample Calculated 118 182 118 132 550

Attained 121 180 129 132 562

Response Rate 103% 99% 109% 100% 102%

3.2.2. Selection of Individual Respondents Peer educators were trained to recruit a random sample of FSWs and MSWs from the sampled hot-spots. A schedule was developed for inviting study participants from the selected spots to a central venue. Throughout the mobilisation process, it was emphasised to the participants that participation in the PBS was by free consent and that non-participation for whatever reason would not jeopardise prospective participants’ access to services provided at the drop-in centres.

3.3. Steps in Conducting PBS Participants were invited to the PBS in groups of 12–15 individuals, organised by type of spot. The PBS sessions proceeded as follows: 1. Participants invited to the PBS were given an individual polling booth in the study venue. Large cartons were used to serve as polling booths. The polling booths were separated at least 1 meter from each other to provide privacy to each individual respondent and assure them of the confidentiality of their responses. Such an arrangement also increases the potential for genuine responses to the questions.

2. Each participant was given three boxes, coloured red, green, and white.

3. Each participant received a pack of cards. The cards were numbered corresponding to the number of questions in the questionnaire.

4. The cards were stacked in a serial/sequential order. The moderator confirmed that each participant had the right number of cards arranged in the correct order before starting to administer the questions.

5. The moderator asked questions, one at a time, and ensured that the questions were clearly understood by the respondents.

6. In terms of responses, the moderator explained the following: a. If the response to the question was YES, the respondent was to put the card with the number corresponding to the question into the GREEN box. b. If the response to the question was NO, the respondent was to put the card with the number corresponding to the question into the RED box. c. If the question did not apply to the respondent, the respondent was to put the card with the number corresponding to the question into the WHITE box. d. If the person DID NOT WANT TO ANSWER the question, the corresponding card was to be KEPT OUTSIDE of the provided boxes.

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7. The moderator explained the PBS with an example and a practice session. This example was to assure participants that their responses will remain anonymous and unlinked.

8. The moderator read the questions one by one. While doing so, the moderator a. kept the exercise lively; b. read each question clearly, slowly, and loudly so that each participant heard the question clearly; c. read the questions in a familiar language, including Kiswahili translation if necessary; d. repeated the question if necessary; e. used situations/stories while asking the questions; f. used local terms; and g. gave sufficient pauses and took care not to hurry through the questions.

9. At the end of administering the questions, the moderator and the assistant a. collected the cards separately for each of the boxes: green, red, and white b. counted the number of cards in each box for each question and recorded the tallies in a prescribed reporting form. (The Reporting Form is provided in Appendix 3 and the Tallying Form is provided in Appendix 4.)

10. The moderator then shared the responses with the respondents. Based on the results, the moderator asked follow-up questions to the participants in a focus-group discussion setting to understand the response patterns.

11. The moderator and the assistant documented the group discussion points.

12. All data generated through the entire PBS process were then given to the supervisor.

3.4. Data Analysis The PBS generated descriptive data that were analysed to show numbers and proportions pertaining to our M&E indicators. An Excel spreadsheet was designed and used to analyse this data. The data generated from multiple PBS sessions were aggregated to provide site-wide estimates for specific indicators and classified by type of spot

Figure 1: A polling booth session in progress.

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Baseline Polling Booth Surveys among Male and Female Sex Workers in Nairobi and Mombasa NASCOP Learning Sites

3.5. Ethical Considerations The polling booth surveys were conducted not as a research activity but as a programme monitoring and evaluation exercise. Data collected through the process were anonymous and unlinked. There were no foreseeable risks to respondents from their participation in the PBS. Individuals sampled for the study were informed that their participation was entirely voluntary. No incentives were provided to participants for taking part in the PBS, except reimbursement for the cost of their travel to the PBS venue and light refreshments at the end of the sessions.

3.6. Field Team and Logistical Arrangements Three teams, each comprising one moderator and an assistant, were recruited to conduct the PBS in each town. A two-day training on the PBS methodology was conducted for all the teams. The moderators and their assistants were not Learning Site staff members. All PBS questions were translated into Kiswahili for ease of administration and comprehension.

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4. Results Part I: Female Sex Workers 4.1. Age The entire study sample was 1,517 FSWs, comprising 824 (54.3%) and 693 (45.7%) FSWs in Nairobi and Mombasa, respectively. Because PBS is anonymous and unlinked, the only background characteristic information that was collected about participants was their age. Participants were young, with a mean age of 28 years, with general uniformity across sites and sex work spot type, as shown in Figure 2.

Figure 2: Participants’ mean age, by area and sex work spot type, FSWs, Nairobi and Mombasa, 2013

4.2. Condom use 4.2.1.Condom Use by Area The PBS asked FSWs whether a condom was used the last time that they had sex with a casual, paying client, and with a regular, non-paying partner, such as a live-in partner or a spouse. Participants were also asked if there was any occasion in the previous one month when they did not use a condom with any paying client. Fifty-nine per cent of FSWs in Nairobi and 68 per cent in Mombasa reported having a regular, non-paying male sexual partner.

Self-reported condom use among study participants was higher in last sex with a paying client (88% and 84% in Nairobi and Mombasa, respectively) than with a regular, non-paying partner (47% in Nairobi and 49% in Mombasa). Despite the reported high condom use at last sex with a paying client, about 40 per cent (39% in Nairobi and 38% in Mombasa) of participants reported occasions when they did not use condoms with paying clients in the preceding one month. Broken down into the specific programme areas, more FSWs in Starehe, Nairobi, (45%) than in all the other areas reported having had sex without a condom with a paying client at least once during the preceding one month. Similarly, reported condom use at last sex with a regular, non-paying partner was higher in Westlands, Nairobi, and the two Mombasa areas than in Starehe (Figure 3).

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Baseline Polling Booth Surveys among Male and Female Sex Workers in Nairobi and Mombasa NASCOP Learning Sites

Figure 3: Consistency of condom use, FSWs, Nairobi and Mombasa, 2013

4.2.2. Condom Use by Spot Type Condom use was also analysed by sex work spot type. In Nairobi, condom use at last sex with a paying client was marginally higher among sex workers operating from bars with lodges (92%) than among those working from other types of spots (range 85%–88%). Correspondingly, the incidence of unprotected sex with a paying client within the past one month was lower among female sex workers operating from bars with lodges than among their counterparts from the other spot types. A similar pattern was seen with reported condom use at last sex with a regular, non-paying client (Figure 4).

partner

Figure 4: Consistency of condom use, FSWs, Nairobi, 2013

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In Mombasa, a higher proportion of FSWs operating from streets/highways/parks reported condom use at last sex with any paying client than those from other types of spots. FSWs operating from hotels/lodges/guesthouses/ massage parlours were more likely to have had sex without a condom with a paying client within the last one month and had the lowest reported level of condom use at last sex with a paying client than their counterparts from the other spots. Condom use at last sex with a regular, non-paying sexual partner was higher among sex workers in Mombasa operating from bars without lodges than those from the other spot typologies (Figure 5).

Figure 5: Consistency of condom use, FSWs, Mombasa, 2013 It is important to learn the reasons for lower condom use at last sex and the high incidence of condoms not being used with any paying client over the past one month among hotels/lodges/guesthouses/massage parlours-based female sex workers in Mombasa.

4.3. Condom Breakage/Burst Both correct and consistent condom use are essential for HIV prevention among female sex workers. In addition to questions about condom use consistency, participants were asked if they had experienced condom breakage/ burst the last time they used a condom. A third of FSWs in Nairobi and a quarter of those in Mombasa reported experiencing condom breakage/burst the last time they used a condom. This experience was more common in Starehe than in the other areas (Figure 6).

Figure 6: Condom breakage/burst the last time a condom was used, FSWs, Nairobi and Mombasa, 2013 10

Baseline Polling Booth Surveys among Male and Female Sex Workers in Nairobi and Mombasa NASCOP Learning Sites

Condom breakage/burst was less common among streets/highways/parks-based FSWs in both Nairobi and Mombasa than among those operating from other types of spots (Figure 7).

Figure 7: Condom breakage/burst, by spot type, FSWs, Nairobi and Mombasa, 2013

4.4. Barriers to Condom Use To assess the influence of common barriers to condom use, the PBS asked female sex workers whether the consumption of alcohol, client refusal to wear a condom, condom unavailability, or an offer of more money for unprotected sex had caused them to have unprotected sex with any partner in the past one month. The most common reason for not using a condom, given by about a third of FSWs in both Nairobi and Mombasa, was client refusal to use a condom. In both cities, about one in four respondents reported that they had engaged in unprotected sex in the past month because of alcohol consumption and because of unavailability of condoms.

In Nairobi, a greater proportion of streets/highways/parks-based female sex workers reported having engaged in unprotected sex because of alcohol consumption than FSWs based in other types of spots. Also, a greater proportion of FSWs working in streets/highways/parks and hotels/lodges/guesthouses/massage parlours in Nairobi reported not having used a condom because of client refusal than FSWs operating from other spot typologies. The percentages of women who reported having unprotected sex due to unavailability of condoms or due to client willingness to pay more did not vary much by type of spot among Nairobi-based FSWs (Figure 8).

Figure 8: Barriers to condom use, by sex work spot type, FSWs, Nairobi, 2013 Baseline Polling Booth Surveys among Male and Female Sex Workers in Nairobi and Mombasa NASCOP Learning Sites

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In Mombasa, streets/highways/parks-based FSWs had the highest incidence of unprotected sex because of client refusal to wear a condom and the lowest incidence of unprotected sex due to alcohol. A greater proportion of sex workers based at bars without lodges and at hotels/lodges/guesthouses/massage parlours reported having had unprotected sex in the past month because of alcohol consumption and because of client willingness to pay more for sex without a condom than FSWs at the other spot typologies in Mombasa. Compared to FSWs working from other types of spots in Mombasa, a higher proportion operating from bars without lodges reported having unprotected sex due to condom unavailability (Figure 9).

Figure 9: Barriers to condom use, by sex work spot type, FSWs, Mombasa, 2013 Condom distribution through hotspots will need to be strengthened in both Nairobi and Mombasa to alleviate the problem of condom unavailability when sex workers need them. It is also programmatically important to establish why sex workers working from bars without lodges and those based at hotels/lodges/guesthouses/massage parlours in Mombasa engage in unprotected sex when the client pays more for such sex.

4.5. Sexual Practices among FSWs Anal sex heightens the risk of acquiring HIV. Accordingly, the PBS sought to determine the prevalence of anal sex among FSWs and of condom use during anal sex. Fifteen per cent of FSWs in both Nairobi and Mombasa reported having had anal sex, while almost equal proportions (8% and 6%, respectively) reported having anal sex within the past one month. In Nairobi and Mombasa, the proportion of FSWs who had ever had anal sex was higher among those based at hotels/lodges/guesthouses/massage parlours than those operating from other types of spots (Figure 10).

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Baseline Polling Booth Surveys among Male and Female Sex Workers in Nairobi and Mombasa NASCOP Learning Sites

Figure 10: Reported anal sex, by sex work spot type, FSWs, Nairobi and Mombasa, 2013 Overall, 59 and 39 per cent of FSWs in Nairobi and Mombasa, respectively, who had ever had anal sex reported that they used a condom at their last anal sexual encounter. This is a worrying finding given that the risk of HIV acquisition is heightened in anal sex.

4.6. HIV Testing and Treatment The knowledge of HIV status is important for promoting HIV-risk reduction behaviours and for facilitating linkage to appropriate care and treatment for those who have HIV infection. Programmatically, both SWOP and ICRHK encourage female sex workers to take an HIV test every three months and for those who are HIV positive to be enrolled in treatment and care within their programme sites. The PBS thus asked participants whether they had taken an HIV test in the past three months and if they had ever been registered in an antiretroviral treatment (ART) programme or were currently on antiretroviral (ARV) medication. Nearly three-quarters (73%) of FSWs in Nairobi and 62 per cent in Mombasa reported taking an HIV test within the preceding three months. A higher proportion of FSWs in Westlands (78%) than in all the other areas (range 62-68%) had taken an HIV test within the past three months (Figure 11).

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Figure 11: Percentage tested for HIV in the past three months, by area, FSWs, Nairobi and Mombasa, 2013 Further analysis by spot type showed that in both Nairobi and Mombasa, FSWs operating from bars with lodges and streets/highways/parks were more likely than those from the other types of spots to have taken an HIV test within the previous three months (Figure 12).

Figure 12: HIV testing in the past three months, by spot type, FSWs, Nairobi and Mombasa, 2013 Overall, 28 per cent of FSWs in Nairobi had ever been enrolled in ART programmes, and 16 per cent were currently on ARV. Corresponding estimates for Mombasa were 20 and 12 per cent. The proportion of FSWs ever enrolled in ART and those currently on ARV by area are shown in Figure 13.

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Baseline Polling Booth Surveys among Male and Female Sex Workers in Nairobi and Mombasa NASCOP Learning Sites

Figure 13: HIV treatment, by area, FSWs, Nairobi and Mombasa, 2013 A breakdown by spot type showed a higher proportion of bar-based and hotels/lodgings/guesthouses/massage parlours-based FSWs in Nairobi to have ever been enrolled in ART than streets/highways/parks-based FSWs. In Mombasa, compared to other spot types, fewer street/highways/parks-based and bars without lodges-based FSWs had ever been enrolled in ART, while a higher percentage of FSWs working from bars with lodges were currently on ARV (Figure 14).

Figure 14: HIV treatment, by spot type, FSWs, Nairobi and Mombasa, 2013

4.7. Structural Factors Structural factors, such as gender-based violence, cultural norms, and repressive legal environments, have been found to affect access to and utilisation of HIV preventive, care, and support services, especially among populations most at risk for HIV infection. The PBS asked participants about their experience of violence in the period of six Baseline Polling Booth Surveys among Male and Female Sex Workers in Nairobi and Mombasa NASCOP Learning Sites

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months preceding the survey and the form of violence—being forced to have sex (sexual violence) or being arrested or beaten up by law enforcement authorities (physical violence). About one in four (27%) and 53 per cent of FSWs in Nairobi had experienced sexual and physical violence, respectively, in the past six months. The corresponding estimates for Mombasa were 17 and 30 per cent. Both sexual and physical violence were more common among FSWs in Nairobi areas than in Mombasa (Figure 15).

Figure 15: Percentage reporting experience of violence, by area, FSWs, Nairobi and Mombasa, 2013 In Mombasa, sexual violence was more prevalent among hotels/lodgings/guesthouses/massage parlours-based FSWs and streets/highways/parks-based FSWs than among FSWs in the other types of spots. In Nairobi, reports of sexual violence were higher among hotels/lodgings/guesthouses/massage parlours-based FSWs than among FSWs in the other types of spots. Reports of violence emanating from law enforcement authorities, such as police, and county authorities in Nairobi varied moderately by the type of spots from which the sex workers operated, while in Mombasa, such violence was more pronounced among street/highways/parks-based FSWs (Figure 16).

Figure 16: Reported experience of violence, by spot type, FSWs, Nairobi and Mombasa, 2013

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Baseline Polling Booth Surveys among Male and Female Sex Workers in Nairobi and Mombasa NASCOP Learning Sites

Another aspect of the structural environment is the ability of female sex workers to organise themselves and participate in formal and informal groups that address their needs. In the PBS, participants were asked if they belong to any group comprising at least six members and primarily formed by and for female sex workers, regardless of whether such groups were formally registered. About half (52%) of FSWs in Nairobi and 39 per cent in Mombasa reported belonging to such groups. There were wide variations in group participation by area, with FSWs in Kisauni reporting the lowest participation in sex worker support groups, as shown in Figure 17.

Figure 17: FSW participation in groups, by area, Nairobi and Mombasa Membership in support groups did not vary substantially by spot type in Nairobi, while in Mombasa, compared to FSWs working in other types of spots, FSWs operating from bars without lodges and FSWs based at hotels/ lodgings/guesthouses/massage parlours reported higher rates of support group membership (Figure 18).

parlours, etc

e

Figure 18: FSW participation in groups, by spot type, Nairobi and Mombasa, 2013 Baseline Polling Booth Surveys among Male and Female Sex Workers in Nairobi and Mombasa NASCOP Learning Sites

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4.8. Knowledge of Sexually Transmitted Infections (STIs) Appropriate knowledge about HIV transmission mechanisms and prevention strategies and non-discriminatory attitudes towards people living with HIV are essential for effective HIV response, not only among female sex workers but in the general population as well. The PBS explored HIV-related knowledge and attitudes through the following questions: űű Can HIV be transmitted by mosquitoes? űű Can one get HIV by touching and hugging someone who has HIV? űű Do you think you can tell by looking at someone if they have HIV? űű Some people say condoms can protect you against HIV. Do you think this is true?

About one in ten FSWs in both Nairobi and Mombasa held the misconception that HIV can be transmitted by mosquitoes, while 17 and 21 per cent, respectively, believed that one can tell the HIV status of a person by their physical appearance. A striking finding was that about one in five (18%) FSWs in Nairobi and one in four (27%) in Mombasa did not think that condoms can protect against HIV. These results highlight the need for continued education on HIV and AIDS among FSWs. Figures 19 and 20 highlight variations by spot typology in these misconceptions among FSW survey respondents.

Figure 19: HIV-related knowledge, FSWs, Nairobi, 2013

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Baseline Polling Booth Surveys among Male and Female Sex Workers in Nairobi and Mombasa NASCOP Learning Sites

Figure 20: HIV-related knowledge, FSWs, Mombasa, 2013

4.9. Sexually Transmitted Infections (STI) The presence of an ulcerative STI is known to facilitate HIV transmission, especially during unprotected sex.

Among sex workers, STIs can indicate risky sexual behaviour and incorrect and/or inconsistent condom use. The PBS assessed the extent of STI among participants. Participants were first asked to identify symptoms of sexually transmitted infections in women. Subsequently, they were asked if they were experiencing STI symptoms (e.g., foul smelling discharge from the vagina, ulcer/wound around vagina, or severe lower abdominal pain during intercourse) at the time of the study. Further, participants were asked if they had received treatment for any STI in the past three months.

Over a quarter (27%) of FSWs in Nairobi reported experiencing STI symptoms at the time of the survey, while 23 per cent had received treatment for an STI within the past three months. In Mombasa, 23 per cent reported experiencing STI symptoms at the time of the survey, and 15 per cent had been treated for an STI in the past three months. There were wide variations in self-reported STI by areas, with Starehe recording the highest percentages of FSWs reporting STI symptoms and having undergone STI treatment in the past three months (Figure 21).

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Figure 21: Experience of and treatment for sexually transmitted infections, by area, FSWs, Nairobi and Mombasa, 2013 In Nairobi, streets/highways/parks-based FSWs had the lowest percentage of women experiencing STI symptoms at the time of the survey, but in Mombasa streets/highways/parks-based FSWs reported a higher rate of STI symptoms than FSWs in other spots (Figure 22).

Figure 22: Self-reported STIs, by spot type, FSWs, Nairobi and Mombasa, 2013

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Baseline Polling Booth Surveys among Male and Female Sex Workers in Nairobi and Mombasa NASCOP Learning Sites

The reported high levels of STI symptoms among streets/highways/parks-based FSWs in Mombasa is inconsistent with the earlier reported condom use at last sex with any paying client, which showed higher condom use (91% versus site average of 84%) and lower reports of sex without a condom with any client in the past one month (35% against the site average of 38%) among this group. The high STI cases among streets/highways/parks-based FSW in Mombasa cannot be explained either by incorrect condom use, given that reported condom breakage at last usage among this group was lower (20%) than the site average (25%).

Programmes in two sites should also explore high rates of STI symptoms among bar with lodges-based FSWs in Nairobi and among street/ highway/ parks-based FSWs in Mombasa and low rates of STI treatment among these two groups.

4.10. Attendance at Drop-In Centres Sex workers reached through both the Nairobi and Mombasa Learning Sites are encouraged to attend drop-in centres/clinics run by the programmes at least once every three months for STI screening and other services. The PBS therefore asked about attendance at the drop-in centres in the past three months. About one-half (52%) and 29 per cent of FSWs in Nairobi and Mombasa, respectively, reported having visited the drop-in centres in the past three months. The lower attendance at the drop-in centres in Mombasa may be explained by the fact that these facilities were new by the time of the survey and may not have been well known to the study participants. The Nairobi drop-in centres had been in operation for over five years, and within this city more FSWs in Westlands than in Starehe had visited these centres within the past three months (Figure 23).

Figure 23: Percentage visited drop-in centres within the last three months, by area, FSWs, Nairobi and Mombasa, 2013

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In both Nairobi and Mombasa, attendance at drop-in centres was lower among FSWs operating from bars without lodges in comparison to those at other types of spots (Figure 24).

Figure 24: Percentage visited drop-in centres within the last three months, by spot type, FSWs, Nairobi and Mombasa, 2013

4.11. Highlights of FSW Findings Although reported condom use among FSWs at last sex with a casual client was high (nearly 90% in Nairobi and 84% in Mombasa), nearly 40 per cent reported having engaged in unprotected sex with a casual client within the past one month.

Condom use at last sex with regular, non-paying partners was less than 50 per cent in both sites.

Condom breakage at last usage was reported by 33 and 25 per cent of FSWs in Nairobi and Mombasa, respectively.

In Nairobi, about half (52%) of the FSWs reported attending a drop-in centre in the past three months, whereas in Mombasa 29 per cent of FSWs reported doing so.

There were also significant variations in the behavioural indicators by area. Starehe recorded the highest level of condom use at last sex with a casual, paying client but also the highest level of inconsistent condom use, with nearly half (45%) of the respondents from this area as compared to 33–38 per cent in the other areas reporting an occasion of unprotected sex with a casual, paying client in the previous one month.

As compared to other areas, Starehe recorded higher proportions of FSWs who had experienced sexual violence (29% versus 16–25% in other areas) and physical violence (61% vis-à-vis 29–45% in other areas) in the past six months. Also, Starehe had the highest proportion of FSWs who were experiencing symptoms of an STI at the time of the study (31% compared to 22–24% in the other areas).

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5.

Results Part II: Male Sex Workers

5.1. Participants’ Mean Age A total of 562 male sex workers were interviewed for this study, with 301 (53.6%) and 261 (46.4%) of them drawn from Nairobi and Mombasa, respectively. MSW spots were defined in two categories—streets/parks/ highways-based and venue-based spots. Participants in Nairobi were slightly older (mean age 27 years) than those in Mombasa (mean 24 years), but there were no major age differences by spot type within each site (Figure 25).

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Figure 25: Mean age of MSW participants, Nairobi and Mombasa, 2013 

5.2. Sexual Practices among MSWs Although it may be assumed that men who have sex with men will have engaged in anal sex, self-disclosure of this practice is important to guide programmes in the delivery of appropriate services. The PBS asked participants if they had ever engaged in anal sex. Overall, 94 per cent of MSWs in Nairobi and 77 per cent in Mombasa reported having had anal sex, with 79 per cent and 56 per cent of them, respectively, having done so within the past one month. The lower self-disclosure of anal sexual practice among MSWs in Mombasa may point to underlying inhibitions because the site was new and many of the respondents may not have been exposed to the programme or to each other. Self-disclosure of anal sexual practice among MSWs also varied by programme areas (Figure 26).

Figure 26: Self-reported anal sex, by area, MSWs, Nairobi and Mombasa, 2013 Baseline Polling Booth Surveys among Male and Female Sex Workers in Nairobi and Mombasa NASCOP Learning Sites

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Self-disclosure of anal sexual practice did not vary substantially by spot type among MSWs in Nairobi, but in Mombasa it was higher among venue-based than among streets/parks/highways-based MSWs (Figure 27).

Figure 27: Self-reported anal sex, by spot type, MSWs, Nairobi and Mombasa, 2013 Similar to anal sexual practice, the survey also sought participants’ self-disclosure of their involvement in exchange of sex for money or other goods with other men. Nearly three-fourths (74%) of respondents in Nairobi as compared to about two-thirds (65%) in Mombasa reported having received money or goods in exchange for sex with other men, with 86 and 80 per cent of them, respectively, having done so within the past three months. About twothirds (65%) of respondents in Nairobi and one-half (52%) of those in Mombasa reported having paid cash, gifts or goods for sex with another man (Figure 28).

Figure 28: Self-reported involvement in sex work and paying for sex with men, MSWs, Nairobi and Mombasa, 2013 24

Baseline Polling Booth Surveys among Male and Female Sex Workers in Nairobi and Mombasa NASCOP Learning Sites

In addition to involvement in sex work, the survey assessed whether the respondents had a live-in/regular female sexual partner or a regular/non-paying male sexual partner. Forty-three per cent of MSWs in Nairobi reported having a live-in/regular female sexual partner, as compared to 58 per cent in Mombasa. More respondents in Nairobi (57%) than in Mombasa (42%) reported having a regular, non-paying male sexual partner. There were minimal differences in these indicators by area (Figure 29).

Figure 29: Other sexual partner types, MSWs, Nairobi and Mombasa, 2013

5.3. Condom Use The PBS asked participants whether a condom was used on the following occasions: a) the last time they had anal sex; b) the last time they received pay for sex; c) the last time they had sex with a live-in/regular female partner; and d) the last time they had sex with a regular, non-paying male sexual partner. Participants were also asked if there was any occasion in the previous one month when they did not use a condom with any paying client.

Reported use of condoms in all the sexual encounters was generally higher among respondents in Mombasa than in Nairobi. Moreover, fewer respondents in Mombasa (30%) than in Nairobi (40%) reported any incidents in the past one month when they did not use condoms with any paying client. Overall, participants reported higher levels of condom use with their live-in regular, female sexual partners and regular, non-paying male sexual partners than they did with casual, paying clients. This finding could be related to receiving more money for not using a condom when selling sex, and could be important programmatically (Figure 30).

Figure 30: Consistency of condom use, MSWs, Nairobi and Mombasa, 2013 Baseline Polling Booth Surveys among Male and Female Sex Workers in Nairobi and Mombasa NASCOP Learning Sites

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Reported condom use at last anal sex did not vary substantially by the programme areas in both Nairobi and Mombasa.

However, only 35 per cent of MSWs in Starehe as compared to 53 per cent in Westlands in Nairobi reported having used condoms at last sex when they received pay for sex with another man. Similarly, in Mombasa, only 48 per cent of MSWs in Kisauni as compared to 61 per cent in Mvita reported condom use the last time they received pay for sex with another man. As already noted, participants from all the areas reported higher condom use at last sex with their regular, non-paying male sexual partners than they did with their casual, paying clients (Figure 31).

Figure 31: Consistency of condom use, by area and sexual partner type, MSWs, 2013 Consistency of condom use was also analysed by type of spot. In Nairobi, condom use at last anal sex and the last time the respondent was paid for sex with another man was higher among streets/parks/highways-based MSWs than among venue-based MSWs, while in Mombasa it was the converse. Condom use at last sex with a regular, nonpaying male sexual partner was higher among streets/parks/highways-based MSWs than among venue-based MSWs in both Mombasa and Nairobi (Figure 32).

Figure 32: Consistency of condom use, by spot and sexual partner type, MSWs, 2013 26

Baseline Polling Booth Surveys among Male and Female Sex Workers in Nairobi and Mombasa NASCOP Learning Sites

5.4. Condom Breakage/Burst Similar to FSWs, correct condom use was assessed among MSWs based on reports of condom breakage/burst at the last sexual encounter when a condom was used. Overall, 20 per cent and 21 per cent of respondents in Nairobi and Mombasa, respectively, reported condom breakage/burst at last usage. There were no wide variations in this experience between the programme areas (Figure 33).

Figure 33: Condom breakage/burst at last usage, by area, MSWs, Nairobi and Mombasa, 2013 Analysed by spot type, condom breakage/burst was comparatively more common among streets /highways/parksbased MSWs in Nairobi and venue-based MSWs in Mombasa (Figure 34).

Figure 34: Condom breakage/burst at last usage, by spot type, MSWs, Nairobi and Mombasa, 2013

5.5. Barriers to Condom Use About 30 per cent of all respondents in Nairobi and Mombasa reported having at least one episode of unprotected sex in the preceding one month because the client did not want to use a condom, because alcohol had been

Baseline Polling Booth Surveys among Male and Female Sex Workers in Nairobi and Mombasa NASCOP Learning Sites

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consumed, and because condoms were not available at the place and time they needed them. Overall, these barriers to condom use were more pronounced among venue-based MSWs than among streets/highways/parksbased MSWs (Figure 35).

Figure 35: Barriers to condom use, by spot type, MSWs, Nairobi and Mombasa, 2013

5.6. HIV Testing The knowledge of HIV status is important for reinforcing HIV-risk reduction behaviours as well as facilitating linkage to appropriate care and treatment services for those who have HIV infection. MSWs in the study were asked if they had taken an HIV test within the past six months. Overall, 76 per cent of respondents in Nairobi and 71 per cent in Mombasa had taken an HIV test in the past six months. More MSWs in Starehe than elsewhere had taken an HIV test within the previous six months (Figure 36).

Figure 36: HIV testing in the past six months, by area, MSWs, Nairobi and Mombasa, 2013

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In both sites, more streets/highways/parks-based MSWs than venue-based MSWs had taken an HIV test within the past six months (Figure 37). This may reflect differences in risk perception by spot type among MSWs.

Figure 37: HIV testing in the past six months, by spot type, MSWs, Nairobi and Mombasa, 2013

5.7. HIV Treatment Participants were also asked if they had ever been registered in an antiretroviral treatment (ART) programme or were currently on antiretroviral (ARV) medication. About a third of respondents in both Nairobi and Mombasa had ever been registered in ART, while 23 per cent and 15 per cent, respectively, were currently on ARV (Figure 38).

Figure 38: HIV treatment, by area, MSWs, Nairobi and Mombasa, 2013 Baseline Polling Booth Surveys among Male and Female Sex Workers in Nairobi and Mombasa NASCOP Learning Sites

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In Nairobi, more streets/highways/parks-based MSWs than venue-based MSWs had ever been registered in ART or were currently on ARV; the opposite was the case in Mombasa (Figure 39).

Figure 39: HIV treatment, by spot type, MSWs, Nairobi and Mombasa, 2013

5.8. Structural Factors Study participants were asked if they had ever been forced to have sex (sexual violence), or arrested or beaten up by law enforcement authorities (physical violence) in the preceding six months. Sexual violence was more common among MSWs in Mombasa than in Nairobi. Whereas in Nairobi reports of violence were higher among streets/ highways/parks-based MSWs than among venue-based MSWs, in Mombasa the converse was true (Figure 40).

Figure 40: Reported violence, by spot type, MSWs, Nairobi and Mombasa, 2013 30

Baseline Polling Booth Surveys among Male and Female Sex Workers in Nairobi and Mombasa NASCOP Learning Sites

Similar to FSWs, participation in self-organising support groups can empower MSWs to address their needs more effectively. In the PBS, participants were asked if they belonged to any group comprising at least six members, primarily formed by and for MSWs. About half (54%) of MSWs in Nairobi and 43 per cent in Mombasa participated in such groups. More MSWs in Starehe than in the other areas belonged to support groups (Figure 41).

Figure 41: Participation in support groups, by area, MSWs, Nairobi and Mombasa Analysed by spot type, in Nairobi, streets/highways/parks-based MSWs were more likely to report participation in support groups than venue-based MSWs, while in Mombasa it was the opposite (Figure 42).

Figure 42: Participation in support groups, by spot type, MSWs, Nairobi and Mombasa

5.9. Sexually Transmitted Infections As noted earlier, the presence of an ulcerative STI can facilitate HIV transmission, especially during unprotected sex, and is also an indicator of risky sexual behaviour. Following the same approach as that among FSWs, MSWs

Baseline Polling Booth Surveys among Male and Female Sex Workers in Nairobi and Mombasa NASCOP Learning Sites

31

were asked if they were experiencing any symptoms of an STI at the time of the survey. The proportion of those with symptoms of an STI was similar between Nairobi and Mombasa (range 16 to 17%), but with differences by spot typology, especially in Mombasa (Figure 43).

Figure 43: Self-reported STI, by spot type, MSWs, Nairobi and Mombasa, 2013

5.10. Attendance at Drop-In Centres MSWs were also asked about their attendance at the drop-in centres in the past three months. Fifty-four per cent of MSWs in Nairobi, as compared to 47 per cent in Mombasa, had visited the drop-in centres within the past three months, with some variations across programme areas (Figure 44).

Figure 44: Attendance at drop-in centres in past three months, by area, MSWs, Nairobi and Mombasa, 2013

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Baseline Polling Booth Surveys among Male and Female Sex Workers in Nairobi and Mombasa NASCOP Learning Sites

There were also variations in the attendance at the drop-in centres in the past three months among MSWs by spot typology in both Nairobi and Mombasa (Figure 45).

Figure 45: Attendance at drop-in centres in past three months, by spot type, MSWs, Nairobi and Mombasa, 2013

5.11 Highlights of MSW Findings • Over 80 per cent of MSWs in both sites reported having exchanged sex for money or goods with another man in the past three months.

• Around half (43% and 58% in Nairobi and Mombasa, respectively) of the respondents in both sites reported having a regular female sexual partner, and around half (57% and 42% in Nairobi and Mombasa, respectively) had a regular, non-paying male sexual partner.

• Condom use was low when respondents last received pay from a man for sex (45% and 54% in Nairobi and Mombasa, respectively).

• About a third of MSWs in both sites reported having had unprotected sex with a male client in the past one month.

• Some area-level differences were notable. Compared to the other sites, Starehe recorded the lowest proportion of MSWs who used condoms when they last received pay for sex (35% against 48–61% in the other areas). However, Starehe had the highest proportion of MSWs who had taken an HIV test in the previous six months (84% versus 66–76% in the other areas), and the highest proportion of MSWs belonging to support groups (60% against 42–51% in the other areas).

Baseline Polling Booth Surveys among Male and Female Sex Workers in Nairobi and Mombasa NASCOP Learning Sites

33

6. Summary and Programmatic Implications This polling booth survey was intended to provide baseline indicators for the assessment of the outcomes of the Nairobi and Mombasa Learning Sites. The survey was conducted among a representative sample of 824 and 693 FSWs in Nairobi and Mombasa, respectively. The MSW sample size was 301 in Nairobi and 261 in Mombasa. Over two-thirds (68%) of FSWs in Mombasa and 59 per cent of those in Nairobi reported having a regular, non-paying sexual partner. Similarly, among MSWs in both sites, 57% in Nairobi and 42% in Mombasa reported having a regular, non-paying male sexual partner, while 43% in Nairobi and 58% in Mombasa had a live-in/regular female sexual partner.

Condom use at the last sex with a paying client was high among FSWs, at nearly 90 per cent in Nairobi and 84 per cent in Mombasa. However, consistency of condom use was a problem, as about 40 per cent of FSW participants in both sites reported having had sex without a condom with a casual, paying client at least once within one month preceding the survey. Nearly one-half of the FSWs in both sites also reported not having used a condom in the last sex with a regular, non-paying partner.

Condom use among MSWs was even lower, with only 54 per cent of participants in Mombasa and 45 per cent in Nairobi reporting condom use at last sex with a casual, paying client. In addition, about a third of MSWs in both sites reported not using a condom with a casual, paying client at least once within one month preceding the survey.

Among FSWs, the dominant barrier to condom use, cited by 34 per cent of respondents in Nairobi and 30 per cent in Mombasa was client refusal.

Client refusal, influence of alcohol, and condom unavailability were cited by almost a third of MSWs in both Nairobi and Mombasa as barriers to condom use. Coupled with inconsistent use was the problem of incorrect condom use, with 20 per cent of MSWs in both sites, and 33 and 25 per cent of FSWs in Nairobi and Mombasa, respectively, reporting condom breakage at last usage.

Over 70 per cent of MSWs in both Nairobi and Mombasa and 73 per cent of FSWs in Nairobi had taken an HIV test within the past 3–6 months; the proportion of FSWs who had been tested for HIV in Mombasa in the past three months was 62 per cent. Sixteen and 12 per cent of FSWs in Nairobi and Mombasa, respectively, were currently on ARV medication; corresponding figures for MSWs were 23 and 15 per cent.

Incidents of violence among FSWs were more common in Nairobi (27% and 53% reporting sexual and physical violence, respectively) than in Mombasa (17% and 30% reporting sexual and physical violence, respectively).

Incidents of sexual violence were reported by 18 per cent and about 26 per cent respectively, whereas physical violence was reported by about 24 per cent of MSWs in Nairobi and Mombasa.

About 16 per cent of MSWs in both sites and 27 and 23 per cent of FSWs in Nairobi and Mombasa, respectively, reported experiencing symptoms of an STI at the time of the survey. Fifty-two per cent of FSWs in Nairobi, 29 per cent of FSWs in Mombasa, and about half of the MSWs in both sites reported attending drop-in centres that offer STI treatment within the past three months.

There were high levels of misconception surrounding HIV among FSWs. About one in ten of FSWs in both Nairobi and Mombasa held the misconception that HIV can be transmitted by mosquitoes, while 17 and 21 per cent, respectively, believed that one can tell the HIV status of a person by looking at them. A striking finding was that about one in five (18%) of FSWs in Nairobi and one in four (27%) of those in Mombasa did not think that condoms can protect against HIV. The survey’s findings indicate a need for continued education on HIV and AIDS among FSWs and MSWs.

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Baseline Polling Booth Surveys among Male and Female Sex Workers in Nairobi and Mombasa NASCOP Learning Sites

Taken together, these results point to the need to strengthen outreach and education among both FSWs and MSWs to improve their access to and use of condoms and STI and HIV prevention, treatment, care, and support services at the drop-in centres. The results also highlight the importance of tackling violence as part of a comprehensive HIV intervention among female and male sex workers.

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35

Appendix 1: Polling Booth Survey Questionnaire – Female Sex Workers 1. The last time you had sex with any paying client, did he use a condom?

2. During the past 1 month, was there any occasion when you had sex with any paying client without using a condom?

3. Do you have a regular partner who does not pay you for sex? (a regular non-paying partner may include livein partners and spouses).

4. The last time you had sex with a regular non-paying partner, did he use a condom?

5. During the past 1 month, was there a time when you wanted to use condoms during sex with any of your sexual partners but did not because the sexual partner did not want to wear a condom?

6. During the past 1 month, was there a time when you intended to use a condom with any of your sexual partners but did not use it because either of you had been drinking alcohol?

7. During the past 1 month, was there a time when you intended to use a condom with any of your sexual partners but did not use it because a condom was not available at that time and place?

8. During the past 1 month, did you have sex without a condom because the client paid you more money for sex without a condom?

9. Have you ever had anal sex?

10. Did you have anal sex in the past 1 month?

11. The last time you had anal sex, was a condom used?

12. Did you take an HIV test during the past 3 months?

13. Have you ever been registered in ART programme (Antiretroviral Therapy for HIV management)?

14. Are you currently taking ARV (Antiretroviral drugs for HIV management)?

15. In the past 6 months, were you ever beaten or otherwise physically forced to have sexual intercourse with someone even though you did not want to?

16. In the past 6 months, were you ever arrested or beaten up by police and City Askaris when you were doing sex work or were at a sex work spot?

17. Do you belong to any groups comprising of at least 6 members that are specifically formed by and for female sex workers?

18. The last time any of your sexual partners used a condom, did it burst or slip away?

19. Can HIV be transmitted by mosquitoes?

20. Can one get HIV by touching and hugging someone who has HIV? 21. Do you think you can tell by looking at someone if they have HIV? (Can a healthy looking person have HIV?) 22. Some people say condoms can protect you against HIV. Do you think it is true?

23. Do you currently experience any of the following symptoms of a sexually transmitted infection – foul smelling discharge from the vagina, ulcer/wound around vagina, or severe lower abdominal pain during intercourse?

24. In the last 3 months, were you treated for any sexually transmitted infections (STIs)?

25. In the last 3 months, did you ever visit the SWOP or ICRHK Drop-In Centre/Clinic?

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Baseline Polling Booth Surveys among Male and Female Sex Workers in Nairobi and Mombasa NASCOP Learning Sites

Appendix 2: Polling Booth Survey Questionnaire – Male Sex Workers 1.

2.

3.

4.

5.

6.

7.

8.

9.

Have you ever had anal sex?

Did you have anal sex in the past 1 month?

The last time you had anal sex, was a condom used?

The last time you had anal sex, did you penetrate/insert into your partner?

Have you ever exchanged sex for money or goods with other men?

Did you exchange sex for money or goods with other men within the past THREE months?

Have you ever paid cash or gifts/goods for sex with another man?

The last time you exchanged sex for money or goods with another man, was a condom used?

During the past 1 month, was there any occasion when you exchanged sex for money or goods with another man without using a condom?

10. Do you have a main/live-in/regular female sexual partner?

11. The last time you had sex with your main/live-in/regular female sexual partner, did you use a condom?

12. Do you have a regular male partner who does not pay you for sex? (a regular non-paying male partner may include live-in partners or spouse).

13. The last time you had sex with a regular non-paying male partner, did he use a condom?

14. During the past 1 month, was there a time when you wanted to use condoms during sex with any of your male sexual partners but did not because the sexual partner did not want to wear a condom?

15. During the past 1 month, was there a time when you intended to use a condom with any of your male sexual partners but did not use it because either of you had been drinking alcohol?

16. During the past 1 month, was there a time when you intended to use a condom with any of your male sexual partners but did not use it because a condom was not available at that time and place?

17. Did you take an HIV test during the past 6 months?

18. Have you ever been registered in ART programme (Antiretroviral Therapy for HIV management)?

19. Are you currently taking ARV (Antiretroviral drugs for HIV management)?

20. In the past 6 months, were you ever physically forced to have sexual intercourse with someone even though you did not want to?

21. In the past 6 months, were you ever beaten up by police, City Askaris, goons, etc, when you were doing sex work or at a sex work spot?

22. Do you belong to any groups comprising of at least 6 members that are specifically formed by and for male sex workers or men who have sex with men?

23. The last time a condom was used with any of your male sexual partners, did the condom burst or slip away?

24. Do you currently experience any of the following symptoms of a sexually transmitted infection– sores on the penis, testicles, anus and surrounding area; white discharge (pus) from penis or anus; painful testicles (balls); pain or bleeding with defecation (bowel movements); itchy genital area, penis or anus; swollen glands on the inside of the legs?

25. In the last 3 months, did you ever visit the SWOP (ICRH) drop-in centre/clinic?

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37

Appendix 3: Polling Booth Survey Reporting Form City/Town:________________________________________________PBS#______________________________ Date of PBS: Date ________________Month________________________ Year___________________________ Time PBS started (24 hours):_______________________ Time PBS ended (24 hours):_____________________ Number of participants in the PBS session: _________________________________________________________ Name of Moderator: ___________________________________________________________________________ Name of the Assistant: _________________________________________________________________________

Details of Participant Serial No. 1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

21.

22.

23.

24.

38

Name of Hot Spot

Age

Baseline Polling Booth Surveys among Male and Female Sex Workers in Nairobi and Mombasa NASCOP Learning Sites

Appendix 4: Polling Booth Survey Tallying Form City/Town:__________________________________________ PBS#____________________________________ Date of PBS: Date _____________________________ Month_____________________ Year_________________ Time PBS started (24 hours):__________________________ Time PBS ended (24 hours):___________________ Number of participants in the PBS session: _________________________________________________________ Name of Moderator: ___________________________________________________________________________ Name of the Assistant: _________________________________________________________________________

QUESTION 1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

21.

22.

23.

24.

25.

YES

NO

NOT APPLICABLE

NO ANSWER

Baseline Polling Booth Surveys among Male and Female Sex Workers in Nairobi and Mombasa NASCOP Learning Sites

TOTAL

39

Appendix 5: Sampling information Sampling Information for Female Sex Workers The following sampling parameters were set for each population group per site: it was assumed that the objective was to detect a 20 per cent change in any of the indicators of interest between a baseline and follow-up survey (e.g., 20% increase in condom use with casual clients from a baseline of 50%), with 95 per cent statistical confidence and 80 per cent statistical power. Cochran’s formula for sampling for proportions was used.

Starehe - Nairobi The calculated sample size was 392 FSWs, which was adjusted to 425 to account for non-response. The sample was stratified further by sex work spot type, based on results from a previous geographic mapping study. A geographic mapping study conducted in 2011 estimated the FSW population in Starehe area of Nairobi at 6,763. The study further identified some 530 active spots from where female sex workers operated in the Starehe area. A subsequent revalidation exercise in 2012 identified 222 spots that were regularly frequented by at least 10 FSWs and estimated the FSWs population in all these spots at 5,480. The revalidation exercise also found the dominant types of sex work spots in Starehe area to be bars with lodges (24%), bars without lodges (23%) and hotels and lodgings (39%).

The required study sample of 425 FSWs was stratified by spot type (Table 1).

Table 1: Sampling for FSW polling booth survey, Starehe, 2013 Spot type

Number (Percentage of spots)

Number (Percentage of FSWs)

Required number of spots

Required number of FSWs (Attained)*

22 19 11

Required number of PBS sessions (Attained)* 9 (10) 8 (7) 4 (4)

Bars with lodges Bars without lodges Streets/highways/ parks Hotels/lodgings/ guesthouses, massage parlours, etc.

Total

53 (24%) 52 (23%) 31 (14%)

1,414 (26%) 1,197 (22%) 726 (13%)

86 (39%)

2143 (39%)

33

14 (14)

165 (154)

222 (100%)

5,480 (100%)

85

35 (35)

425 (420)

110 (121) 95 (96) 55 (49)

*Attainment shown in parentheses

Westlands – Nairobi The geographic mapping study estimated the population of FSWs in Westlands at 2929, representing 11 per cent of the estimated 27,620 FSWs in the whole of Nairobi. The sex workers operated from some 231 spots in the district. These estimates were revalidated in 2013 and the number of FSWs and spots from which they operated was revised to 2,634 and 122, respectively. The calculated sample of FSWs for Westlands was 372. The number of spots required to reach this sample size was 75, while the total number of PBS sessions required was 31 as shown in Table 2.

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Baseline Polling Booth Surveys among Male and Female Sex Workers in Nairobi and Mombasa NASCOP Learning Sites

Table 2: Sampling for FSW polling booth survey, Westlands, 2013 Type of Spot

Bar with lodging Bar without lodging Streets/highways/ parks Lodgings/ guesthouse/ massage parlours/homes Total

Number (Percentage of Spots) N=122 19 (16%) 42 (34%) 49 (40%)

Number (Percentage of FSWs) N=2634 445 (17%) 837 (32%) 1135 (43%)

Required Number of FSWs (Attained)*

Required number of Spots

Required number of PBS Sessions*

63 (68) 119 (131) 160 (171)

13 24 32

5 (6) 10 (11) 13 (14)

12 (10%)

217 (8%)

30 (34)

6

3 (3)

122 (100%)

2634 (100%)

372(404)

75

31(34)

*Attainment shown in parentheses

Kisauni and Mvita – Mombasa The same geographical mapping study identified 151 spots frequented by FSWs and estimated the population of FSWs at these spots at 2,192 in Mvita district. These spots and the FSW population estimates were revalidated in 2013. In the revalidation, 95 spots frequented by 5 or more FSWs were identified and the total FSW population at these spots was estimated at 2,175. Nearly half (46%) of the revalidated spots were characterised as bars without lodges, while about a quarter (24%) were bars with lodges. Streets and highways accounted for 14% of all the revalidated spots. Over one-third (38%) of the revalidated FSW population operated from bars with lodges, while 30% and 9% operated from bars without lodges and streets/parks/highways, respectively.

In Kisauni district, the same geographical mapping study identified 263 spots frequented by FSWs and estimated the FSW population at these spots at 3,617. The revalidation exercise in 2013 identified 121 active spots frequented by 5 or more FSWs. The majority (39%) of the FSW spots were bars without lodges; bars with lodges and streets/highways/parks accounted for 22% and 17% of all the revalidated spots, respectively. The revalidation estimated the FSW population in spots frequented by 5 or more FSWs at 2,617 in Kisauni. Half of the estimated FSW population operated from bars with lodges, while 20% and 13% operated from bars without lodges and streets/highways/parks, respectively.

The revalidated FSW spots and population estimates were used to calculate the sample size for the polling booth survey. The samples calculated for FSWs in Mvita and Kisauni were 326 and 335, respectively. These sample sizes were adjusted by five per cent to account for non-response, hence the final sample for Mvita was 342 FSWs while that for Kisauni was 352 FSWs The number of FSW spots that were to be covered in Mvita and Kisauni was 65 and 58, respectively, and the total number of PBS sessions required was 28 each in Mvita and Kisauni (total 56 sessions) (Table 3a and 3b)

Baseline Polling Booth Surveys among Male and Female Sex Workers in Nairobi and Mombasa NASCOP Learning Sites

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Table 3a: Sampling for FSW polling booth survey, Mvita, 2013 Type of Spot

Bar with lodging* Bar without lodging Streets/highways/ parks Lodgings/ guesthouse/ massage parlours/homes Total

Number (Percentage of Spots) N=122 23 (24.21%) 44 (46.32%) 13 (13.68%)

Number (Percentage of FSWs) N=2634 826 (37.98%) 662 (30.44%) 205 (9.43%)

Required Number of FSWs (Attained)* 130 (126) 104 (97) 32 (32)

Required number of Spots

Required number of PBS Sessions*

23 21 6

10 (9) 9 (7) 3 (3)

15 (15.79%)

482 (22.16%)

76 (79)

15

6 (6)

95 (100%)

2,175 (100%)

342 (334)

65

28 (25)

Attainment shown in parentheses

Table 3b: Sampling for FSW polling booth survey, Kisauni, 2013 Type of Spot

Bar with lodging* Bar without lodging Streets/highways/ parks Lodgings/ guesthouse/ massage parlours/homes Total

Number (Percentage of Spots) N=121 27 (22.31%) 47 (38.84%) 21 (17.36%)

Number (Percentage of FSWs) N=2, 617 1308 (49.98%) 515 (19.68%) 346 (13.22%)

Required Number of FSWs (Attained)* 176 (180) 69 (71) 47 (48)

Required number of Spots

Required number of PBS Sessions*

27 10 9

14 (14) 6 (5) 4 (4)

26 (21.49%)

448 (17.12%)

60 (60)

12

4 (4)

121 (100%)

2,617 (100%)

352 (359)

58

28 (27)

*Attainment shown in parentheses

Sampling Information for Male Sex Workers Starehe and Westlands – Nairobi Based on the geographical mapping study, there were an estimated 1,570 MSWs and other high-risk men who have sex with men (MSM) who cruise sites frequented by MSWs throughout Nairobi, with about half (809 or 51.5%) and 334 (21.3%) of the MSWs and other high-risk MSM being in Westlands and Starehe areas, respectively. The geographical mapping study also estimated the number of active spots frequented by MSWs and other high-risk MSM at 211, with Westlands accounting for 55% of these, followed by Starehe with 36 (17%) of such spots. In addition, the geographical mapping study assessed the distribution of MSWs and other high-risk MSM by the type of spots from which they operated. Results indicated that in Nairobi, MSWs and other high-risk MSM operated predominantly from venue-based spots (78%) and streets (19%).

The spots and population estimates in each spot were revalidated in June 2013. In the revalidation, venuebased spots were unpacked into bars with and without lodgings, strip clubs, casinos, and discos. The revalidation identified 62 spots frequented by MSWs and other high-risk MSM in both Westlands and Starehe. Of these spots,

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Baseline Polling Booth Surveys among Male and Female Sex Workers in Nairobi and Mombasa NASCOP Learning Sites

33 (53%) were streets/highways, while the rest were of a venue type. The estimated population of MSWs and other high-risk MSM from the revalidation exercise was 539 in Westlands and 350 in Starehe.

The sample calculated for the study, based on the above information and adjusted to account for the small population of MSWs and other high-risk MSM in Nairobi, was 286. This sample was adjusted by 5 per cent to account for non-response, thus bringing the study sample size to 300 MSWs and other high-risk MSM in Starehe and Westlands. The sample was stratified by study sites and spot types. (Table 4).

Table 4: Sampling for MSW/MSM polling booth survey, Westlands and Starehe, 2013 Type of Spot

Overall Venue-based spots Streets and highways Total Venue-based Westlands Starehe Total Streets and highways Westlands Starehe Total

Number (Percentage of Spots) N=122

Number (Percentage of MSWs) N=2634

Required Number of MSWs (Attained)*

Required number of Spots

Required number of PBS Sessions*

29 (47%) 33 (53%) 62 (100%)

454 (51%) 435 (49%) 889 (100%)

153 (147) 147 (154) 300 (301)

31 29 60

13 (13) 12 (12) 25(25)

19 (66%) 10 (34%)) 29 (100)

282 (62%) 172 (38%) 454 (100%)

95 (88) 58 (59) 153 (147)

19 12 31

8 (8) 5 (5) 13 (13)

20 (61%) 13 (39%) 33 (100%)

257 (59%) 178 (41%) 435(100%)

87 (92) 60 (62) 147 (154)

17 12 29

7 (7) 5 (5) 12 (12)

*Attainment shown in parentheses

Kisauni and Mvita – Mombasa The same geographical mapping study in 2011/2012 identified 51 and 49 spots frequented by MSWs in Mvita and Kisauni, respectively. The estimated MSW population from that study was 341 in Mvita and 258 in Kisauni. The numbers of MSW spots revalidated in 2013 were 42 and 40 in Mvita and Kisauni, respectively, with corresponding MSW population estimates of 299 and 334. Overall, 62 (75.6%) of all the MSW spots revalidated in both Mvita and Kisauni were of streets/parks/highways-based typology while 20 (24.4%) were of venue-based typology. The majority (79.0%) of the total 633 MSW population from the revalidation operated from streets/parks/highwaysbased spots.

Because of the small MSW population size, a composite sample for both Mvita and Kisauni was calculated. The calculated sample size for MSWs in the two areas was 239, which was adjusted by five per cent to 250. The total number of PBS sessions that were planned to be conducted with MSWs from the two areas was 20. Table 5 summarises the sample allocation by sex work spot typology and the number of PBS sessions.

Baseline Polling Booth Surveys among Male and Female Sex Workers in Nairobi and Mombasa NASCOP Learning Sites

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Table 5: Sampling for MSW/MSM polling booth survey, Mvita and Kisauni, 2013 Type of Spot

Overall Venue-based spots Streets/parks/ highways Total Venue-based Mvita Kisauni Total Streets/parks/ highways Mvita Kisauni Total

44

Number (Percentage of Spots) N=122

Number (Percentage of MSWs) N=2634

Required Number of MSWs (Attained)*

Required number of Spots

Required number of PBS Sessions*

20 (24.39%) 62 (75.61%) 82 (100%)

133 (21.01%) 500 (78.99%) 633 (100%)

53 (65) 197 (196) 250 (261)

11 39 50

5 (5) 15 (15) 20 (20)

5 (25.0%) 15 (75.0%)) 20 (100)

44 (33.08%) 89 (66.92%) 133 (100%)

18 (23) 35 (42) 53 (65)

3 8 11

2 (2) 3 (3) 5 (5)

37 (59.68%) 25 (40.32%) 62 (100%)

255 (51.0%) 245 (49.0%) 500 (100%)

100 (109) 97 (87) 197 (196)

23 16 39

8 (8) 7 (7) 15 (15)

Baseline Polling Booth Surveys among Male and Female Sex Workers in Nairobi and Mombasa NASCOP Learning Sites

References 1. National AIDS and STI Control Programme (NASCOP), Ministry of Health, Kenya. 2013. Kenya AIDS Indicator Survey 2012. Preliminary Report. Nairobi: NASCOP. 2. Baral S, Beyrer C, Muessig K, et al. Burden of HIV among female sex workers in low-income and middle-income countries: a systematic review and meta-analysis. Lancet Infectious Diseases, 2012;12:538-549. doi: 10.1016/ S1473-3099(12)70066-X. 3. National AIDS Control Council (NACC) and National AIDS and STI Control Programme (NASCOP). 2012. The Kenya AIDS Epidemic: Update 2011. Nairobi: NACC & NASCOP. 4. National AIDS Control Council, Kenya (NACC). 2009. Kenya HIV Prevention Response and Modes of Transmission Analysis. Nairobi: NACC. 5. National AIDS and STI Control Programme (NASCOP), Ministry of Health, Kenya. 2012. Most At Risk Populations: Unveiling New Evidence for Accelerated Programming (MARPs Surveillance Report 2012).

Nairobi: NASCOP. 6. Blanchard JF and Aral SO. Program Science: an initiative to improve the planning, implementation and evaluation of HIV/sexually transmitted infection prevention programmes. Sexually Transmitted Infections, 2011;87(1). doi: 10.1136/sti.2010.047555.

7. Joint United Nations Programme on HIV/AIDS (UNAIDS). 2002. National AIDS Councils: Monitoring and Evaluation Operations Manual. Geneva: UNAIDS. 8. Ibid.

9. Joint United Nations Programme on HIV/AIDS (UNAIDS). 2008. A Framework for Monitoring and Evaluating HIV Prevention Programmes for Most-At-Risk Populations. Geneva: UNAIDS. 10. Ibid.

11. Karnataka Health Promotion Trust (KHPT). 2011. Measuring Sensitive Behavioural Indicators: A Methodological Approach. Bangalore: KHPT. 12. Ibid.

13. Lowndes CM, Jayachandran AA, Benandur P, et al. Polling booth surveys: a novel approach for reducing social desirability bias in HIV-related behavioural surveys in resource-poor settings. AIDS and Behaviour, 2012;16(4):1054-62. doi: 10.1007/s10461-011-0004-1.

14. KHPT. 2011. Measuring Sensitive Behavioural Indicators.

15. Cochran WG. 1963. Sampling Techniques, 2nd ed. New York: John Wiley and Sons, Inc.

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National AIDS & STI Control Programme- NASCOP Kenya National Hospital Grounds P.O Box: 19361-00202 Nairobi, Kenya Tel: +254-020-2729502 Email: info@nascop.or.ke

Nairobi Learning Site Sex Workers Outreach Programe (SWOP) AJS House, 4th floor, Keekorock Road, City centre Opp Liddos Pub P.O Box: 19676-00202, Nairobi, Kenya Email: info@csrtkenya.org Tel: 020 901 3648/ 020 802 5270 +254 714 447 626, +254 735 796 636 Blog: swopke.blogspot.com

Mombasa Learning Site International Centre for Reproductive Health Kenya (ICRHK), Tudor, Mombasa P.O Box: 91109 - 90103 Mombasa, Kenya Tel: +254 41 249 4 866, +254 722 208 652, +254 734 466 466 Fax: +254 0 41 245 025 Email: info@icrhk.org Website: www.icrhk.org