INDUSTRIAL ATTACHMENT REPORT

SEX WORKERS’ OUTREACH PROGRAM (SWOP) CLINIC- KAWANGWARE

ODUOR SYLVIA AKINYI

M23/2/1219/016

SUPERVISED BY DR. ENOS BARASA

SUBMITTED ON 17TH MAY, 2021.

An Industrial attachment report Submitted to the Department of Public Affairs and

Environmental Studies in Partial Fulfilment of the Requirements for the Degree of
Bachelor of Psychology of Laikipia University.
DECLARATION.
I, Oduor Sylvia Akinyi, hereby declare that this training report is my original work and has
not been submitted before for any academic award either in this or other institution of higher
learning for academic publication or any other purpose. The references used here from other
journals or materials are indicated in the references section.

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ACKNOWLEDGEMENT.
This report came into being due to the enabling roles played by various individuals. First I
would like to thank God for keeping me alive and enabling me to complete this report
successfully. Much regards to my supervisor Dr. Enos Barasa for his professional guidance
and support throughout the study. I also wish to pay gratitude to my field supervisor Esther
Njihia and the entire SWOP fraternity for improving my skills and their relentless guidance
and support.

My special thanks goes to my entire family, my parents for their moral and financial support
and my siblings for their words of encouragement. May the Lord Almighty bless and reward
you abundantly.

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DEDICATION.
This work is dedicated to the Almighty God who enabled me to be in a position to carry on
with my study by granting me good health throughout. I also dedicate this work to my parents
Mr and Mrs Oduor for their moral support and continuous belief in me.

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 ABSTRACT
SWOP is an indigenous organization that was founded in 2013 through collaborative synergy
between staff and community beneficiaries following successful implementation of sexual
and reproductive health research under the University of Manitoba. With a mission of
attaining a healthy, stigma free and economically empowered community, SWOP prioritizes
community driven solutions in responding to the health and social needs of marginalized and
vulnerable populations. The program is an embodiment of the core values of community
engagement, meaningful partnerships and collaborations with multilevel and multi- sectorial
stakeholders and capacity strengthening of communities. SWOP offers comprehensive
HIV/STI prevention and treatment services, with a key focus on a human’s rights approach
that emphasizes on the involvement and empowerment of disproportionately affected
populations such the adolescent girls and young women, key populations and vulnerable
populations. This report gives a detailed background information about SWOP, its
organizational structure and its policies and objectives making up the first chapter. The
second chapter proceeds to give a description of the activities undertaken while at the facility
during the practicum period, skills learned and closes up with the professional and
institutional challenges faced. The last chapter bears the conclusion then followed by the
recommendations which mark the end of the report

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Table of Contents
DECLARATION.......................................................................................................................ii

ACKNOWLEDGEMENT........................................................................................................iii

DEDICATION..........................................................................................................................iv

ABSTRACT...............................................................................................................................v

ACCRONYMS AND ABBREVIATIONS..............................................................................vi

CHAPTER ONE........................................................................................................................1

INTRODUCTION......................................................................................................................1

BACKGROUND INFORMATION ABOUT S.W.O.P.........................................................1

ORGANIZATIONAL STRUCTURE AND DESCRIPTION...............................................3

POLICIES AND OBJECTIVES OF THE ORGANISATION..............................................5

CHAPTER TWO.......................................................................................................................6

ATTACHMENT ENGAGEMENT...........................................................................................6

CHAPTER THREE..................................................................................................................12

SUMMARY OF ATTACHMENT..........................................................................................12

REFERENCES.........................................................................................................................14

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ACCRONYMS AND ABBREVIATIONS.
AIDS- Acquired Immunodeficiency Syndrome

ART- Antiretroviral therapy

ARV-Antiretroviral

CBD-Central Business District

CDC- Centers for Disease Control and Prevention

CIDA- Controversies in Dialysis Access.

CIHR- Canadian Institutes of Health Research

FSW- Female Sex Worker

GoK- Government of Kenya

HCW- Health Care Worker

HIV- Human Immunodeficiency Virus

IDRC- Infectious Diseases Research Collaboration

KP- Key population

MoH- Ministry of Health

MSM- Men having sex with men

NGO- Non-governmental organisation.

NIH- National Institutes of Health

PEP- Post Exposure Prophylaxis

PEPFAR- U.S. President’s Emergency Plan for AIDS Relief.

PHDA- Partners of Health and Development in Africa

PLWH- People Living with HIV

PrEP- Pre-exposure Prophylaxis

STI- Sexually Transmitted Illness

SWOP- Sex Workers’ Outreach Program

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TB- Tuberculosis

UoM- University of Manitoba

UoN- University of Nairobi

USAID- United States Agency for International Development

USG- United States Grant

VCT- Voluntary Counselling and Testing

VMMC- Voluntary Medical Male Circumcision.

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 CHAPTER ONE

INTRODUCTION
BACKGROUND INFORMATION ABOUT S.W.O.P.
Partners for Health and Development in Africa (PHDA), The University of Manitoba (UoM)
and University of Nairobi (UoN) collaborative research group has been working in Kenya
since 1983 under the name Kenya AIDS Control Project (KACP). In January 2013, the UoM
then registered an international NGO in Kenya to help facilitate expansion of its research
portfolio, scale up the available educational and capacity building opportunities and to
enhance its contribution to international development. This NGO; PHDA has since then
inherited all UoM supported in Kenya.

From the beginning, the UoM now PHDA, has been working with key populations
specifically low socio-economic strata female sex workers residing in the informal
settlements of Nairobi County. The group has been championing HIV prevention and health
rights for FSW’s in Kenya despite the unfavourable legal framework since the early 80’s. Use
of peer leaders and peer led networks in community engagement and demand creation for the
services on offer has been a key strategy in working with this high risk population. Capacity
building through hands on field training to new physicians, nurses and laboratory scientists
from Kenya, U.S.A and Canada in the epidemiology and immune-biology of STI/HIV has
also been a hallmark for the team. The group has therefore been generating data over the past
three decades that continues to influence HIV/AIDS management and policy formulation in
Kenya and the region.

From 1983 to 2004, the research team relied wholly on multiple grants derived from assorted
sources such as NIH, IDRC, CIDA, CIHR, Bill and Melinda Gates Foundation. However, in
2005, the group successfully applied for the newly launched program grants from USG-
PEPFAR. This was a great move as the grant was able to provide the required support for
core costs and expansion of services. This CDC PEPFAR grant no. U62/CCU024510-05
awarded through UoM helped in the scaling up of HIV/AIDS prevention, care and treatment
activities with KP’s. The overall goal of this scaled up program has been the reduction in the
number of new HIV infections in both these populations and the people with whom they
come in contact, including sexual partners, children and other members of the local
population. These activities primarily involved mobilizing Nairobi and environs based male
and FSWs, their family members and friends through peer led networks. The initial grant in
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2005 saw the expansion of the program clinics from three to five and was renewed in 2010.
Funds from the later grant has witnessed further expansion of the program reach to seven sex
workers’ dedicated facilities which is S.W.O.P Clinics based in Kawangware, Donholm,
Lang’ata, City (C.B.D), Majengo, Kariobangi and

Implementation of this program by PHDA which is now in its fourth year has been largely
successful. Over 1000 sex worker peer educators have been trained to help with the
community engagement and demand creation efforts, 15 trained as members of a community
advisory board and at least 25000 FSW’S and 1000 MSM’s enrolled in the seven sex workers
dedicated clinics across Nairobi. A significant reduction in HIV incidence has been noted
among FSWs and more efforts now geared towards the MSMs. All those enrolled in the
program clinics currently access a comprehensive HIV prevention treatment and care
package as per the MoH guidelines.

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 ORGANIZATIONAL STRUCTURE AND DESCRIPTION.

RECEPTION
ROOM 1

ROOM 2
COUNSELLING AND TRIAGE
TESTING

ROOM 4 ROOM 3

DOCTOR’S ROOM
PHARMACY
SISTER TO
R
SISTER
ROOM 5

EXIT

RECEPTION: This is where the client is first ushered in the clinic, both new and regular
clients. Here, information pertaining to a particular client is retrieved via a particular unique
identification number that each client is given when they first visit the clinic. With this easy
retrieval of the patient’s file, the receptionist is able to identify the services the client has
come for such as a general clinic visit or ARV pickup.

TRIAGE: This word is derived from a French term ‘trier’, which means to sort or prioritise.
This seemingly simple act of setting the patient’(s) priority level, where the most critical are
treated first. The clients’ blood pressure is checked together with their BMI in order to
ascertain they are not obese or have any other health issues different from what is known and
has been identified by the clinician.

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DOCTOR’S ROOM: Thorough examination takes place in this room as the patient explain
how they feel to the doctor in charge who will in turn may order for laboratory tests if need
be for such issues as Tuberculosis that require such expertise or may prescribe drugs for such
minor issue as common cold.

COUNSELLING AND TESTING/ SISTER TO SISTER: For new clients and regular
clients who are FSW’s but tested negative on the first testing are always scheduled to VCT
after every three months. Prior to this, the clients are provided with sufficient and reliable
information in relation to HIV/AIDS awareness and its spread in order to enable informed
consent as they are allowed to opt out of being tested if they do not want the test performed.
All counselling and testing is always accompanied by information prevention of future
transmission of HIV whether the patient is infected or not.

After having been provided with sufficient information and the client has consented to testing
and the results have come out negative, she is advised to take on PrEP because sex work
exposes them to a higher risk of contracting HIV given that condoms do not provide enough
protection. Those who test positive are referred to the sister to sister room for further
counselling.

Sister-to-sister is a one on one Evidence Based Intervention (EBI) that targets HIV+ women
with the knowledge, belief, motivation, confidence and skills necessary to help them make
behavioural changes that will reduce their risks of STI/HIV infection. The nurse, health
educators or other professional clinic staff using an implementation manual. They are also
advised on starting ART as early as possible without defaulting to help manage their
condition so that the virus is suppressed which may translate to U=U
(Undetectable=Untransmittable).

PHARMACY: This is where prescribed drugs are dispensed to the clients including ARV’s
and after which the client leaves the facility until the next appointment.

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POLICIES AND OBJECTIVES OF THE ORGANISATION.
S.W.O.P under PHDA is guided by the following set of objectives;
 To provide HIV Prevention services to over 50000 FSW’s and over 3000 MSM’s
within Nairobi County and its environs. These services include outreach activities
where it involves fishing out the sex workers from their hotspots such as bars and
clubs, peer education and promotion, demonstration and distribution of condoms
and lubricants.
 To provide comprehensive and coordinated HIV primary care and treatment
services to HIV- positive adults, adolescents and children by offering services
such as patient education, free HIV counselling and testing nutrition services and
facilitate referrals for substance abuse, treatment and special medical care.
 To provide support to the KP’s access to alternative livelihoods by providing
training and supporting income generating activities. The community training and
involvement is offered through advocacy, sister to sister and peer educator.
 To reduce HIV incidence in Kenya by expanding Adolescent Voluntary Male
Circumcisions, introducing Early Infant Male Circumcision and increasing the
focus on program safety. The main goal of this project is to support the GoK in
implementing the second phase of VMMC programme, which aims to sustain the
gains achieved from the first phase of the programme through improved
governance, capacity strengthening and resource mobilization.
 To disseminate best practice on KP’s programming for replication by other
partners.
 To generate strategic information that contributes to development on national KP
tools, guidelines and policies.

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 CHAPTER TWO

ATTACHMENT ENGAGEMENT
2.1. ACTIVITIES DURING THE PRACTICUM PERIOD.

Client Registry.

This is a daily based activity that takes place at the reception area of the clinic. Involves
retrieval of clients file using their unique identification number after their fingerprints have
been verified by the biometrics system which then makes them able to proceed to receive the
services they came for.

Enrolment of new clients also takes place in this area. New FSW’s or MSM’s are asked a
series of questions that pertains to the nature of their work such as reasons for taking up sex
work, knowledge on HIV/AIDS transmission and prevention. As long as he/she is having
transactional sex, the person is considered a KP and is therefore enrolled into the system in
order to receive care. Consequently, the client is given his/her unique identification number
and enrolled using the biometrics system and officially becomes a SWOP member.

Disclosure Meetings.

Disclosure in this sense is defined as the process of revealing a person’s HIV status, mainly
positive, among patients and their families and support structures is a critically important
component of the care and treatment cascade. The process of disclosure is usually complex,
emotionally and socially as patients frequently experience uncertainty in revealing their
positive status to either spouse, children, friends or family as a whole, which stems from fears
of negative consequences such as psychological which may include inability to comprehend
and deal with the diagnosis and stigma.

Disclosure has been beneficial towards aiding in the care and treatment of HIV as there is
improved adherence among patients making them less likely to experience disease
progression and death, reports of less frustration with taking medication as disclosure is seen
as a motivating factor, improved self -esteem and eventual acceptance of diagnosis.

This process is not always done on a one time visit and hence is done under the
following interventions: HCW or counsellor should ensure a private counselling
room is available, block off a designated uninterrupted amount of time, should
ensure the client is fully available to avoid the conversation being cut off and the

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counsellor should also emphasize confidentiality and engage the patient in a
‘partnership’ based on confidence, privacy and trust.

Multidisciplinary Team sessions (MDT).

PLWH’s may benefit from multidisciplinary care models to help them achieve optimal health
outcomes. MDTs use a team-based approach to care that consists of two or more
professionals from different but complementary disciplines who have specific roles, perform
interdependent tasks and share a common goal.

The MDT at SWOP comprises if the following professionals and their role:

Pharmacist: Develops a medical plan and answer questions about drug safety and side
effects. Offer vaccines including the flu shot which people with HIV need every year.

Mental Health Provider: Mostly comprises of a counsellor who offers emotional and
psychological support and suggest ways to treat mental health disorders as data reveals that
about 6 in 10 PLWH’s have depression and most of them are women.

Social worker-Helps take care of any concerns the client may have while living with HIV.
Offers support and teaches ways to handle issues such as stigma sometimes called patient
navigators.

Nurse- Basically prescribes the medicines one needs such as ARV to control the HIV virus
or any other underlying illness such as common cold. Generally concerned with the general
body health of client.

Community Outreach Services.

These services at SWOP are commonly referred to as community –led outreach which is
where a trained sex worker (peer educator) ensures that the prevention and care needs of a
defined group of individual sex workers are met. This is an essential link between the
community and the HIV prevention, care and treatment offered by a programme. It empowers
sex workers to draw on the knowledge of vulnerability and risk to problem-solve with
members of their community, strengthening access to services and making HIV prevention,
care and treatment viable. Community outreach workers’ build a rapport with other sex
workers, understand their needs as individuals and on a regular basis link them to the clinic
for high-quality services.

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This is always done in the company of a clinician and the counsellor for free VCT services
and basic sex education on safe sex practices such as condom use. These outreaches were
mostly conducted on high risk hotspots of the FSW’s such as in Ng’ando and Kawangware.

Continuous Medical Education (C.M.E)

These sessions are held regularly within the facility on every two weeks basis that helps
everyone in the clinic be informed on the arising issues and how to handle them. For instance,
a session on commodity management helped in understanding how to properly make use of
the commodities supplied to the clinic such as drugs so that the clinic does not run short of or
orders a certain drug in excess which will eventually go to waste due to expiration. Also a
training on Tuberculosis Preventive Therapy aided in understanding the various types of TB,
the risk population such as those with HIV due to suppressed immunity early signs such as
persistent dry cough and profuse sweating at night and also how it can be managed if it is
diagnosed early.

Group facilitations.

Held regularly within the premise of the clinic and its major goal is to help clients get
informed, basically a life skills session that is mainly spearheaded by the peer educators who
are also FSW’s and are considered influential within their areas of work thus makes it easier
to communicate with the rest.

Peer educators work hand in hand with the counsellor all the time and sometimes with the
clinician when biological matters are involved that need medical explanation. Group
facilitations carry a range of topics such as HIV awareness and transmission, safe sex
practices such as condom use and demonstration, family planning, stigma among PLWH’s,
disclosure, PrEP and PEP among others.

Follow- up sessions.

Performed by the counsellor and it involves tracing of clients, both contact and physical (with
the help of peer educators or treatment partners), who had tested HIV positive at the time
they visited the clinic in order to monitor their psychosocial well-being in terms of
acceptance of status, disclosure to family and friends and also adherence to drug intake.

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2.2. SKILLS LEARNED DURING THE PRACTICUM PERIOD.

Attending.

Basically refers to the ways in which a counsellor can be with their clients both physically
and psychologically. Effective attending helped in telling the clients that I was with them and
they could share their world and also put me in a position to listen carefully to what the
clients are saying.

Active listening.

Conveys the counsellors ability to capture and understand the messages the clients
communicate as they tell their stories, whether the messages are verbal or non- verbal.
Involves the counsellor listening to the mix of experiences of the FSW’s, behaviour and
feelings used to describe the problem situation, listening and interpreting the clients’ non-
verbal expressions in that facial expressions such as smiles may indicate deceit or fear of
telling the truth and general appearance such as grooming and dress.

Probing.

Working with FSW’s can prove to be a hard task as most of them fear opening up due to
stigma and this is where probing comes in handy. This involves a series of questions and
statements from the counsellor that enable sex workers explore more fully any relevant issue
of their lives. Probing helps clients to move forward in the helping process and also help
them understand themselves and their problem situations fully.

Empathy.

This is the ability of the counsellor to recognise and acknowledge the feelings of the client by
temporarily forgetting about their own frame of reference and try to see the client’s world and
understand it then later on relating it to the client how it is. Being empathetic when dealing
with sex workers helps in creating trust and hence they freely open up in matters pressing
them.

2.3. PROFESSIONAL AND INSTITUTIONAL CHALLENGES FACED DURING

PRACTICUM.

Creating rapport.

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This proves to be a far much hard task than ever imagined when it comes to working with sex
workers. This is attributed to the fact that they fear being stigmatized when the society gets to
know what they do for a living since sex work in Kenya is considered illegal. They therefore
develop a wall that blocks anyone into their circle of life and thus it takes quite a number of
sessions for a counsellor to break that wall and gain the client’s trust, and thus allow the
counsellor know what goes about in their lives.

Gender Based Violence.

GBV has since time immemorial been the worst fear of any sex worker because this poses a
threat to their lives. GBV mainly arises after a misunderstanding between the client and the
sex worker may be in terms of payment or use of protection or may just be because the
society has decided to take law into its own hands. Physical GBV includes beating, slapping
or hitting, psychological in terms of stigma, verbal in terms of abuse or one may even be
denied services such as medical attention just because he/she is a sex worker.

SWOP clinic reports at least ten cases of GBV every week and this number is still considered
very high because it should be non-existent. Luckily enough, the clinic liaise with the nearest
police station in handling such matters but the sad news is that many are times the culprits are
left scot free in the name of a lack of evidence. As a result the victim is often left with painful
wounds to nurse or even worse, one dies without getting justice.

Commodity shortage.

SWOP heavily relies on aid from PEPFAR and USAID in order to effectively run the clinic
without mishaps. Unfortunately, many are times commodities are in shortage such as drugs
which are very essential for the clinic thus leaving many patients in pain from untreated
illness or even missed ART on HIV positive patients which may increase their viral load
other than lowering it. Also the facility supplies free condoms and when they are in less
supply many clients contract STI because they find it difficult to buy then because they are
used to be given free.

Substance use and addiction.

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Majority of the sex workers at SWOP admit to having a history or are currently using drugs
such as bhang’, alcohol, cigarettes and miraa. It is claimed that alcohol use by sex workers is
majorly for self-medication to help mask some of the negative feelings associated with sex
work, including distress and anxiety. This is a major institutional problem because when
under the influence of alcohol, a sex worker may engage in sex without use of protection or
even worse may be raped and cane lead to contracting HIV thereby raising the bar. Also
sharing of needles when using drugs such as heroine can also lead to HIV contraction.

This becomes a burden to the clinic because the number of HIV positive cases keep on rising
daily and with the limited access to ART, most of them end up not receiving care and
eventually die.

Anxiety.

Dealing with sex workers for the first time brought about feelings of tension and worries and
thoughts. This is because one is uncertain of what to really expect from such people and also
drives in some fear towards them because of the way so society deems them as being violent
and so vulgar. As many of the sex workers may live to justify this statement, a minority of
them are actually very gentle and so respectful in terms of their language and dressing and
would not qualify as a sex worker at first sight

CHAPTER THREE

SUMMARY OF ATTACHMENT.
3.1. CONCLUSION.

There has been an extensive body of research suggesting FSW’s are a vulnerable population
that experience immense amounts of stigma. They are labelled as ‘others’ by the public
because of the type of work they pursue, and close to half of the Kenyan public continues to
see FSW’s as a public nuisance. The criminalization of sex work has entrenched stigma, and

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been shown to foster unsafe and isolated working environments. Sex work has been classified
as one of the riskiest occupations with respect to violence but also in terms of experiencing
higher rates of addiction and poor health outcomes like HIV/AIDS. Though the SWOP
initiative, sex workers have been able to be more health conscious as a result of being
informed on HIV/AIDS. Also those living with HIV have also been able to take up life more
positively and working towards bettering their future despite being infected. This has really
helped in reducing the rate at which HIV is spread especially as a result of sex work and
substance use.

3.2. RECOMMENDATIONS.

PrEP Sensitization.

Refers to Pre-exposure Prophylaxis which is a new HIV prevention method introduced in

2016, which uses ARV’s to protect HIV negative people from acquiring HIV before potential
exposure to the virus and is considered to be 90% effective.

PrEP works by building a protective layer around the body cells thus reducing the risk of HIV
infection in case of unprotected sex and for this to happen it should be taken consistently
every day. However, it does not prevent against STI’s and pregnancies hence other methods
such as condom use can be considered.

HIV Counselling and Testing to sex workers.

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The WHO recommends at least annual voluntary testing for sex workers. This will help them
get informed of their status and how to protect themselves while at work with the help of peer
educators in helping to locate them.

Access to ART.

The recommendation by UNAIDS is that ART coverage must reach approximately 80% of
sex workers, accompanied by increased condom use, in order to have a significant impact
upon the global HIV epidemic. Availing ARV’s to every health facility in sustainable
quantities will help ensure that every sex worker has unlimited access to them without fear of
missing out and eventually becoming a defaulter.

Addressing stigma and discrimination.

Projects such as the Global Network of Sex Work Projects should be on the frontline in
amplifying the voices of similar organisations in order to advocate for rights- based services,
freedom from abuse and discrimination. Consequently, they should vouch for respect to all
sex workers just by the virtue of them being human.

Sex education.

Sex should no longer be viewed as a taboo and therefore should be discussed openly in order
to transmit knowledge to the young generation most especially in schools. They should be
taught on effective condom use if they must indulge in sex, HIV awareness and transmission
should also be included to allow for sound decision- making.

REFERENCES.
1. Available at www.unaids.org/global/report/default.htm
2. Available at www.swopkenya.org-About-us-swopkenya

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