EXPANDING THE EVIDENCE BASE ON COMPREHENSIVE CARE FOR SURVIVORS OF SEXUAL VIOLENCE IN SUB-SAHARAN AFRICA. Completion Report

EXPANDING THE EVIDENCE BASE ON COMPREHENSIVE CARE FOR SURVIVORS OF SEXUAL VIOLENCE IN SUB-SAHARAN AFRICA Cmpletin Reprt Fr the Perid Nvember 2009 December 2013

Expanding the Evidence Base n Cmprehensive Care fr Survivrs f Sexual Vilence in sub-saharan Africa Cmpletin Reprt Fr the Perid Nvember 2009 December 2013 Submitted t: The Swedish-Nrwegian Reginal HIV and AIDS Team fr Africa, Embassy f Sweden, Lusaka Submitted by: The Ppulatin Cuncil, Nairbi May 2014

Table f Cntents Backgrund... 1 Result 1: Best Practices in SGBV service prvisin tested and rigrusly dcumented... 1 Result 2: Suth-Suth TA thrugh a netwrk f implementing partners... 7 Annual netwrk meetings... 7 Partner exchange visits... 8 Facilitating internal netwrking... 9 Website maintenance and hsting... 10 Result 3: Plicy and prgrams influenced thrugh the disseminatin f best practices t key audiences... 10 Reginal Bdies... 11 Natinal and Lcal Bdies... 13 Prgram Challenges... 14 Cnclusin... 14 Appendices... 17 Appendix 1: Reprts and Papers Published and Presented under the Expanding the Evidence Base n Cmprehensive Care fr Survivrs f Sexual Vilence in Sub-Saharan Africa Prgram... 17 Appendix 2: Evidence f Natinal and Lcal Impact Under the Expanding the Evidence Base n Cmprehensive Care fr Survivrs f Sexual Vilence in Sub-Saharan Africa Prgram. 25 i

Backgrund The Expanding the Evidence Base n Cmprehensive Care fr Survivrs f Sexual Vilence in Sub- Saharan Africa prgram was a fur-year agreement between the Swedish-Nrwegian Reginal HIV and AIDS Team fr Africa, Embassy f Sweden, Lusaka ( the S-N Team ), and the Ppulatin Cuncil. Frm 2009 t 2013, the prgram sught t mitigate the impact and incidence f sexual and gender-based vilence (SGBV) in Sub-Saharan Africa by strengthening the capacities f medical, legal, and justice sectrs t care fr survivrs f such vilence. This apprach was intended t serve the S-N Team s larger develpment bjectives f preventing HIV transmissin in Sub-Saharan Africa and prmting the sexual, reprductive and human rights f survivrs acrss the regin. Over this fur-year perid, the prgram aimed t achieve the fllwing results: 1. Best practices in SGBV service prvisin tested and rigrusly dcumented; 2. Suth-Suth technical assistance (TA) prvided thrugh a netwrk f implementing partners; and 3. Plicy and prgrams influenced thrugh the disseminatin f best practices t key audiences. This reprt prvides an verview f the results achieved under this prgram, the impact bserved in regard t natinal and reginal SGBV issues by the cmpletin f the prgram, and the challenges experienced during the prgram perid. Result 1: Best Practices in SGBV service prvisin tested and rigrusly dcumented A netwrk f implementing partners acrss the East and Suthern Africa regin (knwn as the Africa Reginal SGBV Netwrk ) served as the cre f the prgram frm 2009 t 2013. A ttal f six partners were supprted by the prgram t implement individual prjects during this perid, as utlined in Table 1. Table 1: Implementing Partners, 2009-2013 Cuntry Prject Title Implementing partners Imprving the cllectin, dcumentatin, and utilizatin f mediclegal Liverpl VCT, Care and Treatment Kenya evidence in Kenya (LVCT), Kenya Ministry f Health Assessing acceptability and feasibility f screening fr IPV in public Kenyatta Natinal Hspital, Ppulatin health care settings in Kenya Cuncil Malawi Testing feasibility f plice prvisin f emergency cntraceptin Malawi Plice Service, Ministry f Health, Malawi Human Rights Resurce Centre Suth Africa Testing feasibility, impact, and cst-effectiveness f the Zer- Tlerance Village Alliance Mdel Thhyandu Victim Empwerment Prgramme (TVEP) Swaziland Zambia Testing feasibility and effectiveness f a cmprehensive SGBV preventin prject fr in-schl girls in Swaziland; Develping natinal guidelines fr a multisectral respnse Scaling up the Cpperbelt Mdel f Integrated Care (CMIC); Assessing feasibility f imprving PEP access fr sexual vilence survivrs thrugh Zambian Plice Services Swaziland Actin Grup Against Abuse (SWAGAA) Zambia Ministry f Health, Zambia Plice Service, Ppulatin Cuncil 1

Thrugh this structure, six best practices in SGBV service prvisin were tested in 5 cuntries in East and Suthern Africa, with their prcesses and findings rigrusly dcumented. A cmmnality shared by these best practices is their innvatin, cupled with their applicability fr lw-resurce settings which characterize the cntexts in which many survivrs in sub-saharan Africa live. Furthermre, each best practice embraces the eths f the Africa Reginal SGBV Netwrk ( the Netwrk ), which recgnizes that survivrs require access t multi-sectral services, while als acknwledging that it may nt be feasible, apprpriate, r cst-effective t deliver all services in ne lcatin. The best practices are highlighted belw, and detailed reprts dcumenting each f these practices may be accessed here: http://www.svri.rg/ppcuncil.htm. Best Practice #1: Using a lcally-assembled rape kit cupled with a multisectral prvider training mdel t imprve the cllectin, dcumentatin, and utilizatin f medic-legal evidence In partnership with the Kenya Ministry f Health (MH), Liverpl VCT, Care and Treatment (LVCT) implemented t a study fcused n imprving systems fr cllecting, dcumenting, and utilizing medic-legal evidence in Kenya. Prir t this study, rape kits fr facilitating frensic evidence cllectin were nn-existent in public health facilities in Kenya, resulting in inefficient service prvisin fr survivrs f rape during the traumatic pst-rape perid. The intrductin f this rape kit, designed specifically fr lw-resurce settings, served t streamline evidence cllectin and imprve evidence-handling in public health facilities. Prviders frm the medical (dctrs, nurses, clinical fficers, labratry technicians) and justice sectrs (plice fficers statined at Gender Desks, and prsecutrs wh had ever handled rape cases) were jintly trained n frensic examinatin, utilizatin f the rape kit, evidence dcumentatin using natinal pst-rape care and plice medical recrd frms, and n their respnsibility t enlighten survivrs abut the imprtance f having cmpleted frms returned t a plice statin. This jint training f prviders enhanced cmmunicatin between the sectrs and thus enhanced referral linkages as well. Findings frm the evaluatin f this interventin indicated a significant difference between the interventin and cmparisn sites in prvider cmpletin f pst-rape care frms (Chi square 16.45, p=0.000; 95% CI). At endline, interventin site prviders were ver thrice as likely as their cmparisn site peers t have filled ut the plice frm fr survivrs. The cmpletin f bth frms is required fr increasing the likelihd f medic-legal evidence being used in curt. By the endline perid, prviders als perceived that using the rape kit helped t reduce survivr trauma by ensuring that the cllectin f different kinds f frensic evidence ccurred in ne lcatin and with ne prvider. Challenges identified during this study, hwever, included the lack f strage facilities within plice statins fr evidence cllected by bth plice and health care wrkers (particularly, fr survivrs clthing). This infrastructural issue remains a barrier t systematic cllectin f frensic evidence. 2

Best Practice #2: Rutine screening fr the detectin f and respnse t intimate partner vilence (IPV) In cllabratin with Kenyatta Natinal Hspital (KNH), the Ppulatin Cuncil s Kenya implemented and tested a rutine screening interventin in limited-resurce, public health care cntexts, given that evidence is lacking n the utility f rutine IPV screening in healthcare settings in develping cuntries. Prpnents f rutine screening argue it is nw a standard f care in many industrialized cuntries, with research indicating its effectiveness in identifying chrnic cases f dmestic vilence r IPV. Others, hwever, argue that rutine screening may have a negative impact n wmen in envirnments where prviders cannt respnd apprpriately, where privacy and cnfidentiality are nt guaranteed, where referral services and linkages are lacking, and where clients and prviders alike may be unwilling t have the issue addressed. Many f these ptential barriers are presumed, hwever, and had nt been fully tested in health care settings in develping cuntries at the time f this study. The interventin invlved training prviders at KNH t apprpriately screen wmen rutinely fr IPV, and t refer IPVpsitive clients t the n-site GBV clinic fr further care. Study results indicated that 8% f all clients screened (n=1210) reprted experiencing sme frm f IPV. Psychlgical vilence was the mst cmmnly-reprted frm f IPV verall, fllwed by sexual vilence, and, lastly, physical vilence. Tw-thirds f IPV-psitive clients identified by prviders thrugh screening were yuth as defined by the Kenya Natinal Yuth Plicy, 2006 (18-30 years). Prviders demnstrated capacity t screen fr IPV and prvide referrals fr further services. Prviders referred nearly 80% f thse reprting a current experience f IPV t the GBV clinic. Wmen screened at the HIV cmprehensive care center were the mst likely t be psitively screened fr IPV (24%), fllwed by wmen screened at the Yuth Center (17%), and thse screened at the antenatal care center (3%). Resurces t prtect cnfidentiality were perceived as adequate by clients, and client satisfactin with IPV services was high. Referral uptake was relatively lw, hwever, cmpared t the high level f prvider referral. Overall, 40% f thse reprting IPV presented at the GBVRC fr further care after referral. Data analysis shwed that establishing the minimum level f staffing required at GBV clinics during pening hurs, and reminders fr prviders t refer IPV-psitive clients after identifying them culd help t remedy this situatin. Best Practice #3: Decentralizing emergency medical respnses fr rape survivrs t plice (plice prvisin f emergency cntraceptin) Previus research under the Netwrk demnstrated that plice statins are ften the first and nly pint f cntact fr survivrs f rape in the regin. In respnse t this reality, a mdel invlving the prvisin f emergency cntraceptin (EC) by plice t survivrs f SGBV, fllwed by referral t a health facility fr cmprehensive care was develped. The Malawi Plice Service, Ministry f Health (MH), and Malawi Human Rights Resurce 3

Centre (MHHRC) successfully replicated this mdel, further cnfirming its validity as a best practice in SGBV service prvisin in the regin. Findings frm the evaluatin f this interventin indicated that plice effectively prvided EC. Over the life f the interventin, a ttal f 37 dses were administered t qualifying survivrs f sexual assault by plice at the tw plice statins withut any adverse events. Mst survivrs reprting t the hspital fr further care fllwing referral were minrs: 80% that reprted frm January t June 2012 were children aged 18 years and belw. Plice cnsistently prvided referrals fr survivrs that presented at the plice statin, referring 49 cases t the hspital (frm January t June 2012) fr cmprehensive care. Transprtatin frm the plice statins t the hspital was nted as a barrier t referral uptake, hwever. Of the 49 cases referred t the hspital, 13 subsequently sught cmprehensive care. Data frm key infrmant interviews als suggested a tendency t redeply fficers trained in EC prvisin t perfrm ther, cre plice duties, such as public rder management, thus pssibly narrwing access t services fr survivrs. Recmmendatins frm the study included: the need fr SGBV t be better mainstreamed within plice training and services; the need fr child-friendly services t be integrated int all levels f care fr SGBV survivrs; and the need fr cncerted effrts t address transprtatin barriers in rder t enhance the referral prcess between plice and health facilities. Best Practice #4: Decentralizing emergency medical respnses fr rape survivrs t plice (plice prvisin f pst-expsure prphylaxis [PEP]) In cllabratin with the Zambia Ministry f Health and Zambia Plice Services (ZPS), the Ppulatin Cuncil pilted the plice prvisin f a PEP stat dse (3-day starter pack) fr HIV preventin survivrs reprting rape at plice statins, cupled with the referral f these survivrs fr cmprehensive care fr sexual vilence at a health facility. The interventin invlved sensitizing plice fficers n a range f issues relating t sexual vilence, and n PEP and EC prvisin t survivrs, with an emphasis n multi-sectral appraches. Jb aids were als develped t guide fficers in determining PEP eligibility and referral, and cmmunicatin and supply chain systems were established between the MH and district pharmacy units, as well as between the ZPS hspital and the participating plice statins. Results frm the evaluatin f this interventin indicated that: 207 cases f sexual vilence (all females) were reprted at the participating plice statins and plice psts during the prject perid (Nvember 2012 t Octber 2013). Of these, 85% were girls under the age f 16 years, with the mean age f reprt being 13 years. The number f cases reprted t the participating plice statins increased by 56% between the 1 st and 4 th quarters f the prject. 4

Of all cases, 65% (n=135) were reprted within 72 hurs f the incident. Of these, 31 were under 10 years ld and therefre ineligible fr PEP; these girls were referred directly t UTH fr fllw-up care. Plice were able t prvide eligible survivrs with PEP withut any adverse cnsequences 96% f survivrs wh reprted t the plice statins were given a medical referral reprt frm, and 84% (n=173) were referred t the University Teaching Hspital (UTH). Only 2% (n=4) were accmpanied t the hspital by a plice fficer, as stipulated by Zambia s Natinal Guidelines fr the Multidisciplinary Management f Survivrs f GBV Only a quarter f eligible survivrs received PEP. Reasns fr this include the fact that less than half f thse reprting t plice did s during plice fficers fficial wrking hurs. Victim Supprt Unit plice fficers were specifically trained fr the prvisin f PEP, as they are mandated t attend t SGBV survivrs. Hwever, their wrking hurs are limited t the 8 am t 5 pm time perid. Other plausible reasns include: the survivr presented when the plice fficer was n duty but away frm his/her statin; the survivr was already n antiretrviral therapy; the survivr r her family refused PEP; r the incident did nt invlve penetrative sex. This study cnfirmed that Zambian plice fficers can effectively and crrectly prvide SV survivrs with a three-day starter pack f PEP and refer them t health services fr fllwup. Hwever, the study als highlighted issues needed t imprve prgram effectiveness, such as increasing access t PEP at plice statins by mdifying pening hurs; expanding sensitivity training t ther plice fficers (beynd Victim Supprt Unit fficers alne); strengthening management and mnitring systems at plice statins; decentralizing PEP delivery t primary health centers; and strengthening cmmunity-based respnses t sexual vilence cases, and t facilitate PEP access. Best Practice #5: Establishing a Zer-Tlerance Village Alliance against SGBV The Thhyandu Victim Empwerment Prgramme s (TVEP s) Zer Tlerance Village Alliance (ZTVA) mdel invlves mbilizing cmmunities t take a cllective stand against SGBV thrugh educatinal wrkshps, dialgues, and campaigns within cmmunities. Cmmunities that are willing t undertake these activities and that meet certain criteria demnstrating their amenability tward fstering a zer-tlerant envirnment are frmally inducted int the Zer Tlerance Village Alliance during a ceremny that includes a traditinal pledge-taking rite (against SGBV) by traditinal rulers and ther male members f the cmmunity. Fstering such a zer tlerance zne is designed t change scial nrms arund vilence in the cmmunities cncerned, and t address stigma arund SGBV reprting. Results frm the evaluatin f this mdel shwed psitive shifts in knwledge, attitude, and practices fr bth men and wmen acrss 83 independent variables (CI 95%, p-value <0.001). SGBV reprting increased acrss interventin sites during and immediately fllwing the 5

interventin. Data cllected 12 mnths after the interventin revealed a steady decline in rates f SGBV acrss Alliance villages. Best Practice #6: Using a schl-based, cmprehensive SGBV preventin mdel t address vilence against children The Swaziland Actin Grup Against Abuse (SWAGAA) tested a schl-based, Safe Spaces, girls empwerment interventin t help change SGBV knwledge, attitudes, and practices amng in-schl girls in Swaziland; enhance knwledge n ther related health tpics; imprve girls scial assets and leadership skills; and increase girls SGBV reprting. The interventin invlved training yung, female mentrs t lead girls clubs in-schl, which served as safe spaces fr girls t meet, frm friendships, and enhance their SGBV knwledge and self-efficacy arund falling victim t SGBV. An apprpriate, SGBV-fcused curriculum was als develped as part f the interventin. The study findings shwed very high levels f reprted abuse amng in-schl girls in Swaziland: at endline, 34% reprted verbal sexual harassment by classmates; 40% reprted experiencing physical abuse utside schl, and 67% reprted experiencing at least ne frm f SGBV. Study findings als demnstrated significant increases between baseline and endline in: The prprtin f students that reprted ever experiencing any frm f SGBV either at schl r in the cmmunity; Girls scial assets (e.g., having clse friends and cnfidantes, and taking part in extracurricular activities); Psitive changes in the attitudes f students with regard t SGBV in 13 ut f 21 items used t measure these attitudes; Reprting abut being subjected t sexual cmments by fellw students, and awareness abut ther in-schl girls being teased r subjected t verbal sexual harassment; and The prprtin f girls that indicated that they wuld reprt incidents f sexual harassment by a student t teachers, schl principal r the plice. There was, hwever, n significant change in the prprtin f students that wuld reprt incidents f sexual harassment by a teacher. Furthermre, the interventins did nt have any effect n the pssibility that students wuld decline sexual advances frm a student r teacher. The fact that the interventins did nt have any effect n changing the pssibility that students wuld decline sexual advances frm either a teacher r student suggests that the mdel culd be strengthened by incrprating cmpnents aimed at enhancing selfefficacy amng girls. As the mst cmmn perpetratrs f sme kinds f abuse experienced by in-schl girls were fund in the wider cmmunity (strangers, ther persns, male neighburs, male siblings, uncles, and fathers), integrating this tested mdel within the wider cmmunity wuld als be useful. 6

Result 2: Suth-Suth TA thrugh a netwrk f implementing partners The transitin f the initiatives described abve frm pilts t actual best practices required fcused effrts in the frm f technical assistance (TA) between netwrk partners in the glbal Suth between 2009 and 2013. During this perid, the six partner prjects were supprted thrugh Ppulatin Cuncil expertise in areas such as interventin and research design, research prpsal-writing, develpment f data cllectin tls, training f data cllectrs, mnitring f data cllectin, data analysis, reprt-writing, the design f advcacy and cmmunicatin initiatives t prmte the utilizatin f results, and the preparatin f scientific presentatin fr delivery at high-impact reginal and internatinal cnferences. In additin t these effrts, fur key TA activities were built in t the Netwrk t fster peert-peer learning in innvative and engaging ways: annual netwrk meetings, partner exchange visits, the facilitatin f internal netwrking, and the hsting and maintenance f a netwrk website. These activities are described in further detail belw. Annual netwrk meetings On a yearly basis, the Cuncil cnvened partners meetings t review implementatin prgress and prvide a venue fr Suth-Suth technical exchange. When pssible, these meetings were held in cnjunctin with ther reginal r internatinal SGBV events (such as the biennial SVRI Frum and the annual 16 Days f Activism Against Gender Vilence) t increase their impact. Sessin tpics were typically slicited frm partners prir t the meeting t ensure that discussins were directly relevant t partners needs. Issue-fcused sub-grups were als frmed t address special cncerns such as respnding t the needs f child survivrs f SGBV, and new directins fr the netwrk. The annual netwrk meetings als prvided a platfrm fr implementing partners t engage with nn-prject partners. Effrts were made annually t ensure that reginal netwrks (such as SVRI and Raising Vices) and reginal bdies (e.g., the East, Central and Suthern Africa Health Cmmunity, SADC, and UNICEF/ESARO) participated t encurage Suth-Suth exchange n issues such as research and training, cmmunity-based preventin effrts, and adapting reginal SGBV guidelines. An verview f the annual netwrk meetings held during the prject perid is prvided in the Table belw. Links t detailed reprts f each meeting (with the meeting agenda, participants, and prceedings) are als included. 7

Overview f Annual Netwrk Meetings Year Lcatin Objectives # f Participants Meeting Reprt 2011 Feb 7-9 Chisamba, Zambia Facilitate Suth-Suth technical exchanges and infrmatin sharing amng partners 47 http://www.svri.rg/s GBV2011NetwrkMe etingreprt.pdf Expse partners t emerging glbal debates, resurces, and research n SGBV Have partners shwcase and exchange their publicatins, IEC materials, advcacy tls, etc. 2012 June 26-27 Mmbasa, Kenya Facilitate Suth-Suth technical exchanges and infrmatin sharing n the changing landscape f vilence amng partners, dnrs, and ther experts ver the life f the netwrk 31 http://www.svri.rg/s GBVJune2012Annual Meeting.pdf Reflect n the ways in which the netwrk s research is infrming plicy and practice 2013 Dec 4 DC, USA Facilitate Suth-Nrth technical exchanges n SGBV in Africa Build awareness f the netwrk s research and reginal influence, highlight pririties in SGBV research and prgramming in East & Suthern Africa, and fster cllabratins in SGBV amng DC plicy and prgram audiences 54 Frthcming in 2014 as a special editin f a peer-review jurnal (BMC Meeting Abstracts) Partner exchange visits T prmte mre in-depth Suth-Suth technical assistance during the prject perid, partners were als given the pprtunity t request exchange visits with ther partner prjects. This primarily invlved learning visits t partner prject sites, and n-site technical assistance as partners adpted the strategies they bserved during their initial visits. In February 2012, Kenyatta Natinal Hspital had the pprtunity t visit TVEP. As KNH is hme t a ne-stp center (the Gender-Based Vilence Recvery Centre [GBVRC], where implementing partners tested an IPV screening interventin in 2012), KNH used this visit t learn frm TVEP s ne-stp services and systems. The visit deliberately cincided with the ath-taking and village inductin ceremny carried ut by TVEP as a culminatin f their interventin activities. This pwerful ceremny (invlving men such as traditinal rulers and cmmunity leaders) was the end result f an elabrate cmmunity mbilizatin exercise n the part f TVEP. T create awareness abut the GBVRC, KNH engages in cmmunity sensitizatin activities in Kenya. Hwever, the IPV screening acceptability study shwed a need t strengthen these activities in rder t create a higher level f awareness f available 8

SGBV services amng survivrs and the surrunding cmmunities. The visit t TVEP inspired KNH t renew their effrts in this area. In Octber 2012, the Ppulatin Cuncil Zambia Office als paid a learning exchange visit t TVEP. As the wrk f bth rganizatins has invlved the prvisin f PEP t survivrs and engagement with plice, TVEP was cnsidered an apprpriate learning site. A representative frm the Cuncil s Zambia ffice spent time at: TVEP s newest ZTVA cmmunity; TVEP s trauma centers and Help Desks (t better understand the full range f services ffered t survivrs); TVEP s HIV cluster (t learn frm the rganizatin s means f fllwing up n ARV defaulters, and helping them resume treatment); and with TVEP s Access t Justice team (t learn mre abut their fllw-up prcedures with survivrs). As the last partner t be incrprated int the netwrk (and having experienced staff transitins earlier in the year) the Swaziland Actin Grup Against Abuse (SWAGAA) requested a visit t the Ppulatin Cuncil s sites in Nairbi t learn first-hand frm the Cuncil s extensive experience with implementing and adapting safe spaces mdels fr inschl girls. This learning visit was cnducted in Octber 2013 by SWAGAA s new Girls Empwerment Officer in charge f SWAGAA s interventin under the netwrk. During the fur-day visit, SWAGAA had the pprtunity t visit and learn frm 5 Ppulatin Cuncil implementing partners in an urban settlement. The lessns learned frm this visit n mdalities fr sustaining girls clubs, invlving girls mre deeply in running these clubs by themselves, and the rle f financial literacy in mitigating SGBV will be used t strengthen SWAGAA s current prgram. Facilitating internal netwrking Maintaining cmmunicatin amng partners has been ne f the mst challenging aspects f the netwrk. While partners are keen t cntribute during in-persn meetings, participatin in virtual exchanges has been limited, due t time cnstraints and cnnectivity issues. Over the prject perid, internal infrmatin-sharing effrts have primarily cnsisted f direct partner cmmunicatin by prgram staff, including distributing materials, tls, and publicatins. T encurage greater member interactin, a Facebk page was instituted in 2011, t facilitate mre infrmal cmmunicatin. This effrt was nt as successful as hped, due t partners preference fr in-persn engagement. In 2012, the Cuncil started experimenting with Twitter, which is less time-cnsuming, fr enhancing cmmunicatin amng partners. Althugh cmmunicatin via email cntinues t be the preferred methd amng partners, the use f Twitter has served t expand the reach f the netwrk and its resurces. Between 2012 and 2013, the netwrk nearly dubled its number f fllwers (frm 36 t 61), representing a range f lcal, natinal, and internatinal rganizatins arund the wrld. Due t the use f Twitter t create visibility fr the netwrk, the prject directr was als recently recgnized by The Guardian as ne f the Tp 10 Tweeters n Sexuality and Develpment, wh are shaping plicy and practice (http://www.theguardian.cm/glbal-develpment-prfessinalsnetwrk/2014/feb/04/tp-10-tweeters-n-sexuality-and-develpment). 9

Website maintenance and hsting Frm Nvember 2009 t December 2013, the prgram s cllabratin with the Sexual Vilence Research Initiative (SVRI) n the netwrk s website (www.svri.rg/ppcuncil.htm) cntinued t be strategic, high-prfile, and beneficial. Accessible frm the SVRI hmepage, the netwrk s website served as a central repsitry fr partner prducts and ther resurces generated by netwrk partners ver the life f the prgram. As a leading SGBV resurce, the SVRI website als regularly used its internatinal Twitter base t publicize emerging wrk frm the netwrk amng its fllwers. These tweets were als highlighted n SVRI s hmepage. New resurces generated by the prgram were featured n SVRI s influential listserv as well. These effrts played a rle in the number f hits received by the prgram frm year t year (see Figure 1 belw). Furthermre, the netwrk webpage was updated regularly with new dcuments thrughut the prject perid, with nearly 50 psted t date. Figure 1 shws an annual increase in prject page views, apart frm in the year 2013, which was a n-cst extensin year with fewer prject activities. Figure 1: Annual prject website views Result 3: Plicy and prgrams influenced thrugh the disseminatin f best practices t key audiences The ultimate purpse f the prgram was t influence plicy and practice by develping and disseminating a strng, reginally-relevant evidence base in the frm f the best practices described in previus sectins. Althugh best practices can be slw t spread, they tend t d s after a success has been demnstrated. Even then, a lack f knwledge abut current best practices, a lack f mtivatin t make changes invlved in their adptin, and a lack f knwledge and skills required t d s are key barriers t adpting best practices. 1 1 Ruse, M. (2007). Definitin: Best practice. Retrieved frm: http://searchsftwarequality.techtarget.cm/definitin/best-practice. 10

Thus, ver the life f the prgram, Cuncil staff remained actively engaged in reginal and internatinal SGBV dialgues, and widely shared the prgram s evidence (see Appendix 1 fr a detailed list f netwrk presentatins and publicatins). These effrts influenced plicy and prgrams in the regin in myriad ways, as highlighted in this sectin. Reginal Bdies East African Cmmunity The Cuncil actively cllabrated with the East African Cmmunity (EAC) t rganize the first-ever sympsium dedicated specifically t SGBV at the 4 th EAC Health and Scientific Cnference which tk place in Kigali, Rwanda frm March 27-29, 2013. This reginal cnference aimed t cnslidate reginal health pririties and pprtunities amng EAC Member States and partners. The sympsium, entitled Tward a Multi-Sectral and Cmprehensive Respnse t SGBV in East Africa, sught t share emerging lessns frm Phase II f the prgram in rder t stimulate reginal dialgue and actin n the interrelated issues f HIV & AIDS and SGBV thrugh a cmprehensive, multi-sectral, apprach. In additin t EAC Member States, the meeting brught tgether SGBV experts in research, plicy, practice and advcacy; legislatin, health and scial services; and preventin, care and rehabilitatin. In recgnitin f the imprtant wrk carried ut under this prgram, the East African Cmmunity slicited presentatins frm every partner represented in the netwrk. The Cuncil wrked with these implementing partners t ensure they submitted the slicited presentatins, and supprted their attendance f the cnference. The Cuncil als prvided technical assistance t the EAC fr rganizing the sympsium, and made a financial cntributin twards the cnference, ensuring that gvernment fficials frm acrss the regin participated in the sympsium as presenters n SGBV, fr instance. The sympsium culminated in a number f recmmendatins, by attendees, fr reslutins, presented belw: 1. The prvisin, by the EAC Secretariat, f a framewrk fr a multi-sectral respnse t SGBV in the regin 2. Sustained advcacy at natinal and reginal levels t hld Member States accuntable fr resurce allcatin 3. SGBV mainstreaming acrss sectrs 4. Auditing and review f harmful, gender-blind clauses in plicies and laws 5. Male engagement and invlvement in the preventin f, respnse t, SGBV (including SGBV against males) 6. Capacity-building f range f prviders (health, plice, justice, scial services, educatin, etc.) t address the needs f child survivrs f SGBV In 2014, these reslutin recmmendatins will be presented t the relevant sectral Cuncils within the EAC fr cnsideratin. The utcmes f this prcess will then be 11

presented t Ministers f relevant Health, Ministers f Gender, and ther relevant Ministers in the East African Cmmunity. East, Central and Suthern Africa Health Cmmunity The netwrk has had a lng-standing and successful relatinship with the East, Central and Suthern Africa Health Cmmunity (ECSA-HC). As an intergvernmental bdy, ECSA-HC was mandated t fcus n SGBV, including child sexual abuse (CSA), thrugh reslutins at its 2006 and 2009 annual Health Ministers Cnferences. Prject staff actively engaged with ECSA-HC t help peratinalize these reslutins. In 2010, this wrk fcused three prducts: a literature review n child sexual abuse (CSA) in the regin; guidelines fr clinical management f CSA; and a cmprehensive advcacy strategy. The literature review bjectives were: creating understanding f the magnitude and nature f CSA in the ECSA regin; raising awareness abut CSA in the regin; and infrming sectr plicy and prgram respnses, fr preventin and management. The advcacy strategy is intended t: increase awareness and dialgue at all levels abut CSA and its negative cnsequences; advcate fr actin at the natinal level t surpass ratificatin f internatinal rights and treaties and enact and enfrce legislatin n all frms f vilence; advcate fr harmnizatin f laws and prcedures prmting and prtecting children s rights; and increasing reginal, natinal, and lcal resurces (financial, human, material) fr implementing laws, plicies, and prgrams needed fr integrated CSA preventin and respnse. In 2011, the Cuncil prvided supprt t ECSA-HC fr extracting lessns frm its CSA wrk t cmmunicate t the highly-visible, high impact 2011 SVRI Frum. In 2012, ECSA-HC received technical and financial supprt frm the Ppulatin Cuncil t cnvene a meeting f its Member States t help identify and priritize reginal SGBV advcacy cncerns, and develping cuntry-specific SGBV advcacy plans t feed int a cmprehensive, reginal plan. In 2013, the ECSA-HC received further technical and financial supprt t partner with selected Member States (Kenya, Malawi, and Mauritius) in peratinalizing aspects f their advcacy plans. Specifically, ECSA-HC cllabrated with the Kenyan and Malawi gvernments t cnvene ne meeting each, centering n advcacy fr resurce allcatin fr SGBV and CSA by gvernments. Each meeting generated imprtant ideas t encurage resurce allcatin by African gvernments fr SGBV e.g., develpment partners being mre practive by engaging in gvernment budget cycles early n s that SGBV issues are highlighted and budgeted fr; learning lessns frm the strategies used t establish budget lines fr ther reprductive health issues in Kenya and Malawi, such as family planning and HIV and AIDS; and engaging mre clsely with parliamentarians wh can ensure that SGBV/CSA issues are brught t the parliamentary flr fr debate, thus ensuring that these issues gain mre gvernment attentin. ECSA-HC als cllabrated with the Gvernment f Mauritius t cnvene a meeting f stakehlders t advcate fr the integratin f perpetratr rehabilitatin measures int the preventin and management prgrams f the SGBV respnse in Mauritius. A draft strategic framewrk fr the rehabilitatin f the perpetratrs was devised in the curse f this meeting. 12

UNHCR Reginal Supprt Hub Prject staff actively engaged with strategic reginal bdies t strengthen SGBV dialgue and actin in the regin. In 2013, the Cuncil engaged extensively with UNHCR s Reginal Supprt Hub t prmte the utilizatin f prject results amng refugee ppulatins. These effrts led t a cllabrative prject between the Cuncil and UNHCR, cupled with funding frm the MacArthur Fundatin t replicate and test selected netwrk mdels in refugee settings in Uganda (i.e., rutine SGBV screening and the ZTVA mdel). Results frm this initiative are expected t infrm prgramming within UNHCR cuntry ffices and amng UNHCR implementing partners in the regin. UNICEF Eastern and Suthern Africa Reginal Office (ESARO) Recgnizing the Cuncil s thught leadership and the netwrk s cntributins in the area f SGBV, UNICEF ESARO slicited a cmmentary frm the Cuncil fr publicatin in Research Watch a UNICEF publicatin which seeks t share and analyze new research and the views f leading thinkers n critical issues fr children. Prject staff develped a cmmentary n this issue in 2013, drawing n netwrk findings, in rder t generate perspectives and debate n vilence against children and mve the field frward. The published vlume, entitled Vilence against Children What Appraches Wrk?, targeted develpment field staff, decisin-makers and dnrs, and was widely disseminated thrugh UNICEF ffices; the websites f UNICEF partners, the Ppulatin Cuncil, and the SVRI; and media. The cmmentary may be accessed here: http://www.unicef-irc.rg/research-watch/vilenceagainst-children--a-silent-threat/987/, while the cmplete vlume f this Research Watch editin may be accessed here: http://www.unicef-irc.rg/research-watch/vilence-againstchildren--a-silent-threat/cmmentary.html. Wrld Health Organizatin During the prject perid, the Wrld Health Organizatin (WHO) reached ut t prject staff, requesting the Cuncil s participatin in a meeting f researchers n IPV t discuss the current knwledge in the field and t develp strategies fr imprving interventins t reduce IPV amng pregnant wmen in develping cuntries. Prject staff als prvided input int a frthcming WHO Handbk n IPV screening in develping cuntry settings. The draft Handbk currently cites the IPV screening mdel tested under this prgram. Natinal and Lcal Bdies The best practices tested under this prgram had a remarkable influence n natinal and lcal prgramming and plicy, as well as n dnr funding decisins. These prcesses are dcumented in detail in Appendix 2 fr each partner under the netwrk. 13

Prgram Challenges Given its strng fcus n Suth-Suth technical assistance, the prgram was essentially structured t attend t the challenges that wuld nrmally be encuntered in a multicuntry initiative. Cnsequently, many f the challenges experienced by the prgram were viewed as pprtunities t build capacity and were handled as prject activities. The prgram began with the expectatin that partners wuld require technical supprt fr a range f activities. These activities were successfully implemented with technical supprt frm the Ppulatin Cuncil, as described earlier in this reprt. By the end f the prgram, a number f netwrk partners had strengthened their capacity t the pint f being able t build the capacity f ther rganizatins t implement tested interventins, fr instance. The challenge encuntered under the netwrk therefre had mre t d with ensuring the maintenance f a cherent, reginal prgram, despite the varying levels f capacity within varius cuntries represented within the netwrk. The variety f technical assistance appraches used under the netwrk made this pssible. The technical supprt needs f sme reginal bdies als presented a challenge. Althugh reginal bdies may be willing t supprt SGBV-related agendas, experience under the prgram demnstrated that the capacity t rganize this srt f supprt is smetimes lacking due t staffing shrtages r t gaps in technical capacity. The time and effrt required t adequately prvide this kind supprt may have been underestimated, but the prgram allwed prject staff t invest this time and effrt, with several psitive utcmes in the end. Cnclusin Over the years, the Expanding the Evidence Base n Cmprehensive Care fr Survivrs f Sexual Vilence in Sub-Saharan Africa prgram enabled partners in East and Suthern Africa t cllectively test and dcument experiences, develp cst-effective respnses t SGBV, and avid the duplicatin f effrt. Furthermre, the strength f the Africa Reginal SGBV Netwrk gained recgnitin by ther dnrs and partners during the prgram perid. The technical assistance that frms an integral part f the Netwrk apprach (thrugh prpsal and presentatin develpment, remte and n-site supprt fr research and prgrams, partner exchange learning visits, etc.) was a key aspect f the added value brught by the Netwrk apprach. Between the prject cmmencement and end dates, there was heightened interest frm dnrs and reginal bdies in applying and testing aspects f the Netwrk apprach applied in different settings. Discussins with partners and ther stakehlders during the prject perid highlighted several pssibilities fr replicating the current appraches f the netwrk: Reginal replicatin f individual prject mdels that have been successfully tested thrugh the Netwrk in a natinal setting; 14

Replicating hybridized versins f existing Netwrk interventins fr rll-ut acrss cuntries; Replicating a cmmn interventin, based n tested Netwrk respnses that can be pilted reginally; Replicating tested Netwrk respnses amng new ppulatins (e.g., children, refugees) n a reginal level; Replicating certain aspects f the Netwrk apprach reginally (e.g., cmpnents f the Suth-Suth technical assistance mdel t cntinually build capacity and Netwrk strength); and Replicating influencing mdels that Netwrk partners have successfully emplyed t infrm plicy and practice reginally. The dnr interest that became apparent during the prject perid was eventually backed by dnr funding (frm the MacArthur Fundatin) befre the end f the prject perid, geared tward testing netwrk appraches with refugee ppulatins; replicating the Suth- Suth technical assistance mdel t build the capacity f UNHCR implementing partners as well as netwrk strength; and replicating influencing mdels used under the netwrk t infrm prgramming within UNHCR cuntry ffices in the regin. Further funding frm ther dnrs has als been issued at the partner level in sme cuntries, as utlined in Appendix 2. Activities during the 4-year prject perid demnstrated that the face-t-face frms f Suth-Suth interactin characteristic f the Africa Reginal SGBV Netwrk were viewed as being unique, and were f paramunt imprtance t partners. Partners cited myriad examples f being inspired t take actin in their individual cuntries after being affrded undistracted time and space t learn abut ther partners wrk (thrugh annual partner meetings, exchange visits, etc.), and t realize what is dable in their wn settings. In the wrds f ne netwrk partner: There s smething abut interacting with the Netwrk that inspires partners t push fr similar things in their cuntries after they ve cmpared themselves t ther cuntries. There s mre f a hw-t apprach with this Netwrk. It s much mre practical s that partners are able t benchmark themselves against what s happening reginally and it s hard t really d that withut this srt f netwrk structure that we have. Withut this Netwrk, ne tends t think ne is ding enugh, [r that] ne is ding it right. In summary, the exchanges (including technical assistance amng partners, annual partner meetings, partner exchange visits, and ther learning pprtunities) made pssible thrugh the Netwrk s apprach were seen as setting it apart markedly frm ther appraches. The Netwrk apprach has prven t be an efficient, nn-duplicative means f generating a cherent bdy f multi-sectral evidence n SGBV in the regin within a similar time frame. Given the experience garnered by the prgram ver the years, the netwrk is currently cnsidered as a resurce t the regin, with strengths in 1) prviding technical assistance in interventin develpment, research, training, and influencing plicy and practice; 2) 15

replicating respnses t SGBV that have been tested by partners, and 3) testing ut new, innvative respnses t SGBV. 16

Appendices Appendix 1: Reprts and Papers Published and Presented under the Expanding the Evidence Base n Cmprehensive Care fr Survivrs f Sexual Vilence in Sub-Saharan Africa Prgram 2013 Technical Reprts and Published Papers ECSA-HC & Ppulatin Cuncil (2013). Scaling up advcacy fr gender-based vilence and child sexual abuse in the East, Central and Suthern Africa Health regin. Arusha, Tanzania: ECSA-HC. SWAGAA (2013). Effectiveness f a cmprehensive sexual and gender-based vilence preventin prject fr in-schl girls in Swaziland. SWAGAA: Manzini, Swaziland. Thmpsn, J. (2013). Using evidence t make change happen : Strategies and learning frm the Africa Reginal SGBV Netwrk. Nairbi: Ppulatin Cuncil. Thmpsn, J., Undie, C., Askew, I. (2013). Access t emergency cntraceptin and safe abrtin services fr survivrs f rape and defilement in sub-saharan Africa: A reginal verview. Nairbi: Ppulatin Cuncil. Undie, C., Maternwska, M.C., Mak anyeng, M., Askew, I. (2013). Feasibility f rutine screening fr intimate partner vilence in public health care settings in Kenya. Nairbi: Ppulatin Cuncil. Undie, C. (2013). Tward a research agenda n gendered vilence in sub-saharan Africa. Ethnicity and Health 18(5): 449-453. Undie, C. (2013). Why we need t think abut sexuality and sexual Well-being: Addressing sexual vilence in sub-saharan Africa. In (eds.) Andrea Crnwall, Susie Jlly, Kate Hawkins. Wmen, sexuality and the plitical pwer f pleasure. Lndn: Zed Bks. Undie, C., Mullick, S., and Askew, I. (2013). The missing C : Sexual vilence against children in sub-saharan Africa. Research Watch, UNICEF. Zama, M., Price, J., Tpp, S., and Keesbury, J. (2013). Mitigating the cnsequences f sexual vilence in Zambia by decentralizing emergency medical respnses t Plice Victim Supprt Units: Reprt n the feasibility f plice prvisin f PEP fr HIV in Zambia. Lusaka: Ppulatin Cuncil. Cnference Presentatins Undie, C., Mak anyeng, M., Maternwska, C. (2013). Using an IPV screening tl in public health care settings in Kenya: An innvative apprach t imprving the quality f maternal health care. Oral presentatin at the Glbal Maternal Health Cnference, Arusha, Tanzania, January 2013. 17

Mak anyeng, M., Undie, C., Maternwska, C. (2013). A summary f the IPV screening feasibility study, Kenyatta Natinal Hspital. Oral presentatin at the United States Institute f Peace Internatinal Sympsium n The Missing Peace: Sexual Vilence in Cnflict and Pst- Cnflict Settings, Washingtn DC, USA, February 2013. Ajema, C. & Mukma, W. (2013). Imprving the cllectin, dcumentatin, and utilizatin f medic-legal evidence in Kenya. Oral presentatin at the 4 th East African Cmmunity Health and Scientific Cnference, Kigali, Rwanda, March 2013. Denis, M., Zama, M., Price, J. (2013). Assessing the feasibility f imprving access t HIV PEP fr SV survivrs thrugh Zambian Plice Services. Oral presentatin at the 4 th East African Cmmunity Health and Scientific Cnference, Kigali, Rwanda, March 2013. Gawani, C. (2013). Testing the feasibility f plice prvisin f emergency cntraceptin in Malawi. Oral presentatin at the 4 th East African Cmmunity Health and Scientific Cnference, Kigali, Rwanda, March 2013. Katende, M.J. (2013). HIV and AIDS: Reginal perspectives. Oral presentatin at the 4 th East African Cmmunity Health and Scientific Cnference, Kigali, Rwanda, March 2013. Kilnz, N. et al. (2013). Overview f GBV and HIV: Reginal and internatinal perspectives. Keynte speech at the 4 th East African Cmmunity Health and Scientific Cnference, Kigali, Rwanda, March 2013. Mallya, G. & Malaki, B. (2013). Status f SGBV and HIV and AIDS interventins in Tanzania. Oral presentatin at the 4 th East African Cmmunity Health and Scientific Cnference, Kigali, Rwanda, March 2013. Mak anyeng, M., Undie, C., Maternwska, C. (2013). Screening fr intimate partner vilence in public health care settings in Kenya: Lessns frm the East African Regin. Oral presentatin at the 4 th East African Cmmunity Health and Scientific Cnference, Kigali, Rwanda, March 2013. Ministry f Health, Burundi (2013). The status f SGBV and HIV and AIDS interventins in Burundi. Oral presentatin at the 4 th East African Cmmunity Health and Scientific Cnference, Kigali, Rwanda, March 2013. Ministry f Health, Uganda (2013). SGBV and HIV interventins in Uganda. Oral presentatin at the 4 th East African Cmmunity Health and Scientific Cnference, Kigali, Rwanda, March 2013. Ministry f Health, Zanzibar (2013). The status f SGBV and HIV and AIDS interventins in Zanzibar. Oral presentatin at the 4 th East African Cmmunity Health and Scientific Cnference, Kigali, Rwanda, March 2013. Mukasine, C. (2013). GBV and child abuse: A public health issue in Rwanda. Oral presentatin at the 4 th East African Cmmunity Health and Scientific Cnference, Kigali, Rwanda, March 2013. Nyni, N. (2013). Testing the feasibility and effectiveness f a cmprehensive sexual and gender-based vilence preventin prject fr in-schl girls in Swaziland. Oral presentatin at the 4 th East African Cmmunity Health and Scientific Cnference, Kigali, Rwanda, March 2013. Odngi, E. (2013). Sexual and gender-based vilence and HIV and AIDS in Kenya. Oral presentatin at the 4 th East African Cmmunity Health and Scientific Cnference, Kigali, Rwanda, March 2013. 18

Undie, C. (2013). Sympsium n HIV & AIDS and SGBV: Intrductin. Oral presentatin at the 4 th East African Cmmunity Health and Scientific Cnference, Kigali, Rwanda, March 2013. Keke, X. (2013). Lng-term psychscial supprt fr survivrs f sexual vilence: A literature review. Oral presentatin at the 6 th Suth African AIDS Cnference, Durban, Suth Africa, June 2013. Carty, C., Nichlsn, F., et al. (2013). Patriarchal villages in Suth Africa mbilized t break the cycle f endemic and culturally-sanctined human rights abuses: A structured interventin with sustained SGBV impacts. Pster presentatin at the Internatinal AIDS Cnference, Kuala Lumpur, Malaysia, July 2013. Oliel, J. 2013. Sharing experiences n GBV tls used in RH service delivery settings. Oral presentatin at the Gvernment f Mauritius and ECSA Health Cmmunity s Advcating fr integrating the rehabilitatin f perpetratrs int the preventin and management prgrams f SGBV and CSA respnse Meeting, Prt Luis, Mauritius, July 2013. Oliel, J. 2013. Addressing the issue f SGBV perpetratrs in the ECSA regin. Oral presentatin at the Gvernment f Mauritius and ECSA Health Cmmunity s Advcating fr integrating the rehabilitatin f perpetratrs int the preventin and management prgrams f SGBV and CSA respnse Meeting, Prt Luis, Mauritius, July 2013. Ajema, C., Mukma, W. et al. (2013). Utilizatin f a lcally-assembled rape kit in management f sexual vilence in lw-resurce settings. Case study f Kenya. Oral presentatin at the 2013 Sexual Vilence Research Initiative (SVRI) Frum, Bangkk, Thailand, Octber 2013. Carty, C. (2013). Culturally-sanctined SGBV as a driver fr child perpetratin f assault in regins f traditinal leadership in Limpp, Suth Africa. Oral presentatin at the upcming 2013 SVRI Frum, Bangkk, Thailand, Octber 2013. The Thhyandu Victim Empwerment Prgramme (2013). The impact f public athtaking ceremnies n SGBV reprting: Results frm tw traditinal leadership villages in Suth Africa. Oral presentatin at the upcming 2013 SVRI Frum, Bangkk, Thailand, Octber 2013. Thmpsn, J., Undie, C., Askew, I. (2013). Access t emergency cntraceptin and safe abrtin services fr survivrs f rape and defilement in sub-saharan Africa: A reginal verview. Oral presentatin at the 2013 SVRI Frum, Bangkk, Thailand, Octber 2013. Undie, C., Mak anyeng, M., Maternwska, M.C., Askew, I. (2013). Feasibility f rutine screening fr intimate partner vilence in public health care settings in Kenya. Oral presentatin at the 2013 SVRI Frum, Bangkk, Thailand, Octber 2013. Undie, C., Mak anyeng, M., Maternwska, M.C., Askew, I. (2013). Feasibility f rutine screening fr intimate partner vilence in public health care settings in Kenya. Pster presentatin at the 2013 SVRI Frum, Bangkk, Thailand, Octber 2013. Undie, C., Mak anyeng, M., Maternwska, M.C., Askew, I. (2013). Feasibility f rutine screening fr intimate partner vilence at Kenyatta Natinal Hspital. Oral presentatin at Kenyatta Natinal Hspital, Nairbi, Kenya, Octber 2013. Undie, C., Mak anyeng, M., Maternwska, M.C., Askew, I. (2013). Feasibility f rutine screening fr intimate partner vilence in public health care settings. Slicited presentatin at Liverpl VCT, Care, and Treatment, Kenya, Nvember 2013. 19