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HIV and AIDS in Kenya
Kenya has the fourth-largest HIV epidemic in the world. In 2012, an estimated 1.6 million people were living with HIV, and roughly 57,000 people died from AIDS-related illnesses. 1 Moreover, there are now 1.1 million orphans to the epidemic. 2
The first case of HIV in Kenya was detected in 1984, and by the mid 1990s it was one of the major causes of mortality in the country putting huge demands on the healthcare system as well as the economy. HIV prevalence peaked at 10.5 percent in 1996. By 2012, this had fallen to 6.1 percent due mainly to the rapid scaling up of antiretroviral treatment (ART). 3
Key affected groups
However, in recent years, a number of studies have identified concentrated epidemics among certain groups who are particularly vulnerable to HIV transmission.
Men who have sex with men (MSM) and HIV in Kenya
HIV prevalence among men who have sex with men (MSM) in Kenya is almost three times that among the general population. In 2010, HIV prevalence among MSM was an estimated 18.2 percent. 4 In the city of Mombasa, one study found that up to 24.5 percent of MSM were living with HIV. 5
Condom use among MSM is fairly low but has been on the increase. In 2013, an estimated 69 percent of MSM reported using a condom the last time they had anal sex (which has a much higher risk of HIV transmission than vaginal sex), up from 55 percent in 2011. 6
Sexual relations between men are illegal in Kenya and can carry a prison sentence of up to 21 years. Homosexuality is "largely considered to be taboo and repugnant to [the] cultural values and morality" of Kenya. 7 This stance leads to high levels of stigma and discrimination towards MSM as well as other members of the lesbian, gay, bi-sexual and transgender community (LGBT), deterring many people from seeking the HIV services they need.
Moreover, it has been reported that these attitudes have lead to members of the LGBT community being harassed by state officials and held in 'remand houses' without being informed of the charges against them and even brought to court on false charges. Corrupt police have also extorted and blackmailed LGBT people with the threat of arrest and imprisonment. 8
Despite this, a number of organisations such as the Kenya Human Rights Commission work to protect and improve the rights of the LGBT community in Kenya.
People who inject drugs (PWID) and HIV in Kenya
In 2011, an estimated 18.3 percent of people who inject drugs (PWID) in Kenya were living with HIV. 9 The majority of PWID are concentrated in specific geographical areas such as Nairobi and Mombasa. 10
One study found that 3.8 percent of new HIV infections occur among PWID. In the capital Nairobi, this rises to 5.8 percent. 11 Condom use and safe injecting practices are very low among this group (29.8 percent and 51.6 percent respectively) and predominantely responsible for high rates of HIV transmission. 12
Sex workers and HIV in Kenya
Female sex workers (FSW) have the highest reported HIV prevalence of any group in Kenya. In 2011, an estimated 29.3 percent of FSW were living with HIV. 13 By comparison, data from the Sex Workers Outreach Program (SWOP 2011) showed an HIV prevalence of 30 percent among FSW and 40 percent among male sex workers on enrolment. 14
The 2009 Modes of Transmission Study (MOT) reported that 14 percent of new HIV infections occurred among FSW and their clients. However, FSW are reportedly better at protecting themselves from HIV transmission compared to groups such as MSM and PWID. 86 percent of FSW have reported using a condom with their most recent client. 15
Women and HIV in Kenya
Although HIV prevalence among the general population has fallen in Kenya, women continue to be disproportionately affected by the epidemic. In 2012, 6.9 percent of women were living with HIV compared with 4.2 percent of men. 16 Young women (aged 15-24) are almost three times as likely to be living with HIV than men of the same age (3 percent and 1.1 percent respectively). However, HIV prevalence among young women has almost halved since 2003, showing that progress is being made. 17
Like in many parts of sub-Saharan Africa, women and girls in Kenya face discrimination in terms of access to education, employment and healthcare. As a result, men often dominate sexual relationships with women not always able to practice safer sex even when they know the risks.
Young women in Kenya are three times as likely to be exposed to sexual violence than young men. 18 They are forced into early marriage and often unable to negotiate safe sex. 19 Young women also have a lower level of HIV knowledge than young men in Kenya. One study found that only 47.5 percent of young women could correctly identify ways of preventing sexual transmission of HIV and reject misconceptions about HIV transmission compared to 54.9 percent of young men. 20
HIV testing and counselling (HTC) in Kenya
In recent years, HIV testing and counselling (HTC) has been a major feature of the HIV response in Kenya. The country has adopted a number of strategies including provider initiated testing and counselling (PCT), outreach testing and counselling, home-based testing and counselling (HBT) as well as the integration of HTC in antenatal care, sexually transmitted infections (STI) and sexual and reproductive health services. 21
As a result, there has been dramatic progress in terms of the number of people getting tested for HIV. In 2000, there were just 3 voluntary counselling and testing (VCT) sites in Kenya; by 2010 there were over 4000. In 2008, 860,000 people were being tested annually for HIV, by 2013; this had increased to 6.4 million. 22
Though annual testing rates have increased, there remains a significant disparity between men and women. In 2008/9, 22.8 percent of men and 29.3 percent of women aged 15-49 reported having an HIV test in the previous 12 months. 23 In 2012, 35.8 percent of men had a HIV test in the previous year compared with 47.3 percent of women. 24 As a result, there has been a concerted effort to increase testing rates among Kenyan men with community-based testing programmes proving successful in particular. 25
Like HTC coverage among the general population, testing rates among pregnant women have risen substantially. From 2009 to 2013, the percentage of pregnant women tested for HIV increased from 68 percent to 92 percent. 26
As a result, in 2012, nearly half of all Kenyans living with HIV were aware of their status (47 percent) - up from 16 percent in 2007. 27 However, an unacceptable number of people in Kenya still do not know their HIV status.
HIV prevention in Kenya
Kenya is widely regarded as one of sub-Saharan Africa’s success stories where HIV prevention is concerned. Annual new HIV infections are roughly one third of what they were at the peak of the country's epidemic in 1993. 28 In 2012, there were an estimated 100,000 new HIV infections in Kenya. 29
The National AIDS Control Council (NACC) is the body responsible for coordinating the multi-sectoral response to the HIV epidemic in Kenya. Most recently, HIV prevention efforts in the country have centred on the Kenya National AIDS Strategic Plan 2009/10-2012/13 (KNASP III) developed in 2009 following the Modes of Transmission Study, which identified key drivers of new infections and the groups most vulnerable to HIV transmission.
The plan aimed to coordinate a comprehensive combination of HIV prevention, treatment, care and support services in Kenya. KNASP III had four main targets:
- Reduce the number of new HIV infections by 50 percent
- Reduce the number of AIDS-related deaths by 25 percent
- Reduce HIV-related morbidity
- Reduce the socioeconomic impact of HIV and AIDS at both household and community level 30
NACC is currently in the process of reviewing KNASP III and laying the groundwork for KNASP IV. KNASP IV aims to implement HIV prevention initiatives that reflect the evolving epidemic in Kenya shifting from "crisis management" to "strategic and sustainable". 31 Specifically, it aims to assess the efficiency and effectiveness of HIV programmes and to better understand the social drivers of HIV transmission in Kenya. 32
Condom distribution and use in Kenya
The Kenyan government has only actively promoted the use of condoms since 2001, and in that year, announced intentions to import 300 million condoms by the end of 2002. 33 Since then, condom distribution has been scaled up rapidly. In 2004, 10 million condoms were being distributed annually; by 2013 this had increased to 180 million. 34 35
However, many people still find condoms difficult to acquire. For example, one report from rural northern Kenya showed how men could only afford to use condoms once, and due to a shortage in supply, would often wash condoms and hang them out to dry for reuse, or use plastic bags and cloth rags instead:
“Many rural areas in the country are inaccessible due to the poor road network and this makes distribution of condoms difficult and challenging…because government condoms are mostly made available at health facilities and there are not many in rural areas, this creates another challenge in distribution.” - Peter Cherutich, Head of Prevention, NASCOP 36
Even where condoms are widely available, this does not guarantee their use. The 2008-09 Kenya Demographic and Health Survey revealed that in the previous 12 months, only 32 percent of women and 37 percent of men reported using a condom. 37 By contrast, a 2011 study from Kilifi district found that only 23 percent of sexually active adults had used a condom in the previous 12 months. 38
Preventing mother-to-child transmission (PMTCT) in Kenya
Kenya is committed to eliminating the mother-to-child transmission (MTCT) of HIV by 2015. Key strategies to prevent the mother-to-child transmission (PMTCT) of HIV include efforts to increase knowledge of PMTCT, greater male involvement in PMTCT, universal attendance of pregnant women at antenatal clinics, universal uptake of HIV testing among pregnant women, as well as the provision of antiretroviral drugs (ARVs). 39 Indeed, in recent years, PMTCT efforts in Kenya have expanded rapidly.
From 2008 to 2013, 58,000 women annually were offered PMTCT services, out of an estimated 79,000 (76 percent coverage). Between 2010 and 2013, PMTCT coverage actually fell from 86 percent to 70 percent; however, this was due mainly to an increase in demand for PMTCT services. 40
In 2009, the Kenyan government emphasised the importance of male involvement in PMTCT, and in 2010 started a campaign to encourage partner testing, exclusive breastfeeding and the delivery of ART to children. 41 42 From 2010 to 2013, the percentage of women and their infants given ARVs during breastfeeding to prevent HIV transmission via this route increased from 65 percent to 70.6 percent. By comparison, male involvement in PMTCT remains very low in Kenya (4.5 percent). 43
Voluntary medical male circumcision (VMMC) in Kenya
In light of substantial evidence showing that male circumcision significantly reduces a man's risk of acquiring HIV during sex, in 2008, Kenya implemented the VMMC for HIV Prevention programme. The programme aimed to circumcise 860,000 males aged 15-49 by 2013 to achieve universal coverage (80 percent).
Regions with the highest HIV prevalence among uncircumcised adult males - Nairobi (20.2 percent), Nyanza (17.3 percent), Rift Valley (7 percent) and Western (6.8 percent) were selected as priority regions for the implementation of VMMC. 44
Since then, the number of VMMCs performed annually has increased dramatically from 8,000 in 2008, to 190,000 in 2013. During this period, 670,000 VMMCs were performed, about 77 percent of the original target, with roughly 50 percent of male's aged 15-19 circumcised. 80 percent of all operations were conducted in the Nyanza region. 45
In 2012, a new initiative was introduced to boost the number of men being circumcised annually. It involved handing out vouchers to men who had the procedure, which could be exchanged for money upon attending a follow-up appointment. They were also encouraged to bring a friend who was interested in becoming circumcised. 46
Harm reduction in Kenya
Previously, Kenyan drug laws and government policy did not support harm reduction approaches (such as needles and syringe exchange programmes (NSPs) and opioid substitution therapy (OST)) to prevent HIV transmission among PWID.
In 2011, as part of efforts by the National AIDS Control Council (NACC) to provide free HIV prevention and treatment for PWID, previously disallowed harm reduction methods including needle and syringe exchange programmes (NSPs), and services such as psychosocial support were made available. Opioid substitution therapy (OST) is not banned in Kenya but its availability is limited. As part of the new prevention plan, 12 primary healthcare centres in Mombasa started offering OST. The Kenyan government also announced that, with help from the Global Fund, it would be piloting needle exchange programmes in two public hospitals, one in Nairobi and the other in a coastal city. 47
In June 2012, the Kenyan government announced plans to distribute free needles and syringes to over 50,000 PWID. By the end of the programme, the government aims to have distributed over 8 million needles and syringes nationwide. The programme also aims to improve HIV testing uptake, provide antiretroviral drugs (ARVs) and condoms, as well as medication for people who inject drugs who are co-infected with tuberculosis. 48
Most recently, in 2013, the Ministry of Health in Kenya launched National Guidelines for the Comprehensive Management of Health Risks and Consequences of Drug Use, which aims to provide guidance on improving the effectiveness of NSPs, OST and other prevention programmes. 49
Despite this progress, harm reduction initiatives are still lacking. One report found high HIV prevalence levels among PWID in a number of prisons, with many having no access to NSP or OST services. It also found widespread stigma towards PWID among the general public and healthcare workers. Local NGOs working to implement HIV prevention among PWID were reportedly overstretched and therefore could not provide adequate OST or needle exchange services. 50
Although needles and syringes are available for purchase from many pharmacies and other outlets, many pharmacists remain reluctant to sell them. 51
“If we want to talk about HIV prevention, then we cannot afford to ignore any group…We want to provide needle exchange, methadone for treatment and condoms” - Nicholas Muraguri, National AIDS and STI Control Programme 52
HIV education and awareness
HIV education and awareness is an important component of HIV prevention in Kenya. The Education Sector Policy on HIV and AIDS 2013 aims to develop programmes to enhance HIV prevention, care and support for school pupils as well as education personnel (e.g. teachers). It emphasises that strategies must be gender sensitive with women and girls disproportionately affected by the epidemic. 53
HIV and AIDS education has been part of the school curriculum in Kenya since 2003. As a result, HIV and AIDS awareness is higher than in other countries with serious generalised epidemics. However, the 2008-09 Demographic Health Survey found that only half of all young people (15-24) had comprehensive knowledge about HIV prevention highlighting a need to raise awareness of HIV among youth in Kenya. 54 In many places, the curriculum is underutilised as many teachers feel uncomfortable teaching about what are sensitive issues. 55
Certainly, the provision of HIV and AIDS education does not necessarily equate to lower HIV prevalence. For example, KAIS 2012 reported almost no difference in HIV prevalence between those who had completed primary education (6 percent) and those who had completed secondary education (5.8 percent). In fact, the lowest HIV prevalence was among people without any schooling (3.6 percent). Moreover, HIV prevalence was higher among women than men across all education levels. 56
In contrast, one study among participants from both secondary schools and universities found that while both had very high levels of knowledge, knowledge was significantly higher among university students. This shows that education delivered in the correct way can be an effective means empowering people to protect themselves from HIV. 57
Antiretroviral treatment (ART) in Kenya
In 2003, only 6,000 people living with HIV were accessing ART, by 2013 this had increased to 656,000. Since 2008, the expansion of antiretroviral treatment (ART) services throughout the healthcare system has increased the number of adults on treatment from 64 percent to 80 percent ( universal coverage) as of 2013. 58
As in many other countries, the proportion of children recieving ART is significantly lower. However, the scaling up of paediatric ART has increased coverage from 16 percent to 43 percent in the period 2008-13. These coverage figures are based on the 2009 WHO guidelines. The adoption of 2013 WHO guidelines is likely to reduce ART coverage as more people become eligible for it. 59
In Kenya, up to 60 percent of people with tuberculosis (TB) are co-infected with HIV. 60 Antiretroviral treatment for co-infected individuals has been found to improve patient survival if administered immediately after TB treatment. 61 WHO recommends antiretroviral therapy for all HIV and TB co-infected patients, whatever the stage of HIV progression. However, in Kenya, facilities where dual treatment is available are limited and many of those who require antiretroviral drugs (ARVs) as well as TB treatment are not receiving it. 62
HIV stigma and discrimination in Kenya
Though awareness of HIV and AIDS is comparatively high in Kenya, many people living with HIV face high levels of stigma and discrimination. Stigma and discrimination deter many people living with HIV, particularly vulnerable groups such as MSM, PWID, sex workers and women in Kenya, from seeking vital HIV services. 63
For example, many reports from Kenya have shown how pregnant women often do not test for HIV because they fear stigmatisation from their family or healthcare workers. 64
Accepting attitudes among the general population towards people living with HIV has increased in Kenya, rising from 27 percent to 33 percent among men, and from 39.4 percent to 47 percent among women between 2003 and 2009. However, levels of stigma and discrimination remain too high to foster an environment for a more effective national HIV response. 65
Funding the HIV response in Kenya
A lot of money has been spent in Kenya in recent years to combat HIV, particularly through the scaling up of ART. Between 2009 and 2013, spending on the HIV response in Kenya increased from Kshs63 billion to Kshs72 billion. 66 During this period, external funding from donors accounted for over 70 percent of HIV expenditure. The Kenyan government has contributed to 17 percent of funding with private and household spending making up the remaining 13 percent. Since 2010, government spending has remained stable (at 17 percent) but the actual amount has increased from Kshs8 billion to Kshs13 billion. 67
External funding also increased between 2009 and 2013 from Kshs45 billion to Kshs49 billion. 68 In 2011, Kenya received $517.3 million from PEPFAR to support comprehensive HIV prevention, treatment and care programmes. 69 By 2014, the Global Fund had disbursed over $600 million to Kenya to finance its HIV response. 70
As in many countries, the scaling up of antiretroviral treatment means that spending on HIV treatment and care accounted for the majority of HIV expenditure (52 percent) between 2009 and 2013. Prevention, which includes the provision of HIV testing services accounted for 21 percent. 71
The cost of the HIV response in Kenya is expected to increase by 114 percent between 2010 and 2020 representing a funding gap of $1.75 billion. In order to plug this gap, Kenya has established a High Level Steering Committee for Sustainable Financing, which has proposed the establishment of an HIV and Non-Communicable Diseases Trust Fund to pool additional and private resources. 72
New sources of domestic funding are increasingly important with many funding applications in recent years delayed or refused. Corruption and a lack of transparency in the Kenyan government have deterred major donors from investing, although this situation has improved. Despite this, in 2013, Kenya ranked 136 out of 177 countries in Transparency International's Corruption Perception Index. 73
“Kenya has been receiving money from donors such as the Global Fund, but due to bad governance, the money does not get to the intended persons...we are now glad that we have a functioning government that requires an audit of the funds ” - Henry Rotich, National Treasury Secretary 74
The rivalry between the ministries of Medical Services and Public Health who are both responsible for the management of donor funds as well as accounting issues have also been attributed to the denial of funding applications. 75 76
The future of HIV and AIDS in Kenya
In recent years, Kenya has made huge strides in tackling its HIV epidemic and has been pioneering in the provision of HIV prevention, particularly the implementation of VMMC.
However, current efforts are not reaching all of those who need these services. As a result, concentrated epidemics are emerging among vulnerable groups such as MSM, PWID and sex workers. Prevention initiatives need to target these groups as part of wider efforts to stem the HIV epidemic in Kenya.
Moreover, there are still an unacceptable number of people who do not know their HIV status. The scale up of HTC is vital in order for people to learn their HIV status and be referred onto the appropriate treatment, care and support.
However, in order to get more people in Kenya to test for HIV, as well as an increase in the provision of HIV services, a number of social, cultural and legal barriers need to be overcome which prevent many people, particular those belonging to key affected groups from accessing them.
The cost of combating the HIV response in Kenya is predicted to increase dramatically over the next decade. The Kenyan government needs to work to develop sustainable methods of funding to sustain and scale up existing prevention efforts and to reduce the country's reliance on external funding from international donors.
- HIV and AIDS in sub-Saharan Africa
- Impact of HIV and AIDS in sub-Saharan Africa
- Africa HIV and AIDS Statistics
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