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HIV & AIDS in Kenya
Kenya is home to one of the world’s harshest HIV and AIDS epidemics. An estimated 1.6 million people are living with HIV, around 1.1 million children have been orphaned by AIDS and in 2011 nearly 62,000 people died from AIDS-related illnesses.1 2
Kenya’s HIV prevalence peaked during the late 1990s and, according to the latest figures, has dramatically reduced to around 6.2 percent.3 This decline is thought to be partially due to an increase in education and awareness, but also from high death rates.4
Whilst many people in Kenya are still not being reached with HIV prevention and treatment services, access to treatment is increasing. 72 percent of adults who need treatment are receiving it, with around 200,000 additional people on treatment in 2011 than in 2009.5 6 Unfortunately, as with many countries, the proportion of eligible children receiving antiretroviral treatment is much lower. This demonstrates that Kenya still has some way to go in providing universal access to HIV treatment, prevention and care.
The current situation in Kenya
Kenya’s HIV epidemic has been categorised as generalised – meaning that HIV affects all sectors of the population, although HIV prevalence tends to differ according to location, gender and age. Nearly half of all new infections in 2008 were transmitted during heterosexual sex whilst in a relationship and 20 percent during casual heterosexual sex.7
Various studies have revealed a high HIV prevalence amongst a number of key affected groups, including sex workers, injecting drug users (IDUs), men who have sex with men (MSM), truck drivers and cross-border mobile populations.8 Some of these groups are marginalised within society – for example, homosexuality is illegal in Kenya and punishable by up to 14 years in prison. Therefore these groups are difficult to reach with HIV prevention, treatment and care, and the extent to which HIV is affecting these groups has not been fully explored.
In 2008, an estimated 3.8 percent of new HIV infections were among IDUs and in the capital, Nairobi, 5.8 percent of new infections were among IDUs.9 HIV infections are easily prevented in healthcare settings, nevertheless, 2.5 percent of new HIV infections in Kenya occur in health facilities.10
Women are disproportionally affected by HIV. In 2008/09 HIV prevalence among women was twice as high as that for men at 8 percent and 4.3 percent respectively. This disparity is even greater in young women aged 15-24 who are four times more likely to become infected with HIV than men of the same age.11 Kenyan women experience high rates of violent sexual contact, which is thought to contribute to the higher prevalence of HIV. In a 2003 nationwide survey, almost half of women reported having experienced violence and a quarter of women aged between 12 and 24 had lost their virginity by force.12
HIV prevalence is generally greater in urban than rural settings in Kenya, although this disparity has become smaller in recent years.13
HIV prevention in Kenya
A principle aim of the 2009/10-2013/14 Kenyan National HIV and AIDS Strategic Plan (KNASP III) is to reduce the number of new HIV infections by using evidence-based approaches to HIV prevention. Six main outcomes are outlined to be achieved in the latest Strategic Plan:
- Reduced risky behaviour among the general, infected, most-at-risk and vulnerable populations.
- Proportion of eligible PLHIV (people living with HIV) on care and treatment increased and sustained.
- Health systems deliver comprehensive HIV services.
- HIV mainstreamed in sector-specific policies and sector strategies.
- Communities and PLHIV networks respond to HIV within their local context.
- KNASP III stakeholders aligned and held accountable for results.
Following a study in 2009 it was identified that the epidemic was changing and that transmission between discordant couples, where one partner is positive and one partner is negative, accounted for the majority of new infections.14 15 16 As a result, prevention for positive people is to be a central element of Kenya’s new approach to prevention which will, among other approaches, include couple-based testing and encourage partner disclosure and condom use.17 18
There is also a distinctly new focus on MARPs (MSM, sex workers and injecting drug users) in the KNASP III, following a national study which highlighted that a third of all new infections are among this group.19
HIV testing has widely expanded across Kenya since the beginning of the millennium. In 2000 there were only three voluntary counselling and testing (VCT) sites nationwide; by 2010 there were 4,438.20 Alongside voluntary testing, provider initiated counselling and testing (PCT) has expanded and is now available in 73 percent of health facilities.21 PCT is when individuals are offered a HIV test whenever they go to a health facility, rather than patients having to ask for a test.22
One of the 2010 targets set in Kenya’s National HIV and AIDS Strategic Plan 2005/06 -2009/10 (KNASP II) was to test 2 million Kenyans for HIV annually.23 In order to reach the target, international development organisations and the Kenyan government introduced a number of new initiatives. One such programme, launched in late 2009, aimed to provide door-to-door HIV testing and counselling for those living in remote areas with little access to health care.24 This scheme raised concerns from Human Rights Watch, who urged the government to ensure principles of counselling, consent and confidentiality would be properly adhered to.25
The government's enhanced focus on testing has been reflected by the percentage of adults aged 15-49 years who report ever being tested for HIV. In 2003 only 15 percent had taken a test compared to 37 percent in 2007.26 Action to improve access to testing facilities and a high-profile media campaign that ran between 2002 and 2005 is thought to have contributed to the increase in HIV testing uptake.27
Increased testing rates have meant that record numbers of Kenyans have been tested in recent years. In the year 2010, it is estimated that more than 5.7 million Kenyans aged 15 years and over received HIV testing and counselling.28 According to the 2009 Demographic and Health Survey, 73.5 percent of women and 58.6 percent of men have been tested at least once.29 The disparity between the number of men and women who access HIV testing has continued, but efforts to introduce community-based testing programmes have been successful in increasing uptake among men.30
However, increased rates of testing do not always accurately reflect an increased number of people who know their status. This is because people might become infected after an earlier negative test, or may not have received the results. According to the 2007 Kenyan AIDS indicator survey for example, almost two thirds of HIV infected people surveyed and who thought they knew their status mistakenly thought they were HIV negative.31
Often women will be afraid to disclose their status to their husbands because they are worried they may be stigmatised, assaulted or thrown out of the family home.32 It has even been reported that women fail to seek antenatal care from fear of their HIV status being disclosed during routine HIV testing.33
“Men still believe that it is only women who can be a source of HIV in the family, and most of them turn very violent on realizing their HIV status.” - Dr Aggrey Ouko – Suba District medical officer34
“Different cultural beliefs affect the issue of (a child’s) disclosure; in most cases it is the women coming with children to health facilities. It becomes a burden to women to disclose to husbands, causing them to bear the secrecy of their own and the children's status. Then with polygamy still present, the cycle of infection and re-infection sadly continues.“ - Patricia Onguti, Doctor, Kenya35
The Kenyan government has only actively promoted condom use since 2001, when an estimated 12.8 percent of its population were infected with HIV. That year, the government announced its intention to import 300 million condoms.36 Since then, condom distribution has been radically scaled up; 10 million were distributed in 2004 and 124.5 million in 2008.37 38
However, there have been a number of obstacles either preventing people from accessing condoms, or preventing people from wanting to use them. In particular, Kenyans have often received conflicting messages about condom use. Many religious leaders have expressed opposition to condom use,39 40 and in 2006 Kenya’s First Lady said during a visit to some Kenyan schoolgirls:
“I am not telling you to use condoms. I am not in favour of condoms.”41
Preliminary results from the 2008/2009 Kenya Demographic and Health Survey revealed that of respondents who in the last 12 months had sex with two or more partners, only 32 percent of women and 37 percent of men reported using a condom.42 A 2011 study in Kilifi district, found that only 1 percent of married couples regularly used condoms.43 Reports of people washing and re-using condoms, during condom shortages, indicate that more needs to be done to ensure people have consistent access to condoms.44 45
Female condom uptake has also been low, and in 2009 there was a reported shortage of female condoms in public hospitals in Kenya’s Coast Province.46 In the same year Kenyan officials banned a brand of UK produced male condoms after tests revealed that some had leaked.47
Education and awareness
HIV and AIDS education is an essential part of HIV prevention. In Kenya AIDS education is part of the curriculum in both primary and secondary schools,48 and for a number of years Kenya has delivered educational campaigns to raise nationwide awareness of the issue. As a result, awareness about HIV and AIDS in Kenya is high. In Kenya’s national, population-based survey, nearly all adults aged 15-64 had heard about AIDS,49 90 percent knew that a healthy-looking person could be infected with HIV, and most knew how to reduce their chances of becoming infected with the virus. Awareness of the need to use condoms was high with 75 percent of women and 81 percent of men in this age group aware that condoms reduce the risk of HIV infection.50
However, one study of 21 primary and 9 secondary schools highlighted the difficulties in implementing AIDS education in public schools.51 The reasons included; not enough time in the curriculum, a lack of teacher training and support, and reluctance by parents and the Ministry of Education to talk openly about sex and condoms. One recommendation drawn from the study was for the Ministry of Education to have a clearer policy on its stance on condoms.
Preventing mother-to-child transmission (PMTCT)
Since 2000 PMTCT efforts in Kenya have rapidly expanded. There are now more than 3,397 health facilities offering PMTCT services.52 In 2011 an estimated 67 percent of pregnant women living with HIV received the most effective antiretroviral regimen for preventing the transmission of HIV to their babies.53
Prevention services for pregnant women must continue to grow as HIV transmission from mother-to-child is still high. For example, an estimated 1 in 5 babies born to HIV-infected mothers are infected with HIV and PMTCT services are still only available in half of the country's health facilities.54 55
An estimated 220,000 children were living with HIV in 2011, with approximately 13,000 new child infections that year, most of which were probably a result of mother-to-child transmission.56 It is believed these high rates account for the high infant mortality rate in Kenya.57
In August 2009 the Kenyan government introduced the more effective combination therapy to replace single-dose nevirapine to prevent mother-to-child transmission. The government also emphasised the importance of male involvement in PMTCT programmes58 and in 2010 introduced a Sh240 million campaign to encourage partner testing, exclusive breastfeeding and to deliver antiretroviral treatment to more children who need it.59
In light of substantial evidence showing that male circumcision significantly reduces a man’s risk of acquiring HIV during heterosexual intercourse, the Kenyan National AIDS/STD Control Programme has developed a policy on male circumcision. The aim of the policy is to reduce the number of new HIV infections in order to “help create an AIDS free generation”.60 Around 150,000 male circumcisions per year for five years will need to be performed in order for Kenya to reach its target.61
In many districts of Kenya circumcision is a cultural process. Voluntary medical male circumcision programmes were therefore concentrated in those districts that did not hold this tradition. Rates of circumcision increased from 10,000 to 90,000 in just over a year during 2009.62 In 2010, the rate of circumcision continued to rise to an estimated 139,905, falling just below the annual target.63 Increasing circumcision among older, sexually active men has been identified as critical if HIV infection is to be reduced among this age group.64
In 2012, a new initiative was introduced to increase the number of circumcised men. The initiative involved handing out vouchers to men who had the procedure, which could be exchanged for money upon attending a follow-up appointment.65 They were also encouraged to bring a friend who is interested in becoming circumcised.
Harm reduction and needle exchange services
HIV transmission through injecting drug use is a growing problem, particularly in the capital and in coastal areas. HIV prevalence among injecting drug users (IDUs) was 18.3 percent in 201166 and in Nairobi around 1 in 3 IDUs are infected with HIV.67 Even where IDUs in Kenya know how HIV can be transmitted, needle sharing and unprotected sex is commonplace.68 69 Up to 4 percent of all new infections are as a result of injecting drug use.70
Although Kenyan drug laws and government policy have hindered the prevention of new infections among IDUs, there has been a recent change of view in the Kenyan government. This follows a similar turnaround by the American initiative PEPFAR (the largest foreign funder of HIV and AIDS programmes in Kenya), which now supports a variety of harm reduction approaches to HIV prevention among IDUs.71 The 2009/10-2013/14 Kenyan Strategic Plan (KNASP III) highlights the need to prevent new infections among IDUs and to "seek innovative ways to reduce HIV transmission".72
“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, head of the National AIDS and STI Control Programme
In 2011, the National AIDS Control Council (NACC) announced a plan to provide free HIV prevention and treatment for IDUs.73 Included in the plan are previously disallowed harm reduction methods including needle exchange, and neglected services such as psychosocial support for IDUs. Opioid substitution therapy (OST) is not banned in Kenya but the availability of OST has traditionally been severely restricted. As part of the new prevention plan, twelve primary health care centres in Mombasa began to offer opioid substitution therapy in 2011.74 The Kenyan government also announced that, with funding 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.75
The recognition by public health leaders that HIV infection risk among IDUs must be addressed through evidence-based approaches, including harm reduction services, is a promising step. However, many problems remain. A 2011 report into HIV prevention among IDUs in Kenya found that there was a high prevalence of HIV in prisons, but no access to addiction treatment or needle exchange for IDUs.76 It also found that stigma towards IDUs was widespread among the general public and healthworkers. Local NGOs were found to be working on HIV prevention among IDUs but were overstretched and did not provide methadone substitution or needle exchange services. Finally, although needles and syringes are available for purchase from pharmacies and other outlets, it was reported that pharmacists are reluctant to sell syringes to injecting drug users.77 In 2011 it was reported that just over half of injecting drug use was safe.78
HIV and AIDS treatment in Kenya
In 2003 only 5 percent of people needing ART were receiving antiretroviral therapy.79 In 2006, Kenya’s President announced that antiretroviral drugs would be provided for free in public hospitals and health centres.80 By 2009 the number of people receiving antiretroviral therapy had significantly increased to 336,980. However, due to a 2010 change in WHO treatment guidelines, which recommend starting treatment earlier, the proportion of people eligible to receive antiretroviral treatment remained at only 48 percent.81 Under the previous guidelines, treatment coverage would have been 65 percent. By 2010, access to treatment had increased further with 432,621 receiving treatment, around 61 percent of those in need.82 Since that year, treatment access has risen by a further 59 percent.83
“Despite an increase in children accessing treatment, the overall coverage for children remains extremely low.”
The expansion of antiretroviral treatment has led to a 50 percent decrease in AIDS-related deaths since 2005.84 In 2011 a Kenyan pharmaceutical company was given the green light by the WHO to start producing antiretroviral drugs. This could result in significant savings for the government’s treatment programme, as ARVs currently have to be imported from India.85
Around half of those infected with tuberculosis (TB) are co-infected with HIV in Kenya,86 although this varies widely according to region.87 Antiretroviral treatment for co-infected individuals has been found to improve patient survival if it is administered as soon as possible after TB treatment.88 Therefore, WHO recommend antiretroviral therapy for all HIV and TB co-infected patients, whatever the stage of HIV progression. However, facilities where dual treatment is available are limited and many of those who require ARVs alongside TB treatment are not receiving it.89
Despite an increase in access to HIV treatment for children, the overall coverage for children remains extremely low. Only 31 percent of children living with HIV in need of treatment are receiving it.90 A child’s access to treatment can sometimes be inhibited by reasons other than the reach of treatment services. According to Human Rights Watch reasons for this include: neglect on part of the children’s caregivers; a lack of accurate information about medical care for children; and the stigma and guilt associated with HIV and AIDS.91
“Often, when other family members take in AIDS orphans, they really do not want to associate with that child. They are worried that they and their children could get infected.” - Manager of an orphanage for HIV-positive children in Kenya92
Adequate nutrition for people living with HIV is essential. Yet, as poverty levels are high in Kenya and food shortages frequent, people living with HIV are often unable to eat a healthy, balanced diet.93 Evidence shows that malnourished people are less likely to benefit from antiretroviral treatment and are at a higher risk of quicker progression to AIDS. In addition, taking treatment without food can be very painful.
“I eat two or three meals a day, which makes me better off than most, so I share with those who have less… But now, even in my home, things are tight, and sharing my food means that I eat less, so I feel weak when I take my medication.” - Onesmus Mutungi, living with HIV in Kenya94
Obtaining antiretroviral medication for people leading nomadic lifestyles can also be difficult. One report explains how a Maasai family were unable to obtain antiretroviral drugs for their two HIV-infected children, as they had to keep moving for their livestock.95
HIV stigma and discrimination in Kenya
Even though awareness of HIV and AIDS in Kenya is high, many people living with the virus still face stigma and discrimination. Studies have shown that although people are aware of the basic facts about HIV and AIDS, many do not have the more in-depth knowledge that addresses issues of stigma.96 With 16 percent of people living with HIV in Kenya reporting having felt suicidal, social stigma of HIV is an urgent issue.97
One report revealed that only a third of healthcare facilities that have policies to protect people living with HIV against discrimination were actually implementing such policies.98 People are still afraid to disclose their status and will often avoid health centres that provide HIV services, from fear of being seen by neighbours or community members.99 Surveys among people living with HIV have shown that 30 percent have reported being excluded from family events and 79 percent have reported being gossiped about by members of their community.100
Homosexuality is illegal in Kenya and therefore men who have sex with men face significant stigma and discrimination. In an attempt to find out to what extent HIV is affecting the gay community, Kenya has launched a ‘homosexual census’.101 Prevalence is reported to be 18.2 percent among MSM.102 However, with homosexuality still illegal, it is unlikely that the census results will reflect reality.
HIV funding in Kenya
In 2010 total funding for HIV/AIDS in Kenya amounted to $726 million.103 Funding comes from a range of donors, the most significant of which is the USA government. The Global Fund, which is the second largest contributor to HIV/AIDS funding in Kenya, distributed $15,266,186 in 2010.104 105
Corruption is a major deterrent to donors and a lack of transparency of the distribution of funds may result in donors withholding funding. In 2009 Kenya was ranked in the bottom third of countries worldwide for corruption (146 out of 180).106 These problems have directly affected the influx of funding, as in 2003, 2008 and 2009 the Global Fund delayed and refused applications for funding to Kenya.107 It has been suggested a lack of clarity and accounting problems were the cause of Kenya’s most recent grant refusal in 2010.108 Other sources have attributed the refusal to rivalries between the ministries of Medical Services and Public Health who are dually responsible for the management of donor funds.109 The effects of the Global Fund's rejection of recent applications will inevitably be felt by future programmes.110
The flat-lining of PEPFAR funds also raises financial concerns for the future as funds will be fixed whilst costs continue to increase with inflation. With funding shortfalls already calculated to be around $1.7 billion by 2013 for HIV prevention, treatment and care,111 the need for sustainable funding for HIV and AIDS in Kenya has become increasingly apparent.112
The Kenyan government have pledged to address their HIV funding crisis by focusing on past and present shortfalls in financial management, tracking and transparency.113 In addition, Michel Sidibé, executive director of UNAIDS, has identified Kenya’s need to achieve financial sustainability for its AIDS programmes through domestic funding.114 The government of Kenya has pledged $34 million annually for five years to go towards HIV and AIDS programmes, and has domestic funding has doubled between 2008 and 2010.115 116 However, external sources continue to account for more than three quarters of all HIV funding.117
Although Kenya has seen a dramatic reduction in HIV prevalence figures since 2000, the country is still facing a severe AIDS epidemic. In order to make progress in Kenya, the following areas need to be addressed:
- The Kenyan government needs to increase the number of people who know their HIV status by promoting and expanding access to HIV testing.
- Social, economic and legal gender inequalities in Kenya need to be addressed in order to reduce the disproportionately high HIV prevalence among women.
- Among high-risk groups, Kenya needs to expand its HIV prevention work and increase access to HIV testing and treatment.
- Stigma and discrimination towards those living with HIV must be eradicated.
- As Kenya’s antiretroviral treatment programme continues to expand, the country needs to find sustainable sources of money to finance the growing need for antiretroviral drugs.
The history of HIV and AIDS in Kenya
Between 1983 and 1985, 26 cases of AIDS were reported in Kenya.118 Sex workers were the first group affected – a study from 1985 reported an HIV prevalence of 59 percent amongst a group of sex workers in Nairobi.119
Towards the end of 1986 there were an average of four new AIDS cases being reported to the World Health Organization each month.120 This totalled 286 cases by the beginning of 1987, 38 of which had been fatal.121
One of the Kenyan government’s first responses was to publish informative articles in the press and to launch a poster campaign urging people to use condoms and avoid indiscriminate sex.122 A year later in 1987, the Minister of Health announced a year-long health and education programme, funded by a £2 million donation from high-income countries.123
By 1987 HIV appeared to be spreading rapidly among the population – an estimated 1-2 percent of adults in Nairobi were infected with the virus,124 and HIV prevalence among pregnant women in the capital increased from 6.5 percent to a staggering 13 percent between 1989 and 1991.125
The government was criticised for not responding aggressively to the emerging epidemic, unlike governments in its neighbouring countries, such as Uganda. The government was also accused of playing down the threat of AIDS because of the damage it could do to Kenya’s tourism industry.126
In a speech at an AIDS awareness symposium in 1999, Kenyan President Daniel Arap Moi declared the AIDS epidemic a national disaster and announced that a National AIDS Control Council would be established imminently. Critics argued that in the speech the President failed to promote the use of condoms as a preventative measure and a way forward for tackling the epidemic.129 However, at the end of 1999 President Moi broke his silence surrounding condoms and declared in a speech to students at the University of Nairobi:
“The threat of AIDS has reached alarming proportions and must not be treated casually; in today’s world, condoms are a must.”130
In 2000, plans were drawn up to build a condom factory in Nairobi, with the aim of producing 100 million condoms a year.131 However, by 2001 the company planning the build moved its project to South Africa, apparently due to excessive government regulations and a lack of responsiveness.132
HIV prevalence began to decline from its peak of 13.4 percent in 2000 and continued to decrease steadily to 6.9 percent in 2006.133
The decrease in prevalence coincided with the rapid expansion of preventative interventions since 2000, which resulted in a change in sexual behaviour and the increased use of condoms.134 The decline has also been attributed to the large number of people dying from AIDS in Kenya, which totalled 150,000 in 2003 alone.135
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