Kenya is home to one of the world’s harshest HIV and AIDS epidemics. An estimated 1.5-2 million people are living with HIV; around 1.2 million children have been orphaned by AIDS; and in 2006 85,000 people died from AIDS related illnesses.¹

Kenya’s HIV prevalence peaked during 2000 and, according to the latest figures, has dramatically reduced to around 6.3 percent.² This decline is thought to be partially due to an increase in education and awareness, and high death rates.³

Many people in Kenya are still not being reached with HIV prevention and treatment services. Only 1 in 4 children needing treatment are receiving it.⁴ This demonstrates Kenya still has a long way to go in providing universal access to HIV treatment, prevention and care.

The history of HIV and AIDS in Kenya

Between 1983 and 1985 26 cases of AIDS were reported in Kenya.⁵ 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.⁶

Towards the end of 1986 there were an average of four new AIDS cases being reported to the World Health Organization each month.⁷ This totalled 286 cases by the beginning of 1987, 38 of which had been fatal.⁸

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.⁹ A year later in 1987, the Minister of Health announced a year-long health and education programme, funded by a £2 million donation from Western countries.¹⁰

By 1987 HIV appeared to be spreading rapidly among the population – an estimated 1-2% of adults in Nairobi were infected with the virus,¹¹ and between 1989 and 1991 HIV prevalence among pregnant women in the capital had increased from 6.5 percent to a staggering 13 percent.¹²

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.¹³

By 1994 an estimated 100,000 people had already died from AIDS¹⁴ and around one in ten adults were infected with HIV.¹⁵

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.¹⁶ 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.¹⁷ 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.”¹⁸

In the same year, Kenyan religious leaders were criticised for rejecting the use of condoms.¹⁹

In 2000 plans were drawn up to build a condom factory in Nairobi, with the aim of producing 100 million condoms a year.²⁰ 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.²¹

HIV prevalence began to decline from its peak of 13.4 percent in 2000 and continued to decrease steadily to 6.9 percent in 2006.²²

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.²³ The decline has also been attributed to the large number of people dying from AIDS in Kenya, which totaled 150,000 in 2003 alone.²⁴

The current situation in Kenya

Kenya’s HIV epidemic has been categorised as generalised – meaning that HIV affects all sectors of the population. Nearly half of all new infections were transmitted during heterosexual sex whilst in a relationship and 20 percent during casual heterosexual sex.²⁵

HIV prevalence is higher amongst specific groups and tends to differ according to location, gender and age.

Various studies have revealed 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.²⁶ 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. Up to 33% of new infections in 2008 were within these ‘most at risk populations’.²⁷

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.²⁸ Laws prohibiting harm reduction services, such as needle and syringe exchanges, significantly hinder the prevention of new infections among IDUs.²⁹

Women are disproportionally affected by HIV. In 2008/09 HIV prevalence among women was twice as high as that for men at 8% and 4.3% 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.³⁰ 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 one in four women aged between 12 and 24 had lost their virginity by force.³¹

Adult HIV prevalence is greater among urban areas (8.4 percent) than rural areas (6.7 percent) of Kenya.³² However, as around 75 percent of people in Kenya live in rural areas, the total number of people living with HIV is higher in rural settings (1 million adults) than urban settings (0.4 million adults).³³

HIV prevention in Kenya

A principle aim of the 2005/06-2009/10 Kenyan National HIV and AIDS Strategic Plan is to reduce the number of new HIV infections by using new, evidence-based approaches to HIV prevention.³⁴ The main prevention strategies outlined in the Plan include:

• Increasing availability and access to counseling and testing
• Condom promotion
• Strengthening sexually transmitted disease (STD) and HIV programme linkages
• Expanding services for prevention for mother-to-child transmission (PMTCT)
• Ensuring more effective and targeted behaviour change communication
• Promoting abstinence, safe sex and delayed sex debut among young people
• Improve availability of safe blood supplies
• Ensure injection safety and expand access to post exposure prophylaxis and universal precautions
• Ensure mutually supporting prevention and treatment efforts.

HIV testing

HIV testing has widely expanded across Kenya since the beginning of the millennium. In 2000 there were only three voluntary counseling and testing (VCT) sites nationwide; by 2007 there were almost 1000.³⁵ Alongside voluntary testing, provider initiated counseling and testing (PCT) has expanded and is now available in 73 percent of health facilities.³⁶ 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.³⁷

One of the 2010 targets set in Kenya’s National HIV and AIDS Strategic Plan 2005/06 -2009/10 was to test 2 million Kenyans for HIV annually.³⁸ 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.³⁹ 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.⁴⁰

The governments 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 2007.⁴¹ According to 2008/09 figures 40.4 percent of men and 56.5 percent of women were tested during this period and by 2009 the total amount of adults older than 15 tested for HIV was 3,471,567.⁴² 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.⁴³

However, many HIV infected Kenyans are still unaware of their HIV status. In the 2007 Kenyan AIDS Indicator Survey, 83 percent of HIV-infected adults aged 15-64 were unaware they were infected, because they had never been tested for HIV, had been tested but did not receive the result, or they thought they were uninfected based on their last test.⁴⁴ Most of those who had not had an HIV test believed themselves to be at low risk of HIV infection.

Often women will be afraid to disclose their status to their husbands because they are worried they may be stigmatized, assaulted or thrown out of the family home.⁴⁵ It has even been reported that women fail to seek antenatal care from fear of their HIV status being disclosed during routine HIV testing.⁴⁶

“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 officer⁴⁷

As part of the National HIV and AIDS Strategic Plan 2009/10 - 2013/14 a new approach to preventing new HIV infections has been implemented.⁴⁸ 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.^{49 50} 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.^{51 52}

Condom use

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.⁵³ Since then, condom distribution has been radically scaled up; 10 million were distributed in 2004 and 124.5 million in 2008.^54 55

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,^{56 57} 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.”⁵⁸

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.⁵⁹

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.⁶⁰ In the same year Kenyan officials banned a brand of UK produced male condoms after tests revealed that some had leaked.⁶¹

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,⁶² 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,⁶³ nine out of ten adults 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.⁶⁴

However, one study of 21 primary and nine secondary schools highlighted the difficulties in implementing AIDS education in public schools.⁶⁵ 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.⁶⁶ In 2008 an estimated 65 percent of pregnant women were tested for HIV and by 2009 72 percent of pregnant women living with HIV received antiretrovirals for preventing transmission of HIV to their babies.^67 68

However, 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 4 babies born to HIV infected mothers are infected and PMTCT services are still only available in 50 percent of health facilities.⁶⁹

In 2009, there were approximately 22,259 new child infections and an estimated total of 184,052 children were infected with HIV, most of which were probably from mother-to-child transmission.⁷⁰ It is believed these high rates account for the high infant and young child mortality in Kenya.

In August 2009 the Kenyan government introduced combination therapy to replace single-dosed nevirapine to prevent mother-to-child transmission. The government also emphasised the importance of male involvement in PMTCT programmes.⁷¹

Male circumcision

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”.⁷² Around 150,000 male circumcisions per year for five years will need to be performed in order for Kenya to reach its target.⁷³

In many districts of Kenya circumcision is a cultural process. Voluntary medical male circumcision programmes were therefore concentrated in those districts which did not hold this tradition. Rates of circumcision increased from 10,000 to 90,000 in just over a year in 2009, which although substantial, remains short of policy aims.⁷⁴ Increasing circumcision among older, sexually active men has been identified as critical if HIV infection is to be reduced among this age group.⁷⁵

HIV and AIDS treatment in Kenya

In 2003 only 5 percent of people needing ART were receiving antiretroviral therapy.⁷⁶ In 2006 Kenya’s President announced that antiretroviral drugs would be provided for free in public hospitals and health centres.⁷⁷ In 2007 treatment coverage was low at 42 percent with only 172,000 on treatment.⁷⁸ Nevertheless, by 2009 the number of people receiving antiretroviral therapy had significantly increased to 336,980 a coverage of 70.4 percent.^79 80 Due to this expansion, the number of people that have died from AIDS has declined since its peak in 2003.⁸¹

Despite an increase in children accessing treatment, the overall coverage for children remains extremely low. Figures show 75 percent of Kenyan children living with HIV who urgently need treatment do not have access to it.^82 83 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.⁸⁴

“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 Kenya⁸⁵

Poverty is high in Kenya and food shortages frequent, which means that people living with HIV are often unable to eat a healthy, balanced diet.⁸⁶ 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 Kenya⁸⁷

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.⁸⁸

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 are not informed of the more in-depth knowledge that addresses issues of stigma.⁸⁹

One report revealed that of healthcare facilities that have policies to protect people living with HIV against discrimination, only a third admitted to implementing such policies.⁹⁰ 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.⁹¹

As mentioned earlier, homosexuality is illegal in Kenya and therefore men who have sex with men face a high level of stigma and discrimination. In an attempt to find out to what extent HIV is affecting the gay community, Kenya has launched a ‘homosexual census’.⁹² However, with homosexuality still illegal, it is unlikely that the census results will reflect reality.

HIV funding in Kenya

In 2008/09 total funding for HIV/AIDS in Kenya amounted to $687 million.⁹³ Funding comes from a range of donors, the most significant of which is the U.S. government. In FY 2009 funding from the U.S. President’s Emergency Plan for AIDS relief (PEPFAR) amounted to $541.5 million.⁹⁴ The Global Fund is the second largest contributor to HIV/AIDS funding in Kenya, having distributed $87,417,519 in total.⁹⁵

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 146 out of 180 countries, with a corruption perceptions index of 2.2.⁹⁶ 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.⁹⁷ It has been suggested a lack of clarity and accounting problems were the cause of Kenya’s most recent grant refusal.⁹⁸ 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.⁹⁹ The effects of the Global Fund rejecting recent applications will inevitably be felt by future programmes.¹⁰⁰

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. Moreover, in 2010 the Clinton HIV/AIDS Initiative will terminate funding for paediatric ARVs and second line treatment, further hindering aims to achieve universal access by 2013.¹⁰¹ With funding shortfalls already calculated to be around $1.7 billion by 2013 for HIV prevention, treatment and care,¹⁰² the need for sustainable funding in Kenya is becoming increasingly apparent.¹⁰³

The Kenyan government have pledged to address their HIV funding crisis by focusing on past and present shortfalls in financial management, tracking and transparency.¹⁰⁴ In addition, Michel Sidibé, executive director of UNAIDS, has identified Kenya’s need to achieve financial sustainability for its AIDS programmes through domestic funding.¹⁰⁵ The government of Kenya has pledged $34 million annually for five years to go towards AIDS programmes.¹⁰⁶ However, at present external sources amounts to 70% of all HIV funding.¹⁰⁷

Conclusion

Although Kenya has seen a dramatic reduction in HIV prevalence figures, the country is still facing a severe AIDS epidemic. In order to make any 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.
• Kenya needs to focus more on how HIV is affecting specific groups.
• Stigma and discrimination towards those living with HIV needs to be eradicated.
• As Kenya’s antiretroviral treatment programme continues to expand, the country needs to find sustainable sources of money to finance the growing demand for antiretroviral drugs.

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