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 among those in heterosexual relationships and 20 per cent during casual heterosexual sex. 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, truck drivers and cross-border mobile populations. Some of these groups are marginalised within society.
For instance, homosexuality is illegal in Kenya and punishable by up to 14 years in prison. This makes it difficult for the groups to reach HIV prevention, treatment and care. The extent to which HIV is affecting these groups has not been fully explored. In 2008, an estimated 3.8 per cent of new HIV infections were among IDUs and in the capital, Nairobi, 5.8 per cent of new infections were among IDUs. HIV infections are easily prevented in healthcare settings. However, 2.5 per cent of new HIV infections in 2008 occurred in health facilities. Women are disproportionally affected by HIV.
In 2008/9, HIV prevalence among women was twice as high as that for men at eight per cent and 4.3 per cent, respectively. This disparity is even greater in young women in the 15 to 24 age bracket who are four times more likely to become infected with HIV than men of the same age. 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 the women reported having experienced violence and a quarter of women aged between 12 and 24 had lost their virginity by force. Adult HIV and Aids prevalence is greater in urban areas at 8.4 per cent than rural areas at 6.7 per cent. However, as around 75 per cent of people in Kenya live in rural areas, those living with HIV in rural settings are estimated at one million adults, compared with 400,000 in urban settings.
The 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. These are:
- Reduced risky behaviour among the general, infected, most-at-risk and vulnerable populations.
- Proportion of eligible people living with HIV (PLHIV) 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 the other is negative, accounted for the majority of new infections. 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 couplebased testing and encourage partnerdisclosure and condom use. There is also a distinctly new focus on men having sex with men, 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 these groups.
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 2007, there were almost 1,000. Along side voluntary testing, provider -initiated counselling and testing (PCT) has expanded and is now available in 73 per cent of health facilities. PCT entails offering HIV tests to individuals whenever they go to a health facility, rather than patients having to ask for it.
One of the 2010 targets set in Kenya’s National HIV and Aids Strategic Plan 2005/06 -2009/10 (KNASP II) was to test two million Kenyans for HIV annually. To reach the target, international development organisations and the Government introduced a number of new initiatives. One such programme, launched in late 2009, aimed at providing door-to-door HIV testing and counselling for those living in remote areas with little access to health care. 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 per cent had taken a test compared to 37 per cent in 2007.
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. Increased testing rates have meant that record numbers of Kenyans have been tested in recent years. In 2009, it is estimated that more than 4.4 million Kenyans aged 15 years and over (approximately one in four of the adult population) received HIV testing and counselling. According to the 2009 Demographic and Health Survey, 73.5 per cent of women and 58.6 per cent of men have been tested at least once.
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. For a number of years, Kenya has delivered educational campaigns to raise nationwide awareness on the issue. As a result, awareness about HIV and Aids in Kenya is high. In Kenya’snational, population-based survey, nearly all adults aged between 15 and 64 had heard about Aids, 90 per cent 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 per cent of women and 81 per cent of men in this age group aware that condoms reduce the risk of HIV infection.
Preventing mother-to-child transmission (PMTCT)
Since 2000, the effort has rapidly expanded. There are now more than 3,400 health facilities offering preventing mother-to-child transmission (PMTCT) services. In 2008, an estimated 65 per cent of pregnant women were tested for HIV and by 2009, 73 per cent of pregnant women living with HIV received antiretrovirals (ARVs) for preventing the transmission of HIV to their babies. However, only half of HIV-exposed infants received ARVs for PMTCT in the same year. Prevention services for pregnant women must continue to grow as HIV transmission from mother-to-child is still high. For example, an estimated one in four babies born to HIV infected mothers are infected and PMTCT services are still only available in half of the country’s health facilities. In August, 2009, the Government introduced the more effective combination therapy to replace single-dose nevirapine to prevent mother-tochild transmission.
There was also emphasis of the importance of male involvement in PMTCT programmes. In 2010, a Kshs 240 million ($2.83 million) campaign was introduced to encourage partner testing, exclusive breast-feeding and to deliver antiretroviral treatment to more children who need it.
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/ Sexually Transmitted Diseases Control Programme has developed a policy on male circumcision. The aim is to reduce the number of new HIV infections in order to “help create an Aids free generation”. Around 150,000 male circumcisions annually for five years will need to be performed for Kenya to reach its target. In many areas, circumcision is a cultural process. Voluntary medical male circumcision programmes were, therefore, concentrated in those regions 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.
Needle exchange services
HIV transmission through injecting drug use is a growing problem, particularly in the capital city, Nairobi, and in coastal areas. The 2009/10- 2013/14 Kenyan Strategic Plan (KNASP III) highlights the need to prevent new infections in this group and to “seek innovative ways to reduce HIV transmission”. In 2011, the National Aids Control Council (NACC) announced a plan to provide free HIV prevention and treatment for injecting drug use. Included in the plan are previously disallowed harm reduction methods, such as needle exchange, and neglected services, such as psychosocial support for the users. Opioid substitution therapy (OST) is not banned in Kenya but its availability has traditionally been severely restricted. As part of the new prevention plan, 12 primary health care centres in Mombasa began to offer OST in 2011. The 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.
HIV and Aids treatment
In 2003, only five per cent of people needing ART were receiving antiretroviral therapy. In 2006, President Kibaki announced that anti-retroviral drugs would be provided for free in public hospitals and health centres. In 2007, treatment coverage was low at 42 per cent, with only 172,000 on treatment. Nevertheless, 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, it is now estimated that only 48 per cent of Kenyans in need of HIV treatment are receiving it. Under the previous guidelines, treatment coverage would have been 65 per cent. Despite an increase in children accessing treatment, the overall coverage for children remains low.
In 2008/09, total funding for HIV and Aids in Kenya amounted to $687 million. Funding comes from a range of donors, the most significant being the US government. Funding from the US President’s Emergency Plan for Aids Relief (PEPFAR) amounted to $541.5 million. The Global Fund is the second largest contributor to HIV and Aids funding in Kenya, having distributed $87.4 in total. With funding shortfalls already calculated to be around $1.7 billion by 2013 for HIV prevention, treatment and care, the need for sustainable funding for HIV and Aids in Kenya has become increasingly apparent. The Government has pledged to enhance the HIV funding financial management,tracking and transparency.