Groups most affected by HIV in Kenya
Sex workers have the highest reported HIV prevalence of any group in Kenya. The most recent data from 2011 estimates 29.3% of female sex workers are living with HIV. Similarly, a 2015 study of female sex workers in Nairobi found that around one-third were living with HIV.
Kenyan sex workers face heightened risk of violence with little or no protection from law enforcement officers. For example, whilst many sex workers experience rape and access post-rape medical care, none reports the incidents to the police for fear of being prosecuted for engaging in sex work. For those sex workers living with HIV, frequent arrests and detention result in an interruption of HIV treatment.
Despite this, female sex workers are reportedly better at protecting themselves from HIV transmission compared to other groups who are vulnerable to HIV such as men who have sex with men. This may be due to the fact that 76% of sex workers are estimated to be able to access HIV services, higher than among other key population groups.
Condom use is high, estimated at just under 92%, with 330 condoms distributed to each sex worker enrolled in HIV prevention programmes in 2016. Antiretroviral treatment coverage is also high at 79.7% among those aware of their status.
Men Who Have Sex with Men
HIV prevalence among men who have sex with men (sometimes referred to as MSM) in Kenya is almost three times that among the general population. The most recent data from 2010 estimates HIV prevalence among men who have sex with men at 18.2%.
Condom use among men who have sex with men has been rising. In 2016, 80% of men who have sex with men reported using a condom the last time they had anal sex, up from 55% in 2011.
Homosexuality is illegal in Kenya and can carry a prison sentence of up to 14 years. This, coupled with entrenched social attitudes, leads to high levels of stigma and discrimination towards men who have sex with men as well as people who are lesbian, gay, bisexual and transgender (LGBT), deterring many people from seeking the HIV services they need. As a result, programming and policy to address the HIV epidemic among Kenyan men who have sex with men has lagged behind.
In 2013, a group of Kenyan civil society organisations presented a report to the Committee Against Torture stating that people who are LGBT in Kenya face constant harassment, violence and death threats by police officials, who also blackmail them with threats of arrest if they refuse to pay bribes. Although such harassment still exists, there have been an increasing number of court rulings in the favour of LGBT communities, for example in 2015 the high court ruled that the ‘National Gay and Lesbian Human Rights Commission (NGLHRC)’ could formally register their organization with the Non-Governmental Organizations coordination board. Originally, their request to join had been rejected as their organisation was seen as ‘unacceptable’ and at odds with the illegal status of homosexuality in Kenya.
People Who Inject Drugs
In 2011, an estimated 18.3% of people who inject drugs (sometimes referred to as PWID) in Kenya were living with HIV. The majority of people who inject drugs are concentrated in specific geographical areas such as Nairobi and Mombasa.
Condom use amongst people who inject drugs is increasing, rising from 24.7% in 2011 to 70.3% in 2015. The introduction of harm reduction services since 2012 is also helping to address unsafe injecting practices, and in 2016, UNAIDS found nearly 90% of people who inject drugs had used a clean syringe last time they injected, compared to 51.6% in 2012.
More than half (51%) of all new HIV infections in Kenya in 2015 occurred among adolescents and young people (aged 15-24 years), a rapid rise from 29% in 2013. Many of these infections will have occurred among young key populations.
Young women are almost twice as likely to acquire HIV as their male counterparts, and accounted for 33% of the total number of new infections (23,312) in 2015. In comparison, young men accounted for 16% of all new HIV infections (12,464).
More than half (51%) of all new HIV infections in Kenya in 2015 occurred among adolescents and young people (aged 15-24 years). A number of factors contribute to the increasing rate of HIV infection among young people including incorrect perception of HIV risk; and having unprotected sexual intercourse under influence of alcohol or drugs.
Forced sex and sexual violence also increase young people’s vulnerability to HIV. This particularly affects young Kenyan women who are three times more likely to be exposed to sexual violence than young Kenyan men. It is estimated that 33% of girls in Kenya have been raped by the time they reach the age of 18, with 22% of girls aged 15-19 describing their first experience of sexual intercourse as forced.
In 2016, women accounted for 910,000 of the 1.6 million people living with HIV in Kenya. As in many parts of sub-Saharan Africa, women 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. For example, in 2014, 35% of adult women (aged 15-49) who were or had been married had experienced spousal violence and 14% had experienced sexual violence.
Targets set for the next strategic period aim to reduce new infections in women by 50% and eliminate unmet family planning needs among this group. They also aim to reduce gender-based violence by 50%.
HIV Testing and Counselling (HTC) in Kenya
More than half (53%) of the 1.6 million people living with HIV in Kenya are unaware of their HIV status.
HIV testing and counselling (HTC) has become a major feature of Kenya’s HIV response. This is in part a response to the large number of HIV sero-discordant couples, in 2012 it was estimated that there were 260,000 sero-discordant couples in Kenya (when one partner is HIV negative and one is positive). These couples significantly contribute to new infections, especially when individuals are unaware of their status.
The country has adopted a number of innovative approaches to HIV testing in recent years, including targeted community-based HIV testing, door-to-door testing campaigns, and the introduction of self-testing kits. These efforts have led to a dramatic rise in the number of people testing for HIV. In 2008, 860,000 people were being tested annually for HIV. By 2015, this had increased to 9.9 million.
Kenya has adopted a number of innovative approaches to HIV testing in recent years, including targeted community-based HIV testing, door-to-door testing campaigns, and the introduction of self-testing kits.
There remains a significant disparity between men and women. In 2014, 53% of women had tested for HIV in the past 12 months and received their results, compared to 45% of men. To address this, there has been a concerted effort to increase testing rates among Kenyan men, with community-based testing programmes proving particularly successful.
One such approach is to give home-based testing kits to pregnant women to pass on to their male partners. One study found this achieved 91% testing coverage in male partners within three months, compared to 51% among men who were invited to take a test at a clinic.
Like HTC coverage among the general population, testing rates among pregnant women have risen substantially. Between 2009 and 2013, the number of pregnant women tested for HIV increased from 68% to 92%.
In May 2017, the Kenya government introduced self-testing kits, as part of their ‘Be Self Sure’ campaign. The kits are now available to buy from pharmacies across the country for around US$8 each. Recent studies have shown a high-demand for self-testing among people in Kenya but for some the price of tests will be a barrier.
HIV prevention programmes in Kenya
Kenya is widely regarded as one of sub-Saharan Africa’s HIV prevention success stories. Annual new HIV infections are less than a third of what they were at the peak of the country’s epidemic in 1993. In 2016, there were an estimated 62,000 new HIV infections in Kenya, following a trend of falling figures year on year since 2013 when 100,000 new infections occurred.
Impressive gains have been made in particular areas, with 16 counties reducing their number of new HIV infection by more than 50%. This reduction has been driven by the National AIDS Control Council (NACC), the body responsible for co-ordinating the HIV response in Kenya. In 2013, NACC launched the Prevention Revolution Roadmap to End New HIV Infections by 2030. Linked to this, the Kenya AIDS Strategic Framework (KASF) outlines how it aims to reduce new infections by 75% through a combination of biomedical, behavioural and structural interventions, some of which are outlined below.
Condom Availability and Use
The Kenyan government has only actively promoted the use of condoms since 2001, but distribution has substantially increased year on year. In 2013, around 180 million free condoms were distributed, although this fell far below demand.
Condom use appears to be increasing. The 2014 Kenya Demographic and Health Survey (KDHS) reported just 40% of women and 43% of men who had two or more partners in the last 12 months used a condom the last time they had sex. However, data published by UNAIDS in 2017 indicates 73% of men and 55% of women used a condom the last time they engaged in sex with a non-marital, non-cohabiting partner.
HIV Education and Awareness
HIV education and awareness is an important component of HIV prevention in Kenya. HIV education has been part of the school curriculum in Kenya since 2003. The most recent HIV education policy, published in 2013, includes education about HIV prevention, care and support for school pupils and education personnel (e.g., teachers).
Knowledge of HIV prevention among young people is increasing. In the 2008 KHDS, 48% of young women and 55% of young men demonstrated adequate knowledge of HIV prevention, compared to 73% of young women and 82% of young men in 2014.
Teaching young people about HIV and sexual health remains controversial. KDHS 2014 found 40% of adults were against educating young people about condoms. Many cited fears of encouraging young people to have sex as a reason.
Mass media and sporting campaigns are also used to raise awareness about HIV with adolescents and young adults. For example, MTV Shuga, a show about the lives of a group of young people, began in Kenya with subsequent series in Nigeria and South Africa, and has been hugely successful in spreading HIV prevention messages to young people. Similarly, the Maisha County League taps into young people’s passion for football while disseminating awareness on HIV and aims to reach 10 million youth with HIV prevention education.
Preventing Mother-To-Child Transmission (PMTCT)
Kenya is committed to eliminating mother-to-child transmission of HIV. In 2015, 59,000 women were offered preventing mother to child transmission (PMTCT) services, out of an estimated 79,000 who were eligible (74% coverage). This is lower than the 2010 coverage rate of 86% but this is largely a result of to the increased demand for PMTCT services.
The number of children (0-14 years) newly infected with HIV fell from 12,000 in 2010 to 6600 in 2015, due in large part to PMTCT services. Starting in 2010, the Kenyan government has implemented various programmes to encourage male involvement in PMTCT, accompanying them to appointments and receiving HIV testing at the same time. However, this involvement remains low, standing at 4.5% in 2014.
Voluntary Medical Male Circumcision (VMMC)
In 2008, Kenya implemented voluntary medical male circumcision (VMMC) as an HIV prevention measure. Since then Kenya has made impressive progress in implementing VMMC programming. In 2015, Kenya was one of only three countries in sub-Saharan Africa that had an increase in VMMC, despite a worrying decline in this intervention throughout the rest of the region.
By 2016, 92.6% of men in the country were circumcised. The next phase of Kenya’s VMMC strategy aims to see 98% of men circumcised by 2025 and will focus on infants (0-60 days) and adolescents (10 to 14 years).
Harm Reduction in Kenya
In 2012, Kenya introduced needle and syringe programmes (NSPs) and opioid substitution therapy (OST) to help reduce HIV transmission among people who inject drugs.
Harm Reduction programmes in Kenya offer:
distribution of clean injecting equipment;
sexual and reproductive health information and services;
HIV and TB counselling and testing; and
medically assisted therapy (MAT) with methadone.
Between 2012 and 2015, around 10,000 people who inject drugs (out of an estimated population of 18,000) were reached by information, health and NSPs. By 2016, 155 clean needs and syringes were distributed in Kenya for each person who injects drugs. In the same year, UNAIDS found nearly 90% of people who inject drugs had used a clean syringe last time they injected, compared to 51.6% in 2012.
OST is less accessible, with only 8.8% of people who inject drugs able to access OST in 2016. However, the Kenyan government has committed to making OST services accessible to 6,000 people by 2018.
While Harm Reduction programmes have concrete improvements offering people who inject drugs more stability in their lives, more strategies are needed for their reintegration into wider society. Following Kenya’s success in introducing and scaling-up harm reduction, programmes based on their achievements are being adapted and applied to eight other countries in Eastern Africa in a programme led by the Kenyan AIDS NGOs Consortium (KANCO), supported by the Global Fund to Fight HIV, Tuberculosis and Malaria.
Pre-Exposure Prophylaxis (Prep)
In 2016, Kenya became the second country in sub-Saharan Africa to issue full regulatory approval of pre-exposure prophylaxis (PrEP), which uses antiretroviral drugs to protect HIV-negative people from HIV before potential exposure to the virus. The Kenyan government has subsequently committed to providing PrEP to 500,000 people annually who face substantial ongoing risk of HIV infection and to make at least half of all Kenyan adults aware of PrEP. PrEP is also available to purchase in private hospitals and clinics.
Research is also being conducted into the acceptability and impact of PrEP among young women and girls in high-incidence areas.
Antiretroviral Treatment (ART) In Kenya
In 2015, Kenya adopted the World Health Organization’s recommendations to immediately offer treatment to people diagnosed with HIV. As a result, in 2016, around 940,000 adults and 60,000 children were accessing antiretroviral treatment (ART). This equates to 64% of adults who are in need of treatment receiving it, and 65% of children.
Men living with HIV are significantly less likely to be on treatment than women. The most recent statistics showed that only 58% of men accessed treatment, compared to 68% of women. ART coverage is markedly lower among key populations, ranging from 6% among men who have sex with men to 34% among female sex workers.
In 2015, 81% of people initiated on treatment were still in care after 12 months, an improvement on the 2013 retention rate, which stood at 70%. Of those people on treatment in 2015, 64% were virally suppressed, which equates to 51% of all people in Kenya living with HIV. This is when treatment has suppressed the level of HIV in someone’s body to the extent that their health is in good condition and HIV will not be transmitted to others.
Initiating and staying on treatment is particularly problematic for adolescents and young people. In 2014, only 34,800 out of 141,000 adolescents (aged 10-19) with a known HIV positive status were on ART, of whom 22,600 were virally suppressed. AIDS remains the leading cause of death among adolescents and young people in the country with 9,720 adolescents and young people dying from AIDS-related illnesses in 2014.
Poor adherence to treatment can also lead to increased drug resistance. Drug resistance monitoring tests are not routinely performed in Kenya, so assessing levels of drug resistance in the country is difficult. In a recent study sample transmitted drug resistance of at least one type was recorded in 9.2% of cases. This is where patients have been infected with a form of HIV already resistant to some medications, which can make treatment options more limited before they have even started ART.
Civil Society’s Role in Kenya
Kenya has a large and diverse civil society, and the rights to freedom of association, expression, and peaceful assembly are guaranteed under Kenya’s 2010 Constitution. These rights are only partially respected in practice, although recent government crackdowns have tended to focus on civil society organisations working on electoral and governance matters.
NACC estimates that 14,000 civil society entities are engaged in HIV and AIDS activities in Kenya. The NACC is vocal in recognising the importance of these groups, especially those led by people living with HIV, and people from key affected populations.
Tuberculosis and HIV Co-infection in Kenya
In 2014, it was estimated that Kenya made up 3.3% of the total number of people living with an HIV/TB coinfection globally. Up to 38% of people with tuberculosis (TB) in Kenya are co-infected with HIV.
However, it is reported that 83% of people with a co-infection are being treated for both illnesses. This high figure shows commitment to tackling both public health issues. However, efforts to prevent co-infection have been slower, only 11% of people living with HIV were enrolled on TB preventative therapy in 2016.
Barriers to the HIV Response in Kenya
Kenya has demonstrated commitment in providing an enabling legal, social and policy environment at the national and county level to reduce barriers to health services for people living HIV. The country established the first HIV tribunal in the world to increase access to justice related to HIV issues.
HIV Stigma and Discrimination
Although awareness of HIV and AIDS is comparatively high in Kenya, and there have been countrywide anti-stigma campaigns, many people living with HIV continue to face high levels of stigma and discrimination. This deters many people living with HIV – particularly vulnerable groups – from seeking vital HIV services.
Attitudes towards people living with HIV are measured by the Kenya Demographic and Health Survey. The 2014 results – the most recent available – found 44% of men and 26%of women expressed wholly accepting attitudes towards people living with HIV, levels that were slightly lower than in the 2008 survey when 48% of men expressed wholly accepting attitudes and 33% of women did.
Unfortunately, people most at risk of HIV still face stigma, discrimination and violence. This adds to their vulnerability. Research shows that 44% of female sex workers, 24% of men who have sex with men and 57% of people who inject drugs were arrested or beaten up by police or city ‘askaris’ (vigilantes) in the last six months.
Legal and Structural Barriers
Homosexuality is currently criminalized in Kenya. Between 2010-2014, the Kenyan government prosecuted 595 cases of homosexuality.
The current law, coupled with the deeply entrenched social attitudes that it fuels, stops many men who have sex with men or people who are LGBT from accessing HIV services. A 2017 study amongst healthcare workers in Mombasa and Kilifi, home to relatively large communities of men who have sex with men, identified a range of discriminatory practices. For example, some healthcare workers reported facing discrimination from colleagues for tending to men who have sex with men.
In 2016 a group of civil society organisations began to challenge the current law as being unconstitutional. In February 2018, Kenya’s High Court began considering the coalition’s application to decriminalise consensual same sex conduct. A verdict is expected later in 2018.
The case before Kenya’s High Court…is of monumental significance for Kenya and beyond. A positive ruling would affirm that same-gender loving Kenyans are just as deserving of equality, privacy and dignity as anyone else.
Human rights gains are also being made in other areas of Kenyan law. In 2015, the High Court of Kenya declared a law that obliged people living with HIV to disclose their HIV status unconstitutional. Kenya is the first country in the world to take such a stance, seen by many as a breakthrough for the rights of people living with HIV.
Funding the HIV Response in Kenya
Funding for the HIV response in Kenya remains a significant challenge that needs to be addressed in order to provide scalable integrated health services, particularly for key populations.
As at 2018, approximately 75% of Kenya’s national HIV response was externally funded. Although government spending has more than doubled between 2006 and 2018 (from $US 57.49 million to $US153 million), dwindling funds from international donors pose a challenge for the sustainability of Kenya’s HIV response.
Kenya’s reclassification to lower middle-income status in July 2015 may see it miss out on vital funding as donors focus on low-income countries. Indeed, in the 2015/2016 financial year, a funding gap for Kenya’s HIV response of US $315.27 million was reported.
In addition, the cost of Kenya’s HIV response is expected to increase by 114% between 2010 and 2025, representing a funding gap of US$1.75 billion. In order to plug this, 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.
As in many countries, HIV treatment and care accounts for the majority of HIV expenditure (52% between 2009 and 2018). Prevention, which includes the provision of HIV testing services, accounts for around 21%.
The Future of the HIV Response 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, self-testing and PrEP. If implemented successfully, the Kenya HIV Prevention Revolution Road Map will enable the country to avert 1.1 million new HIV infections and 761,000 AIDS-related deaths by 2030.
The roadmap explicitly recognises what it describes as the “disparities” of the HIV epidemic, and commits to combination interventions, targeted towards the different needs of key populations and geographical locations. In order to achieve this, stigma and discrimination, arising from the criminalisation of key population groups and entrenched gender inequalities, must also be addressed if Kenya is to truly curtail its epidemic.
Further targeted interventions specifically for young people, plus enhanced monitoring and reporting, will also be crucial. Again, HIV-related stigma is the main barrier preventing young people from getting tested and staying on treatment, and innovative approaches are needed to address this.
Kenya will also need to further strengthen health systems, including finding new domestic funding sources, in order to stay on target and ensure 1.6 million people living with HIV are on treatment by 2025.