Kenya has the joint fourth-largest HIV epidemic in the world (alongside Mozambique and Uganda) in terms of the number of people living with HIV, which was 1.6 million people in 2016. Roughly 36,000 people died from AIDS-related illnesses in the same year, although this figure is steadily declining from its total of 51,000 in 2010.
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% in 1996, and had fallen to 5.9% by 2015. This is mainly due to the rapid scaling up of HIV treatment and care.
Key affected populations in Kenya
Kenya’s HIV epidemic is often referred to as generalized – affecting all sections of the population including children, young people, adults, women and men. Up to 2015, 660,000 children were recorded as being orphaned by AIDS.
30% of new HIV infections in Kenya are among people from key populations
However, in recent years a number of studies have identified concentrated epidemics among certain groups who are particularly vulnerable to HIV transmission. The government’s current HIV/AIDS strategy, the Kenya AIDS Strategic Framework 2014/2015 – 2018/2019 [pdf] (KASF) acknowledges this, describing the epidemic as “deeply rooted among the general population” alongside “concentration of very high prevalence among key populations.”
It is estimated that 30% of new annual HIV infections in Kenya are among people from key populations. This is disproportionate to how many people from these groups exist within the population.
Geographic location is also a factor, with 65% of all new infections occurring in nine out of the country’s 47 counties – mainly on the west coast of Kenya.
Men who have sex with men (MSM) and HIV in Kenya
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 statistics, from 2010, estimate HIV prevalence among men who have sex with men at 18.2%.
Condom use among men who have sex with men is fairly low but has been rising. In 2013, an estimated 69% 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 “largely considered to be taboo and repugnant to [the] cultural values and morality” of Kenya.
The act of sodomy is illegal in Kenya and can carry a prison sentence of up to 14 years.
These legal and social attitudes lead to high levels of stigma and discrimination towards men who have sex with men as well as other members of the lesbian, gay, bisexual and transgender (LGBT) community, deterring many people from seeking the HIV services they need.
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.
People who inject drugs (PWID) and HIV in Kenya
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.Low condom use and unsafe injecting practices exacerbate transmission.
In 2012, Kenya introduced needle and syringe programmes and opioid substitution therapy to help reduce HIV transmission among people who inject drugs.. In 2016, 155 clean needs and syringes were distributed per person who injects drugs. In the same year, UNAIDS found nearly 90% had used a clean syringe last time they injected, compared to 51.6% in 2012.
Sex workers and HIV in Kenya
Sex workers have the highest reported HIV prevalence of any group in Kenya. In 2011, an estimated 29.3% of female sex workers were living with HIV. By comparison, 2011 findings from the Sex Workers Outreach Project showed an HIV prevalence of 30% among female sex workers and 40% among male sex workers.
This is echoed in a 2015 study of female sex workers in Nairobi, which found around one-third to be living with HIV.
However, 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. For example, the 2015 Nairobi study (mentioned above) found 86.9% reported using a condom with their last client and almost two-thirds (62.6%) always using a condom with clients. Testing rates were also high with 86.6% having ever tested for HIV and 63.1% having tested for HIV in the past 12 months.
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 2014, 7.6% of women were living with HIV compared with 5.6% of men.
Young women (aged 15-24) account for up to 21% of all new HIV infections with a prevalence of between 4 and 6 times higher than males of the same age. This is found across all groups and across all geographic areas, from young female sex workers and young women who inject drugs to young women in discordant couples and young women in and out of school.
As 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.
33% of girls in Kenya have been raped by the time they reach the age of 18
In addition, young Kenyan women are more than three times more likely to be exposed to sexual violence than young Kenyan men.About 33% of girls in Kenya have been raped by the time they reach the age of 18, with 22% of girls aged 15-19 reporting their first sexual intercourse to have been forced.
Young Kenyan women also have a lower level of HIV knowledge than their male peers. The 2014 Kenyan Demographic Health Survey (KDHS) found that only 54% of young women could correctly identify ways of preventing sexual transmission of HIV and rejecting misconceptions about HIV transmission, compared to 64% of young men.
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. There are an estimated 260,000 couples in HIV sero-discordant couples (when one partner is HIV negative and one is positive). These couples significantly contribute to new infections.
As a result, HIV testing and counselling (HTC) has become a major feature of Kenya’s HIV response. The country has adopted a number of innovative approaches to HIV testing in recent years, including targeted community-based HIV testing and door-to-door testing campaigns. In 2015, Kenya announced plans to introduce self-test kits and began evaluating distributors.There has been a dramatic rise in the number of people testing for HIV. In 2008, 860,000 people were being tested annually for HIV. By 2013, this had increased to 6.4 million.
Although annual testing rates have nearly doubled since 2008/2009, 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.
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%.
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 which witnessed 100,000 new infections across the country.
The National AIDS Control Council (NACC) is the body responsible for co-ordinating the response to the HIV epidemic in Kenya. The KASF 2014/15-2018/19 sets out four objectives over its five-year duration:
- reduce new HIV infections by 75%
- reduce AIDS-related mortality by 25%
- reduce HIV-related stigma and discrimination by 50%
- increase domestic financing of the HIV response to 50%.
In 2015, government representatives from Kenya, Zimbabwe and South Africa met to plan the development of a regional roadmap to increase the use of combination HIV prevention services in each country. Combination prevention mixes behavioural, medical and structural interventions and is widely regarded as the most effective approach to preventing new infections.
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.. It is currently conducting research into the uptake and impact of PrEP, specifically with young women and girls in high-incidence areas.
Condom distribution 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.One report from rural northern Kenya found men reusing condoms or using plastic bags and cloth rags due to shortages and difficulties accessing free supplies at government health facilities.
Even when condoms are available, this does not guarantee their use. The 2014 KDHS found only 40% of women and 43% of men who had two or more partners in the last 12 months reported using a condom the last time they had sex.
Preventing mother-to-child transmission (PMTCT)
Kenya is committed to eliminating mother-to-child transmission of HIV. Strategies to achieve this include efforts to increase knowledge of PMTCT, greater male involvement, universal attendance of pregnant women at antenatal clinics, universal uptake of HIV testing among pregnant women and the provision of antiretroviral drugs for those who test positive.
In 2015, 59,000 women were offered 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 mainly due 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, due in large part to PMTCT services.
Starting in 2010, the Kenyan government has implemented various programmes to encourage male involvement in PMTCT. However, involvement remains low, standing at 4.5% in 2014.
Kenya was one of only three countries in sub-Saharan Africa to increase VMMC in 2015.
Voluntary medical male circumcision (VMMC)
In 2008, Kenya implemented the voluntary medical male circumcision (VMMC) for HIV prevention programme. Areas with the highest HIV prevalence among uncircumcised men were prioritized.
By 2015, the programme had circumcised 860,000 males (aged 15-49) and met its universal coverage target of 80%.By 2016, 92.6% of men in the country were circumcised.
Kenya was one of only three countries in sub-Saharan Africa to increase VMMC in 2015. There has been a worrying decline in this intervention throughout the rest of the region..
HIV education and awareness
HIV education and awareness is an important component of HIV prevention in Kenya. The most recent policy on HIV education, published in 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 because women and girls are disproportionately affected by the epidemic.
Only 54% of young women and 64% of young men had comprehensive knowledge about HIV prevention.
HIV and AIDS education has been part of the school curriculum in Kenya since 2003. However, the 2014 KDHS found that only 54% of young women and 64% of young men (aged 15-24) had comprehensive knowledge about HIV prevention. A 2014 study found HIV knowledge to be significantly higher among university students.
Teaching young people about HIV and sexual health remains controversial. The KDHS 2014 found around 60% of both men and women to be in favor of educating young people about condoms, with the remaining 40% against it. Many cited fear of encouraging young people to have sex as a reason for being against the promotion of condoms.
Antiretroviral treatment (ART) in Kenya
In 2015, Kenya began to adopt 2015 World Health Organization recommendations to immediately offer treatment to people diagnosed with HIV. This should increase ART access further.
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.
Tuberculosis and HIV co-infection
In Kenya, up to 38% of people with tuberculosis (TB) are co-infected with HIV. 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.
HIV stigma and discrimination in Kenya
Although awareness of HIV and AIDS is comparatively high in Kenya, many people living with HIV 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 KDHS. The 2014 results – the most recent available – reported 92% of women and 95% of men saying they would be willing to care for a relative who became ill due to HIV. 77% of women and 84% of men said that they would be willing to buy fresh vegetables from someone with HIV, and 88% of both women and men agreed that a female teacher who has HIV but is not sick should be allowed to continue teaching.
These levels have improved since measuring began in 2003.However, levels of stigma and discrimination remain high and continue to hamper the national HIV response.
In 2015, the High Court of Kenya declared as unconstitutional a legal provision which obliges people living with HIV to disclose their HIV status. 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.
Unfortunately people most at risk of HIV still face stigma, discrimination and violence. This adds to their vulnerability. Research from 2014, 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.
Funding the HIV response in Kenya
Approximately 68% of Kenya’s national HIV response is externally funded.The remaining 30% is funded by the Kenyan government (17%) and private individuals (13%)%).
Although government spending has more than doubled between 2006 and 2012, dwindling funds from international donors pose a challenge for the sustainability of Kenya’s HIV response.
As in many countries, HIV treatment and care accounted for the majority of HIV expenditure (52%) between 2009 and 2013. Prevention, which includes the provision of HIV testing services, accounted for 21%.
Although government spending has more than doubled between 2006 and 2012 (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 middle-income status, in July 2015, may see it miss out on vital funding as donors focus on low-income countries.
In addition, the cost of Kenya’s HIV response is expected to increase by 114% between 2010 and 2020, 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.
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.
In 2014, the Ministry of Health published the Kenya HIV Prevention Revolution Road Map. This outlines a new approach to drastically reduce new HIV infections that is “evidence-informed, rights-based and gender sensitive”. Its goal is to bring HIV infections to “near zero” 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.
Progress on the roadmap is yet to be reported. However, if implemented successfully, the government projects it will avert 1,149,000 new HIV infections and 761,000 AIDS related deaths by 2030 and save the country $US 19.9 billion.