Kenya quietly takes public health approach with HIV most at-risk groups

Chief Rose Ayere talks to a group of injecting drug users in Nairobi.

This was originally published on Global Health TV on May 27, 2014.

NAIROBI and KISUMU, Kenya — Anti-gay legislation recently signed into law in Uganda and Nigeria has alarmed organizations implementing HIV prevention in Africa, fearing that such laws will further stigmatize and marginalize at-risk populations already hard to reach with health services.

So when I traveled to Kenya this month to interview men who have sex with men (MSM), injecting drug users (IDUs), and people working in programs trying to help them supported by the International HIV/AIDS Alliance, I wondered whether I would encounter “the next Uganda” in gay rights. I did not, but what I did find surprised me.

Certainly there is a great deal of stigma and discrimination toward gay people in Kenya, everybody told me. I already knew this from 2012, when I was working on abortion in Kenya and a health provider told me that abortion was the most stigmatized issue in Kenya, except for homosexuality.

But the Kenyan government has quietly adopted mostly sensible and evidence-based policies towards both MSM and IDUs, according to the many HIV, MSM and IDU activists and implementers with whom I spoke.

So perhaps it should not be surprising that serious progress is being made against HIV in Kenya: HIV prevalence has dropped from 7.2% in 2007 to 5.6% in 2012, according to the Kenya AIDS Indicator Survey 2012. UNAIDS says the number of new infections declined by 32% between 2001 and 2011. Of new infections in Kenya, 15% come from MSM and prisoners and 4% come from IDUs, according to the National AIDS and STI Control Program.

“If you look at the government and the support it gives to the drop-in centers [for MSM and sex workers], you see that Kenya is doing better than other countries [in terms of its approach to most at-risk groups],” according to Teresa Watetu Maina, who runs such a drop-in center just outside Nairobi. At that center, government provides condoms, lubricants and technical assistance.

That program even collaborates with the police, although that is challenging because of constant reassignments and transfers. “It has been hard work,” said Watetu Maina. “You go the police, they buy in, you have a very good commanding officer and then he’s transferred. You have to go back and start the work all over again.”

Earlier this year, an anti-gay bill, like the one in Uganda, was introduced in Parliament.

“I know several people who lobbied a few members of Parliament to make them understand what the repercussions of having such a law in Kenya would be from a public health perspective,” said Jack Ndegwa of the Kenya AIDS NGO Consortium (KANCO), which implements MSM and IDU programs for the Alliance. “I am so grateful to the Ministry of Health that came out with a very comprehensive statement, saying the law was likely to have very negative health repercussions for key populations.”

The bill has not gone anywhere and, for the moment, is no longer being discussed.

The government’s evidence-based approach is not limited to MSM; it is also being applied to HIV prevention with IDUs.

In Muthurwa, a poor area of central Nairobi, I attended an unusual meeting between the local administration and a dozen IDUs.

“Nowadays, we don’t want to arrest you for using drugs, we want to help you overcome drugs,” Chief Rose Ayere told the drug users. “Use condoms. Get tested. If you have TB, there is a clinic in town. Go for early treatment so we don’t lose you to TB. If you are infected with HIV, the government has ARVs. It is free and you can take it in privacy. To take ARVs, you need good nutrition. NOSET (the Nairobi Outreach Services Trust, an implementing organization of the Alliance) can help you with that.”

If Chief Ayere sounded more like a public health expert than a government bureaucrat, it is because of a project called Community Action on Harm Reduction (CAHR), the first harm reduction program in Kenya, implemented by KANCO in Nairobi and the Coastal Region with support from the Alliance.

Chief Ayere told me that before the advent of CAHR, she used to arrest IDUs. “We didn’t know that IDUs are sick people who need special treatment and attention. Through training and facilitation by NOSET our mindset has changed and we became partners in the harm reduction program. These people need protection, not harassment, by security agencies in order to undergo treatment and reform.”

Now Chief Ayere is on a campaign to convince other chiefs to take a similar approach. She believes the number of HIV infections has dropped as a result. In July, CAHR expects to start a methadone program — the first such program in Kenya — to help IDUs manage the harmful consequences of drug use. A new publication of UNAIDS shows that harm reduction programs can significantly reduce HIV.

Even a police raid on the offices of Men Against AIDS Youth Group (MAAYGO), a men’s health and advocacy organization in Kisumu, last month provided an advocacy opportunity. MAAYGO used subsequent meetings with police and local authorities to educate them on how HIV prevention with MSM can help bring down the 15.1% HIV prevalence in Nyanza Province, the highest in all of Kenya. At the time of my visit, MAAYGO had returned to its MSM work from a new office.

Over and over again, I heard that on MSM and IDU issues, government is part of the solution and the main impediments are media and the mainstream churches. 

Kenyan media consistently misreports, exaggerates and sensationalizes both of these issues in negative and irresponsible ways, program implementers say.

However, the role of churches is mixed. “The big churches, like Anglicans, Catholics and Seventh Day Adventists, are very much against us,” according to Kennedy Otieno of MAAYGO. “But the reformed and redeemed churches, the Peacemakers and the Quakers are very much supportive and will accept gay men in their congregations.”

People told me that overall, stigma from the general population is the greatest challenge for preventing HIV infection among MSM.

“Government has to play a stronger role in explaining to the public why MSM work is important,” said Otieno. This was the strongest criticism I heard of the government’s approach to most at-risk populations. But Otieno also thought government was playing a constructive role.

The rest of Africa has a lot to learn from Kenya in terms of responding to the needs of its most at-risk groups and in preventing HIV infections.