HIV and AIDS in Kenya:

A Brief Overview and Analysis of the Present and Future HIV Epidemic

Photo by Catherine Nyambura. Source: http://ruralreporters.com/where-we-are-30-years-since-kenya-

documented-first-hiv-case/

Maria Osborne
Due June 3rd, 2016
Honors 222A
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1. Current State, Trends, and Context of the HIV epidemic in Kenya

Since Kenya’s first documented case of AIDS in 1984, the East African nation’s HIV

epidemic has grown into the fourth largest in the world, with an estimated 1.5-1.6 million

infected residents. 6% of people living with HIV and AIDS (PLWHA) in sub-Saharan Africa

live in Kenya, the third highest percentage out of all sub-Saharan African countries after South

Africa and Nigeria (UNAIDS Gap Report 17). Kenya experiences a generalized epidemic, with

about 6.7% HIV prevalence among the general population and most new infections occurring as

result of heterosexual contact. However, it is concentrated by region, with most infections

occurring in a few counties in the southwest of the country: adult prevalence peaks at 27.1% in

Homa Bay county. There are also certain populations that are at higher than average risk. Sex

workers in particular have extremely high prevalence of about 30%, but men who have sex with

men (MSM), people who inject drugs (PWID), and women are also disproportionately affected.

Prevalence for MSM and PWID is at about 18%, and adult female prevalence as measured in

2008 was 8% versus 4% adult male prevalence (Gadlin-Cole et al. 2013, 11). A fifth of the total

new HIV infections every year occur among young women aged 15-24 (Kilonzo et al. 2014).

The HIV epidemic was devastating to Kenya in the 1990s and was declared a national

disaster in 1999. But due to interventions and responses mounted by the government and NGOs,

epidemiological trends over the last two decades have largely been very positive. In general, new

infections and mortality has been declining since peaks in the late 1990’s and early 2000’s

(Progress Towards Zero 2014). Particularly encouraging is that the number of AIDS-related

deaths dropped by 60% from 2005 to 2013 (Progress Towards Zero 2014). While Kenya comes

in third place among sub-Saharan African countries in terms of number of PLWHA, it is 7th in

terms of AIDS-related mortality. The number of PLWHA people on antiretroviral therapy (ART)
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has also increased drastically, from virtually zero in 2003 to almost 800,000 today. However,

some trends are less encouraging in that they have leveled off in recent years, including rates of

child infection from HIV positive mothers (Progress Towards Zero 2014, 23). The total number

of yearly new infections has also been relatively stable ever since declining to a rate of 100,000

per year in 2000 (Kilonzo et al 2014, 4). The number of new infections per year from 2009 to

2013 only declined from 116,000 to 100,000 (Progress Towards Zero 2014).

Important demographical factors to consider include that most of the population is below

the poverty line of living on $1 or less per day. Furthermore, Kenya is a rural country with 75%

of the workforce engaging in agriculture, primarily subsistence farming (Gadling-Cole et al.

2012, 1). HIV Prevalence has historically been lower in rural areas that urban areas; however,

prevalence has converged to the national rate of 6.7% in both urban and rural settings. While

urban prevalence has decreased to that number from a peak of 18% prevalence in 1997, rural

prevalence has only decreased from a peak of 8% in 1997 (Progress Towards Zero 2014). This

slower decline can be accounted for in part simply by the fact that such high urban prevalence

led to high numbers of deaths among urban populations, but it also reflects the challenges of

providing testing, counseling, education, and treatment to remote populations. Currently, rural

men are more likely to have HIV than urban men (Progress Towards Zero 2014). Kenya also

hosts a substantial mobile population, due to issues like poverty, ethnic violence, and the nature

of common occupations like commercial farm work and sex work. Migrant populations can be

vulnerable to infectious diseases for various reasons, ranging from language barriers to less

access to education, to having regular sexual partners in various locations, to the risk of sexual

violence faced by migrant women and sex workers (UNAIDS Gap Report 2014, 159).
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The cultural, political, and social context surrounding the HIV epidemic in Kenya is rich

and complex. HIV and AIDS are still heavily stigmatized in Kenya, and stigma of the disease

often overlaps with and exacerbates the stigma of marginalized populations where HIV is

concentrated. One of these populations is gay men and men who have sex with men exclusively

(MSME). In a 2005 survey, about 35% of MSME were infected with HIV, which was much

higher than rates for bisexual men and men who have sex with both men and women (Carter

2013). MSM in general experience greater barriers to accessing care and sex education, because

same-sex sexual activity among men is often culturally unacceptable as well as technically

illegal in Kenya. Homophobia and anti-gay laws have had negative effects on the effort to study

HIV/AIDS and provide treatment and support to infected individuals in the Kenyan MSM

community; for example, there have been instances of police-conducted raids and disruptions of

advocacy organizations that aim to educate MSM about HIV (Nordling 2014).

The traditionally patriarchal structure of Kenyan society has also created an intersection

between the stigma of HIV and that of being female. Like many other sub-Saharan African

nations, HIV prevalence is higher among women than men. In Kenya, the HIV epidemic has

often been framed in terms of women as spreaders of the virus and men as their victims.

Women’s perceived sexual promiscuity is a source of blame among infected men, despite how

Kenyan culture is much more accepting of men having multiple sexual partners than women

(Kamau 2013, 29). Differing standards in female and male monogamy is a driver for behaviors

that put both men and women at risk for contracting sexually transmitted infections. It is socially

acceptable for men, including married men, to have multiple sexual partners, which puts female

partners at substantial risk for contracting STIs even if they are monogamous (Ambasa-

Shinsanya 2009, 96). 16% of married Kenyan women are in polygamous unions, and some
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ethnic groups, such as the Luo, traditionally practice widow inheritance and use sexual

“cleansers” (Gadling-Cole et l. 2012, 11).

The gender differences in HIV infection may be partially explainable at the education

level: while the majority of Kenyan children complete primary school, there is still a literacy gap

between men and women, for example (Progress Towards Zero 2014). But even if women are

theoretically informed of safer sex practices and HIV transmission, sexual power dynamics and

decision-making in practice are often male-centric. For example, many women in communities

such as the Abaluhya and Luo communities rely on their male sex partners to make the decision

to use a condom (Ambasa-Shinsanya 2009, 90). Cultural expectations regarding motherhood and

the gender dynamics of procreation are another potential problem in preventing HIV infections.

Couples’ desires for children leads them to make certain decisions about contraception: married

women are less likely than single women to use condoms. Such practices reflect larger social

attitudes regarding gender dynamics and the role of women in society. For many Kenyan women,

to not bear children is to risk their marriage or their own social standing (Kimani et al. 2015).

The majority of the Kenyans practice some form of Christianity, and about 28% of the

population is Catholic. Since most African Catholic churches do not condone condom usage,

religious attitudes further inhibit safer sexual behavior (Ambasa-Shisanya 2009, 66).

Additionally, the Christian view of women as sexual temptresses of men has perpetuated

gendered stigma of HIV/AIDS (Kamau 2013, 33).

Pregnant women also may actively avoid getting tested for HIV due to stigmatization. A

“normal,” healthy birth is seen as one that does not need to take place in a health care facility, as

is suggested for pregnant women with HIV. Therefore some expecting mothers reject prenatal

care and antenatal clinics altogether (AVERT 2015). Fortunately, rates of HIV testing of
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pregnant women has increased enormously over the course of just a few years, and as of 2013,

over 90% of pregnant Kenyan women were being tested for HIV (AVERT 2015). Provider

Initiated Treatment and Care (PITC) or “opt-out” testing HIV approaches tend to be aimed at

pregnant women, which probably accounts for why this number is so high (National AIDS and

STI Control Programme 2015).

Early age of sexual debut is also associated with higher risk of contracting HIV among

women and girls. Young girls are likely to make their sexual debut with a man who has more

sexual experience and therefore might have been exposed to STIs, and young people in general

exhibit riskier sexual behavior including very low condom use. Around 20% (slightly higher if

only counting boys) of Kenyan youth report having sex before age 15, and among 15-24 year

olds in Kenya, HIV prevalence is four times higher in female than in males (Onsomu et al. 2013,

47). However, data from the Kenya AIDS Indicator Survey shows that over time fewer teenagers,

both male and female, have been making their sexual debut before the age of 15 (Progress

Towards Zero 2014). Thus there are some shifts occurring in attitudes and practices regarding

sexuality.

2. Structural, Biomedical, and Behavioral Control Efforts and Intervention Strategies

Kenya has a substantial history of instituting structural/policy level programs to address

the national HIV epidemic. In 1999, the president established the National AIDS Control

Council (NACC). The NACC brings together people from governmental ministries, the private

sector, PLWHA, representatives from faith-based and community organizations and forms the

single most important agency formulating strategies to combat the HIV epidemic in Kenya. It

advocates behavioral changes to prevent the spread of HIV, and developed the “ABC” approach
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to prevention in the early 2000’s, which stands for Abstinence, Being faithful, and using

Condoms. In 2006, Kenya passed legislation entitled the HIV and AIDS Prevention and Control

Act. There are now upwards of 1,200 voluntary HIV counseling and testing (VCT) sites in the

country. Also in 2006, the government pledged to remove fees on ART following a food crisis

that left many Kenyans unable to afford medication. ART is now provided for free to PLWHA in

Kenya. Funding for public health programs and HIV responses largely comes from international

organization and donors, especially the United States President’s Emergency Plan For Aids

Relief (PEPFAR). PEPFAR funds 64% of HIV responses in Kenya, with the next highest sources

of funding being the Government of Kenya (20%) and the Global Fund (8%) (PEPFAR 2015,

13).

The 1990’s saw widespread campaigns aimed at increasing awareness of HIV and how

the virus is spread, and mass media awareness campaigns are still an integral part of responses to

the HIV epidemic. At least on a basic level, awareness and education campaigns have largely

been very effective: virtually all adult Kenyans have heard of HIV and most know that it is a

sexually transmitted infection, for example. The Ministry of Education also introduced an

HIV/AIDS/STI curriculum to be taught in primary and secondary schools in the early 2000’s.

Gaps still exist in education: only a slight majority of young people can identify correct

information about preventing the spread of HIV and misinformation about HIV transmission,

and boys are better at doing so than girls (AVERT 2015). This could be resultant of how the

official curriculum recommendations have focused primarily on the medical facts of HIV and

abstinence as prevention, rather than prevention strategies like condom usage. Of course, public

education and mass media campaigns are only the first step in combatting the HIV epidemic: it is

not enough for information to exist—it needs to inspire individuals to change their behavior, get
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tested for HIV, and access health services. In terms of implementation, success of interventions

has been mixed.

One such behavioral intervention with varying levels of success employed in Kenya is

condom usage. The Ministry of Health introduced a national condom policy and strategy in 2001,

and male condoms became available for free at government health facilities around the same

time. Demand for condoms has indeed risen over time, and drastically within short time periods:

from 50 million in 2002 to 110 million in 2004, for example. Condom use in the general

population remains lower than is ideal: only 40% of adults who had multiple sexual partners in

the last year report using a condom during the last time they had intercourse (Progress Towards

Zero 2014). People living in rural areas are especially likely to forgo condoms or to wash and

reuse condoms due to limited availability, and Kenya has experienced condom shortages that

have further inhibited their accessibility. However, among certain high-risk populations condom

use is actually quite high: over 80% of female sex workers report that they used a condom during

their last sexual encounter (AVERT 2015). And both Kenyan government and NGO’s have been

quite proactive in addressing the epidemic among sex workers. The Bar Hostess Empowerment

and Support Programme (BHESP) is an example of a national non-governmental organization

formed in 1998 that advocates for the health of women who have sex with women, female sex

workers, and women who inject drugs. Much of their activity surrounds protecting and educating

these women using peer-educator approaches. Studies done among sex workers in Mombasa in

2007 showed peer-mediated interventions both increased consistent condom use and decreased

HIV prevalence among sex workers, who can be difficult to reach through traditional health care

avenues (Luchters et al.l 2008).

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On the side of biomedical interventions, Kenya was one country where the efficacy of

male circumcision as a method of preventing spread of HIV was tested. Although circumcision

at adolescence is a traditional ritual within some ethnic communities in Kenya such as the

Maasai, it is not a widespread cultural or religious practice. Voluntary medical male

circumcision (VMMC) programs began in 2008, and from 2008 to 2013 the number of total

VMMCs in Kenya rose from around 8,000 to over 670,000 (Progress Towards Zero 2014).

Young men, under age 20, are much more likely to get circumcised than middle-aged and older

men (MMWR 2012). While this is problematic given that men above age 20 are much more

likely to contract HIV than younger men, it does perhaps indicate a shifting culture surrounding

acceptability of circumcision and will likely benefit the younger generation.

HIV testing is integrated into VMMC programs in Kenya, but getting other individuals

into medical facilities to be tested and receive personalized counseling remains a challenge. VCT

sites tend to be underutilized despite their availability (Ambasa-Shinsanya 2009, 25). There is

also a gender disparity in VCT use, with more women accessing services than men. Reasons

commonly cited for not visiting VCT facilities include perceived lack of need for testing,

especially due to trusting one’s partner/spouse to be monogamous (Epule et. al. 2013, 41). As a

result of such attitudes, VCT is particularly underutilized in married couples. As most of HIV

infection in Kenya occur between heterosexual partners, and marriage very often does not ensure

monogamy (in addition to male infidelity, Kenyan sex workers are very often married), skewed

perception of risk is damaging the way in which individuals contact and receive counseling from

health care professionals.

Besides male circumcision and free distribution of ART, other biomedical interventions

may alter the face of the projected epidemic. In December of 2015, Kenya’s Pharmacy and
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Poisons Board approved oral pre-exposure prophylaxis (PrEP) for use among high-risk

individuals (AVAC 2015). Recent studies surrounding PrEP use in Kenya have investigated its

potential effectiveness both in high-risk populations (MSM and female sex workers) and among

heterosexual serodiscordant couples. It remains to be seen whether PrEP will be cost-effective

enough to become available for widespread use, but it has the potential to very positively impact

the future of the Kenyan HIV epidemic by reducing transmission between serodiscordant couples.

3. Projected Epidemic

In terms of general disease burden, according to 2011 projection by the Kenya Health

Service Support Project (KHSSP), total deaths from communicable diseases in will drop from

over 250,000 per year in 2010, to under 150,000 per year in 2030 (KHSSP 2012). This projection

also indicates that the number of deaths from communicable diseases will fall to below the

number of deaths by non-communicable diseases by that year (in 2010, there were about 2.5

more deaths by communicable diseases than deaths by non-communicable diseases).

HIV-specific projections are less precise. In general, HIV prevalence is not expected to

drop substantially in the near future (Sanchez et al. 2008). This is unsurprising, as the substantial

drop in prevalence after 2000 was primarily due to mortality. Now that more infected individuals

are living longer and new infections are generally stable, it is unlikely that overall HIV

prevalence will change significantly in the next decade. It is also possible that the number of new

infections could start to increase after 2020 along with overall population increases, even with

improved prevention strategies. HIV is currently the number one leading cause of death in Kenya,

and there will be an estimated 60,000 AIDS-related deaths per year up to the year 2020,

according to projections by UNAIDS (PEPFAR 2015, 36). Life expectancy in Kenya, like many
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other African nations, dropped drastically due to AIDS mortality, but is now steadily recovering.

As of 2012, life expectancy was at 52 years (KHSSP 2012). According to some models, life

expectancy in East Africa will raise to over 60 years by 2030, so a general decline in HIV-related

morbidity and mortality is to be expected (African Development Bank 2011, 16).

Economic and demographic trends over the next several years have the potential to

impact the HIV epidemic in a variety of ways. For one, Kenya is undergoing urbanization, and as

people move into urban areas they are more likely to have access to government health care

facilities and therefore to HIV testing, prophylaxis, condom distribution sites, etc. GDP is also on

the rise. However, there will likely be a large strain on public health resources going forward.

The population of Kenya actually has one of the highest growth rates in the world. Such

population growth is putting stress on natural resources and thus exacerbating issues faced by

impoverished communities such as food shortages/insecurity (Rural Poverty Portal 2014). And

with numbers of new HIV infections not declining substantially, the economic burden of

providing ART (especially now that life-long ART is the recommended protocol) is going to

remain high for the next several years. Environmental issues like climate change are also

affecting and will continue to strain poor communities and government resources allocated to

funds like drought and food assistance (Rural Poverty Portal 2014). So it is difficult to say

exactly what the HIV epidemic will look like in a decade, as these wider contextual issues have

the potentially to both positively and negatively affect poverty and public health in general.

However, there hopefully there should be improvements within high-prevalence populations due

to targeted intervention strategies, as discussed in the next section.

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4. Control Efforts: Meeting the 90-90-90 Goals by 2030.

Kenya has extremely ambitious development goals for the year 2030, both in terms of

health care (including HIV and other infection diseases) as well as other metrics. In some facets,

their goals are even more ambitious than the already lofty 90-90-90 goals: the Kenyan

government is currently seeking to essentially end their HIV epidemic by 2030. Kenya has a

history of aiming high in terms of public health goals: rates of MTCT, for instance, were

supposed to be effectively zero by 2015, which clearly has not happened (AVERT 2015). The

National AIDS Control Counsel currently has goals very similar to the 90-90-90 goals in place

for 2019. In fact, the NACC report refers to 90% ART coverage, 90% ART retention after 12

months, and 90% viral suppression among those on treatment as “expected results” by 2019

(“Strategic Direction 2” 2015).

At the 2011 National HIV Prevention Summit, the Kenyan Government presented their

“Prevention Revolution Road Map,” a plan which seeks to bring new HIV infections in Kenya

down to 0 in the year 2030 (Kilonzo et al. 2014, 3). A primary focus of this plan is shifting

prevention efforts into a more behavioral-focused capacity, rather then relying as heavily on

biomedical prevention and treatment. This includes, for example, expanding condom availability

to a point where 30 condoms per adult person are distributed per year (up from less than 1 as is

current), as well as promoting use of female condoms and as extending accessibility of condoms

to all areas and populations. On a structural and legal level, this plan includes changing laws that

stigmatize at-risk populations like MSM and sex workers and developing interventions that offer

financial incentives for accessing care (Kilonzo et al. 2014, 36). It also recognizes the need to

target high-risk populations though implementation of, for example, alcohol and substance abuse

programs for sex workers and PWID.

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Kenya’s goals for the year 2030 include not only HIV-specific aims, but also general

improvements in the country’s economy, standard of living, poverty rates, etc. In terms of

resources, the Road Map also sets goals for substantial increased domestic funding of HIV

research, treatment, and interventions. It also aims to increase private sector involvement in HIV

research and programs. It is important that these goals acknowledge the intersection of disease

and economics, since poverty and public health are closely intertwined, but that doesn’t mean

that such goals are necessarily feasible. According to the Kenya Institute for Public Policy

Research and Analysis, achieving these 2030 goals would require an increase in gross domestic

product of 10%, which is in excess of current and historical trends (Progress Towards Zero

2014).

5. Opinion and Recommendations

While Kenya has made extraordinary and commendable progress in addressing its HIV

epidemic, it still faces immense challenges in reaching the 90-90-90 goals at every stage of the

care cascade. I believe that these challenges will be too immense to overcome within the next

13-14 years, and that Kenya will fail to meet the 90-90-90 goals by 2030. This starts at the first

goal which centers around extensive testing and knowledge of one’s HIV status. Kenya actually

has some of the best statistics for number of people that have been tested for HIV in Sub-Saharan

Africa; unfortunately, the numbers are still far from universal. According to the DHS, just over

half of adult women and 40% of adult men in Kenya had ever received an HIV test. Results from

the Kenya Aids Indicator Survey conducted in 2012 concluded that more than half of adults are

unaware of their current HIV status, and models estimate that about 52% of infections are
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undiagnosed (Carter 2014). HIV testing will have to reach much more people on a more

consistent basis to reach the goal of 90% of those infected having a formal diagnosis.

At the next step of the cascade there are, for various reasons, significant gaps between the

number of people getting tested and finding they are HIV positive and eligible to receive ART

and those who actually begin treatment. Estimates of the number of eligible infected individuals

who are on anti-retroviral treatment vary. 2013 information from the Kenyan Ministry of Health

places national adult ART coverage at 79%, however, this figure probably reflects outdated

standards of treatment. Now that international guidelines recommend that all infected individuals

receive ART regardless of CD4 count, 2013 data from UNAIDS that places adult ART coverage

at 55-60% of all infected adults is probably more representative of reality (UNAIDS Gap Report

2014, 237). So there is a problem both with making people aware of their HIV status and with

making sure infected individuals actually begin treatment.

A 2011 study from Nairobi found that a third of eligible persons in a cohort of

serodiscordant couples had yet to begin ART a year after testing positive. Part of this gap can be

accounted for economically: while ART is free in Kenya, individuals may face transportation

costs in order to get somewhere that distributes medication, for example. However, there was

also a perception among infected individuals with relatively high CD4 counts that since they

were not currently experiencing the effects of AIDS, that they had no need to start treatment and

risk side effects of treatment (Leach-Lemens 2011). And now that international guidelines count

all infected individuals as eligible for ART, the gap between those diagnosed and those on

treatment could be higher than these figures fro 2011. There are now likely more asymptomatic

individuals with high CD4 counts that not highly inclined to start medication, especially if they

face preexisting accessibility issues. Retention of those on treatment also remains a challenge.
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After 12 month, the retention rate for those on ART is about 92%, but the 60-month retention

rate drops to 70% (UNAIDS Gap Report 2014). Related to retention issues are the number of

people who are virally suppressed, which is currently less than 40% of infected individuals

(Cherutich et al. 2016). Even if ART becomes more widely available, there will still be a long

way to go in terms of improving adherence to the point where most people have an undetectable

viral load.

ART coverage also drops to 35-40% for people with HIV below age 15. As of 2013,

only about 60,000 children in Kenya were receiving ART (AVERT 2015). Additionally, only

around 60% of infected pregnant women are on ART, (UNAIDS Gap Report 2014, 40). Kenya

actually has commendable national guidelines regarding counseling of pregnant women, but the

challenges lie in meeting those guidelines. Even though 90% of pregnant women are tested, most

do not attend all their recommended antenatal appointments and most infected women don’t

receive antiretroviral medication (Sirengo et al. 2014). The percentage of children born to HIV

positive mothers has stalled at around 14% in the last 3-5 years (Progress Towards Zero 2014,

23). Many of Kenya’s prevention efforts have been centered around raising awareness of HIV

transmission by means of sexual intercourse among adults, so to have a better chance at reaching

the 90-90-90 goals, there must be more focus on enforcing guidelines to treat child-bearing

women and prevent vertical transmission. There also needs to more follow-up testing and

treatment for children once they are born and their mothers are no longer receiving antenatal care,

to reduce the significant gap in ART coverage among children with HIV.

According to the HIV Testing Serviced Guidelines published by the ministry of health

and last updated for 2015, both Client Initiated Testing and Counseling (CITC) and PITC are

currently acceptable approaches to HIV testing (National AIDS and STI Control Programme
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2015). I mentioned previously that PITC is utilized most often with pregnant women, and it is

also currently used in VMMC sites, where about 80% of men undergoing the procedure agree to

the test (MMWR 2012). I would recommend that opt-out testing become more universal in the

Kenyan Medical System. It’s worth noting that there are some ethical issues with opt-out testing,

since the Kenyan ministry of health has issued guidelines stating that HIV testing should only

occur with the patient’s consent, barring extenuating circumstances such as the patient being

unconscious. PITC has been criticized in that excellent rates of HIV testing among pregnant

women, especially rural-dwelling and less educated women, have come at the expense of

informed consent of women accessing prenatal care (Center for Reproductive rights 2008, 11). I

do not believe this is cause for eliminating PITC or opt-out testing, but rather for retooling the

way it is utilized. This could involve training medical personnel to understand consent more

thoroughly, conducting awareness campaigns so women know their rights, and implementing

structures like formal complaint mechanisms to protect those rights (Center for Reproductive

rights 2008, 63).

Kenya also continues to struggle to address the epidemic sufficiently as it exists in

populations with very high HIV prevalence, including injection drug users, of whom about 18%

are infected. Kenya has implemented some harm reduction programs, including needle

exchanges, but very few facilities have been set up and only about 15% of injection drug users

are accessing needle exchange programs (AVERT 2015). Sub-Saharan Africa in general has

done very poorly in providing coverage to PWID, and recent statistics show that only 1% of HIV

positive injecting drug users in Kenya are on ART (UNAIDS Gap Report 2014, 180). (I

mentioned in the introduction that just in the last decade, ART coverage has gone from

practically zero to about 800,000 people. If that rate were to continue, then there would actually
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be a chance of reaching near-universal coverage by 2030. The reason I doubt that this rate is

sustainable is because of abysmal statistics like this one—until difficult-to-reach populations like

PWID or rural communities or migrant workers also have near-universal access to ART, Kenya

cannot possibly “end” its epidemic as it aims to by 2030.) So given that this is one of the highest

risk groups in Kenya, tailoring interventions to injection drug users is both crucial for addressing

the epidemic and sorely insufficient at the present time. I would strongly recommend expanding

the needle exchange system in Kenya.

As instituting harm reduction programs like needle exchanges depends on the social

acceptability of PWID, targeting other vulnerable populations such as MSM requires significant

shifts in cultural attitudes towards sexuality. The first step in combatting this problem would be

to eliminate the laws that make homosexuality illegal, however, homophobia as a social norm

will be difficult to address. Cultural attitudes towards violence will also need to change. Kenyan

sex workers also experience violence and rape at extremely high rates; over 80% of female sex

workers in Mombasa report incidents of sexual violence. It is estimated that infection incidence

among sex workers could be reduced by 25% by reducing sexual violence (UNAIDS Gap Report

2014, 192). A simpler change that could positively impact sex workers would be to change the

way sex work is criminalized. Kenyan police use condom possession as evidence of sex work,

which could discourage their use among sex workers and non sex workers alike, and thus leave

many people vulnerable to STI’s (UNAIDS Gap Report 2014, 193).

The point is that various social taboos and political structures make it difficult to address

the HIV epidemic in highly affected populations. It is the marginalized members of society that

bear the most concentrated burden of the epidemic as well as face the most substantial cultural

and practical barriers to care or protection (Kamau 2013, 28). It is important to realize that
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significant behavioral changes cannot just rely on appealing to the social and cultural status quo

to be effective. Goals like reducing homophobia, stigma around drug use, and acceptability of

sexual violence constitute broad shifts in cultural paradigms and thus will be extremely difficult

to achieve. One potential starting point of combatting these social attitudes would be to work

with churches, since the vast majority of Kenyans are religious.

So my recommendations for strategies largely center around better tailoring interventions

to these specific groups including PWID, MSM, sex workers, and children. Tailoring

interventions to address how women are disproportionately affected by the HIV epidemic is

crucial as well. Part of this includes aiming preventative measures at men since, as many sub-

Saharan African nations, men are less likely to know their HIV status and HIV spreads more

easily from a male to a female partner than the other way around. The typical “ABC” awareness

campaigns have been criticized for not addressing the needs of women, so one approach is to

develop education and mass media campaigns that are more specifically relevant to Kenyan

women (Kamau 2013, 30). One possible intervention would be better availability and awareness

of female condoms. Female condoms are currently unavailable at many PMTCT and

circumcision facilities (Whipkey et al. 2014, 1). And many women still do not either know of

their existence or how to use them (Ambasa-Shinsanya 2009, 91). Making female condoms

widely available would be the first step, but health care providers would also need to be trained

to counsel women and couples on their use. Female condoms have the potential to empower

women to make conscious decisions about their sexual health within relationships where they

might feel less influential in sexual/reproductive health choices than their male partners.
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6. Conclusions

My assessment that Kenya will likely not reach the 90-90-90 goals by 2030 is not to say

that the country has not made truly admirable progress in reducing HIV infections, morbidity,

and mortality. Rather it reflects how lofty the 90-90-90 goals are, and that the challenges of

shifting everything from public health policy to general economic conditions to normative social

and cultural attitudes in order to meet those goals will be very great. We’ve already seen some

trends, like mother to child transmission and total new infections, start to stall, which is

indicative that Kenya may have trouble sustaining the progress its made. This is especially true

now that Kenya faces the challenges of implementing interventions in hard-to-reach groups of

people. While I do not believe that those challenges will be completely overcome by 2030, I do

think that there are many steps that would take the country in the direction of hitting the 90-90-

90 more quickly. Kenya is headed in the right direction with many of their interventions, and

many of my recommendations would center around increasing the scale of interventions that

have already been moderately effective: medical male circumcision, for example. They also need

to step up efforts to stop the disconnect between women and the health care system that occurs

after they give birth, and start diagnosing and treating more pediatric HIV cases. Going forward,

there needs to be more education on the benefits of starting ART whether or not individuals feel

sick or have low CD4 counts, in accordance with new standards of treatment. Lastly, Kenya

needs support for marginalized populations like MSM and PWID, and more practical education,

like widespread teaching of how female condoms work, that can empower women to make safer

sex decisions. Much of the history surrounding Kenya’s HIV epidemic can be a considered
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successful, and while goals as high as the 90-90-90 goals are perhaps out of reach, we will

hopefully see more success stories coming out of the country in the future.
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