Monday, April 6, 2009

A Short History of HIV in Kenya

[UPDATE: August 10 2014 - I am completely revising this short history and posting the new version in parts, on this blog and on my other blogs, Blogtivist.and Don't Get Stuck With HIVPart I Part II Part III Part IV]

In response to a recent blog post on the history of the HIV epidemic in South Africa, I would like to provide a brief history of the HIV epidemic in Kenya.

Kenya had a very different history from South Africa. In fact, the histories of most African countries may share similarities but are also subtly different. Therefore, each country is now experiencing very different HIV epidemics and need different sets of HIV prevention interventions.

Following independence in the early 60s, Kenya under Kenyatta saw many changes, some good and some bad. Spending on education, health, infrastructure and various social services increased. The country underwent a transformation and enjoyed a level of prosperity that was unmatched, before or since.

The early independence period was not perfect, of course. Some gained, some remained in the position they had always been in. In general, many people were employed and social and economic indicators showed improvement. But at the same time, those in the Kenyatta government had already started the process of enriching themselves from the public purse.

It is important to note an advantage that Kenya had over some other African countries. They opposed the soviet regime and were well rewarded for the part they played in the cold war. Kenya continues to support the current ‘war against terror’ and appears to be generally sympathetic to US aggression. It is probably not an accident, therefore, that they currently receive the tenth highest share of US aid money.

So, while health, education and other social infrastructures were being built up during the 70s, politics and governance were taking shape to eventually undermine many of the earlier gains. Kenyatta died and was replaced by Moi in 1978. (The current president, Mwai Kibaki, held senior cabinet posts in the Kenyatta and Moi regimes, so there is a high level of continuity between the early independence years and the present decade.)

HIV probably first reached Kenya in the late 1970s, coming from the Western Equatorial region via Uganda and perhaps via Tanzania. This was still some years before it would be identified, though some health professionals working in Kenya at the time retrospectively noted an unusual health situation characterised by acute versions of relatively common conditions.

1980: retrospective tests of blood samples from Nairobi commercial sex workers (CSW) show zero HIV prevalence (the percentage found to be HIV positive), but a sexually transmitted infection (STI) programme was established. So the virus may well have already been present in other areas because in 1981, retrospective tests show a prevalence of 4%. Around this time the US Center for Disease Control (CDC) noted a new disease that affected gay men.

Kenya had been receiving loans from the International Monetary Fund (IMF) and the World Bank for some years but it was in the 1980s that these institutions started to build conditionality into its loans. ‘Structural Adjustment Policies’ (SAP), which resulted in reduced spending on education, health, infrastructure and social services, had an enormous impact on the country. When HIV prevention efforts started, belatedly, they were seriously curtailed by these SAPs.

These SAPs continue to this day, sometimes under different names. This is despite clear evidence that their effects are almost entirely destructive. They play a major part in what can only be described as retrogressive development and the sooner they are reformed the better. As long as developing countries are compelled to reduce health, education and other services, they will be unable to develop or, therefore, to reduce the spread of HIV.

1982: AIDS is named and vertical (mother to child) and heterosexual transmission are recognised. The following year a virus is identified that is suspected of causing AIDS. It is later named HIV and World Health Organisation (WHO) HIV surveillance starts. In 1984 the first case of HIV in Kenya is identified and in the following year the National AIDS Committee is established.

For the whole of the 1980s and 1990s, even into the 2000s, Kenyan leaders persisted in denying the existence of HIV. There was plenty of evidence that HIV was a serious problem in Nairobi because prevalence among CSWs there peaked at 81%. Prevalence subsequently declined, despite the fact that HIV prevention efforts were not very widespread until many years later. In fact, it remains unclear why prevalence peaked so early among CSWs and then declined.

1987: the WHO formed the Global Programme on AIDS. The following year, Kenya’s Ministry of Health issues guidelines stating that patients should be told their HIV status. In 1989, President Moi is said to have ordered the quarantining of people with HIV/AIDS but the order was quietly ignored. By 1990, there were an estimated 7.5 million people living with HIV, globally.

Without the Kenyan government substantially moving from their position of denial, HIV incidence (the number of new infections per year) peaked at 2%. Prevalence in one province, Rift Valley, peaks at 14% in the same year. At this time, Moi publicly refused to admit that the HIV epidemic had become national in scope. Prevalence peaks in Western Province at 17% in 1994 and the government as a whole recognises HIV as a critical issue.

But in 1995, the Kenyan government still seems uninterested in the epidemic. Donor funds are not distributed or go missing and, although the countries blood stocks are found to be unsafe, the government denies that this poses a major problem. At this time 17.5 million people are living with AIDS, globally. Prevalence in Nairobi peaks at 17% and national prevalence is estimated at between 10 and 14%.

1996: Highly Active Anti-Retroviral Therapy is developed (HAART). In the same year, a Kenyan cardinal condemns the use of condoms to prevent HIV infection. The following year, HIV prevalence peaks. Early prevalence figures were subsequently revised and it is now thought that HIV prevalence peaked at 9 or 10% in the late 1990s.

1997: UNAIDS (Joint United Nations Programme on HIV/AIDS) is formed. The Kenyan Parliament approves a 15 year national AIDS policy and forms the National AIDS Council. Moi bows to election year pressure from religious leaders and shelves sex education plans.

1998: incidence is thought to have peaked globally at around 3.4%. A large number of Kenyan public sector employees die as a result of AIDS. The Great Lakes Initiative on AIDS (GLIA) is established. The following year, HIV in the last of Kenya’s provinces peaks; North Western Province peaks at a relatively low rate, 6%, although this and other figures are often questioned.

In the same year, Moi declares AIDS a national disaster but is still reluctant to do anything about it. He says he feels it would be improper to encourage the use of condoms in schools and colleges. However, the National AIDS Control Council was formed and is still in operation.

2000: an estimated 27.5 million people are living with AIDS, globally. Kenya develops a five year National AIDS Strategic Plan and plans AIDS education for all schools and colleges. The Millennium Development Goals (MDG) are adopted by the international community and reducing the spread and impact of HIV are include in this initiative.

2001: the Global Fund to Fight AIDS, TB and Malaria (Global Fund) is formed by the World Bank. Moi, in the run up to another election, publicly expresses reluctance to spend public money on condoms. He recommends abstinence as protection against AIDS. Christian and Muslim leaders join him in opposing condoms.

2002: the new president, Mwai Kibaki, declares ‘Total War on AIDS’. However, the following year, Global Fund grants are withheld because of corruption allegations. Widespread corruption, misuse and disappearance of funds are discovered and, unusually, some people are held accountable.

2003: Kenya’s prevalence is found to have dropped to 6.7% and the death rate peaks at 120,000 per year. These are highly significant milestones. As HIV incidence peaked in 1993 and declined thereafter, it would follow that prevalence would peak some years later, around the end of the 90s, say. A few years after that, it follows that many people would die of AIDS and prevalence would drop dramatically. The first wave of the HIV epidemic ended in the early 2000s.

2005: globally, 37 million people are living with HIV. AIDS deaths peak at around 2.2 million. Kenyan prevalence is said to stand at around 6.1%. A new five year strategic plan, due to run up to 2010, is published. The following year, Kenyan prevalence is said to have fallen again, to around 5.1%.

2007: global prevalence is revised downwards as a result of improved reporting methods. HIV figures are confusing, but data collected in Kenya suggest that prevalence had been rising since 2004 and had reached 7.8%. This is despite the previous assumption that prevalence had been falling continuously since the late 90s and had dropped to about 5.1%

The data published in 2008 show rising prevalence and my interpretation is that this may indicate a ‘new wave’ of the HIV epidemic. On the other hand, it may indicate no such thing. Estimations are very imprecise and predictions are dangerous. Some say HIV in Kenya is declining, some say otherwise. Personally, given the apparent connections between the spread of HIV and the country’s history, I would suggest that that Kenya is in a worse state now than it was in the 1980s and is therefore experiencing another serious HIV epidemic.

Holding a pessimistic position when everyone wants something to be optimistic about is hazardous; people want you to be wrong. But, as I have said elsewhere on this blog, I too would like to be wrong. I am not an epidemiologist, I could well be ignoring many factors and exaggerating the effects of others. No doubt it will be some years before the true picture is known. It is to be hoped, in the meantime, that some effort is made to improve health, education, social services and governance. These are in serious need of attention, regardless of what the HIV epidemic is doing at present.

allvoices

11 comments:

apostleshadamishe said...
This comment has been removed by a blog administrator.
Tamaku said...

Hi Simon,

This is a fascinating insight. I'll link to this article when I post on gay men and hiv aids. Thanks.

Simon said...

Hi Tamaku. Thanks, I have seen your blog, it's great. I have written very little on gay men in Kenya because I haven't really researched the area much yet. But I hope to do so some time. S

MrK said...

Hi,

It is very easy for people to misdiagnose 'HIV/AIDS', especially as it is 'a syndrome' without a single pathology. The only thing that distinguishes someone showing for instance TB from someone with TB and HIV/AIDS, is a (series of) positive test(s).

At the same time, it is very tempting for corporations to renege on their obligation to pay compensation for the health impact of their corporate policies, and blame their workers illnesses on a contagious STD ('they did it themselves'). So for instance, when a diamond mine in South Africa lets it's miners dig for diamonds, which are found in layers of asbesthos dust, and it does nothing to protect them from asbesthos - it is easy to claim that this is not asbesthosis, but tuberculosis caused by HIV/AIDS ('their own' irresponsible behavior).

The same thing could very easily be going on in Kenya, or any country that is subject to Structural Adjustment Programmes, which originate with the IMF/World Bank, part of which is always a reduction in healthcare spending and educational services to those who cannot afford fees.

How easy would it be to misrepresent thousands of children roaming the streets because the government no longer hires teachers, as 'AIDS orphans'? And of course, in the new absence of hospital services, treatable diseases become deadly. What better way for the IMF/World Bank to shirk it's responsibility for this, than to blame Kenyans' own behavior?

There are several interesting articles about HIV/AIDS predictions, and how they so massively missed the boat around the world.

From a BBC article back in 2007 titled Experts Doubt Widespread HIV Risk:

Dr James Chin was head of a WHO Global Programme on Aids unit from 1987-1992. In a new book, he says people in the general population outside Africa are unlikely to contract HIV/Aids, as it is restricted to certain high-risk groups. ... Dr Chin says it is only in sub-Saharan Africa, where unprotected sex outside marriage is common, that the risk of heterosexual HIV transmission is high.

Apparently, HIV does not spread heterosexually anywhere on the globe... except in Sub-Saharan Africa, because 'people have sex outside of marriage there'. Undoubtedly, everyone in the USA, Europe, South America and Asia are all faithful to their spouses, and that is why...

But wait a minute. HIV/AIDS is not spread widely throughout SS-Africa, because the predicted HIV/AIDS infection rates have been revised downward for West, Central and East Africa, just not for Southern Africa. From The Boston Globe, back in 2004:

Estimates on HIV called too high
New data cut rates for many nations
By John Donnelly, Globe Staff | June 20, 2004

PRETORIA -- Estimates of the number of people with the AIDS virus have been dramatically overstated in many countries because of errors in statistical models and a possible undetected decline in the pandemic, according to new data and specialists on the disease.

In many nations, analysts are cutting the estimates of HIV prevalence by half or more.

MrK said...

Rwanda, for instance, a new United Nations estimate due out next month will put HIV prevalence at about 5 percent, according to Rwandan officials, down from more than 11 percent four years ago. In Haiti, a recent unpublished study by the Centers for Disease Control and Prevention has found HIV prevalence was less than 3 percent, compared with the UN's most recent estimate of 6 percent. And the numbers in India are coming under increasing scrutiny because surveys in AIDS hot spots are indicating a prevalence rate that is much lower than the national average.What was going on here, is that UNAIDS, the UN organisation created to push the campaign about HIV/AIDS, knowingly used models that increased estimates of HIV/AIDS infection in Africa out into the stratosphere. This is how they did that. They (1) used an unrepresentative subset of the population, namely pregnant women at antenatal clinics. They (2) used only a single screening test, which is extremely sensitive, and gives many false positives without confirmation, which through the WHO, they were allowed to do in surveys. Testing for diagnosis in the USA for instance is very different. You have to have 2 screening tests, followed by 2 confirmation tests, all of which have to be positive, before you can be allowed to be called 'HIV positive'. This standard is lowered in Africa, and it is lowered to a single screening test in use of surveys in Africa. This practice is still in place today, both in the Antenatal Clinic Surveys, and in statistically representative Demographic and Healthcare Surveys (DHS). Another peculiarity of the single ELISA screening test, is that it gives very high rates of false positive in women, specifically women who have been pregnant before. (To quote dr. Robert Frascino in this article: " 1. No, there is nothing wrong with you or the women in your family. It's primarily a limitation of the testing assay that picks up cross-reacting proteins that can occur in women who are or who have been pregnant. These cross-reacting proteins cause the HIV-antibody test to read positive or indeterminate (in the case of some Western Blots), even though the person is HIV negative. That's why we call it a "false-positive". Other tests can easily and definitively differentiate a true- from a false-positive (see below). ")

MrK said...

However, even though these two survey types use the same single ELISA test, the DHS survey was less flawed than the one testing only pregnant women at antenatal clinics. This is because they are women (and not men, relevant if HIV passes from men to women more easily than from women to men, which is why there is no heterosexual epidemic anywhere in the world, in my opinion), they are pregnant (meaning, not girls or abstent), they went to antenatal clinics (relevant if most of the population lives in rural areas and STDs would spread more easily if there is more opportunity for contact, like in cities), and they were adults (and not children). This, to any 1st year political science student, makes them unrepresentative for the general population, which is how these results were treated.

In an article that is basically the same as the Boston Globe article, but was published two years later in the Washington Post, shows the dramatic downward revision of HIV infection rate estimates. Rwanda went from 11% to 3%. Kenya went from 15% to 6.7%. Sierra Leone went from 2.99% to 0.9%.

All of this resulted simply from using a statistically representative survey type. How much farther these data should be revised downward, from using a DHS survey, with confirmation tests, is speculation, because it has not been done to this date.

The experts have now come down from the 'Everybody Is At Risk' line (see this article named "The authorities have lied, and I am not glad", by dr. Michael Fitzpatrick), which they pushed to give more awareness to HIV/AIDS. Today, they are pushing the same "There is no more HIV/AIDS epidemic worldwide... just in Southern Africa" line, to save their faces. No public explanation of why they got it so massively wrong, no apologies, just, oh, ok, what's next?

To quote from this article:

For Chin, the British AIDS story is an example of a ‘glorious myth’ – a tale that is ‘gloriously or nobly false’, but told ‘for a good cause’. He claims that government and international agencies, and AIDS advocacy organisations, ‘have distorted HIV epidemiology in order to perpetuate the myth of the great potential for HIV epidemics to spread into “general” populations’. In particular, he alleges, HIV/AIDS ‘estimates and projections are “cooked” or made up’.

Another interesting article from back in 2004, when these data first came out:

As if AIDS isn’t bad enough ...the UNAIDS campaign in Africa is making it worse.
Stuart Derbyshire

From back in 2001:

AIDS in Africa: why the West is interested
How the UN donor countries are distorting the extent of AIDS, and using safe sex messages to push African societies around.
by Stuart Derbyshire

Erin said...

Hey Simon I was wondering if you had sources for this info, I am writing on HIV and AIDS in Kenya and thought I might be able to use some of your sources. Much thanks,
Erin

Simon said...

Hi Erin
Thanks for your message. The items are mostly from standard sources, UNAIDS reports, Kenya HIV reports, Demographic and Health Surveys, Human Rights Watch reports, Human Development Reports, that kind of thing. It was just an appendix to my MA dissertation, added when I had too little time to put in the references, though they would all be in the bibliography!

Some of the most up to date papers on HIV in Kenya now include the final Kenya Aids Indicator Survey, the HIV Prevention Response and
Modes of Transmission Analysis and the latest National Aids Strategic Plan. These are all available online.

I hope that's useful, do get back to me if you need something more specific and good luck with your study.
Regards
Simon

Simon said...

Hi again, Erin
Here's a paper that looks at Kenya's delayed response to Aids. It's also a kind of history of HIV in Kenya:
http://www.allacademic.com//meta/p_mla_apa_research_citation/3/6/4/0/4/pages364047/p364047-1.php

Eric Mugambi, MD said...

Excellent post. I got here while looking for a 'history of HIV in Kenya' for my article on Elimination of mother to child transmission in Kenya. I must say this is about the best information I have come across to date. Thanks!

Simon said...

Thank you Dr Mugambi, I wouldn't mind reading your article when it's available.