Friday, September 5, 2014

Revised History of HIV in Kenya - Part VI - Family Planning & STIs

Could sexually transmitted infection (STI) programs that started many decades before have been involved in the inadvertent transmission of HIV as early as the 1970s in Kenya? Those targeted by STI programs were women and men who attended STI clinics, or presented with STIs or STI symptoms. A short paper by Peter Piot is often cited to show that HIV prevalence went from 4% in 1981 to 61% in 1985 (Piot P, 1987), and that therefore sex workers (and their clients) must have been incredibly sexually active, and also far more efficient at transmitting the virus to men through heterosexual sex than one might expect (given what has been shown about transmission rates since then). But the possibility that these sex workers and their clients were infected through unsafe healthcare practices in STI and other clinics has never been ruled out.

Jacques Pepin in The Origins of AIDS argues that early STI programs were almost definitely involved in spreading HIV (Pepin, 2011) in the Democratic Republic of Congo. But he uses Piot's paper to argue that sexual behavior took over from unsafe healthcare at some time; why this happened, or when, is not very clear. However, the papers below suggest that the very people among whom HIV prevalence was found to be high would also have been frequent clients in STI clinics. Conditions in health facilities probably improved during the 80s and 90s, which would have accounted for the rate of new HIV infections peaking in the early 90s and subsequently declining. But given that healthcare is not particularly safe in Kenya now, we don't know if HIV is still transmitted through unsafe healthcare, albeit at a far lower rate.

Could invasive family planning methods such as intrauterine devices (IUD), inserted in insanitary health facilities, have been involved in the transmission of HIV, perhaps also as early on as the 1970s? Family planning was most accessible and most availed of in urban areas, and the users were more likely to be better educated, wealthier and formally employed (these are still true of family planning users). Some of the earliest institutions to work with HIV in African countries were those involved in family planning. They were already well established in many countries and persuading people to have smaller families, through any means possible, was what they knew best. That’s not to say they were particularly successful, but they certainly received the lion’s share of funding at one time, until the HIV industry became the top heavy, cash rich bureaucracy that it is today, where any big NGO that toes the party line will get ample funding. Perhaps some of the industry’s obsession with sexual transmission, to the exclusion of most forms of non-sexually transmitted HIV, relates to their origins, which can include puritanical religious beliefs, Malthusianism and neo-eugenicism, to name but a few.

Kenya is said to have been “the first country in Africa south of the Sahara to adopt family planning as a national policy” (Fendall & Gill, 1970), with the earliest family planning efforts starting in Mombasa in 1952. At first, it was decided that Kenya’s population growth was not particularly worrying and the policy started off fairly moderate. There were 25 clinics by 1965 in a country with a population of about 11 million (as of 1969). But in the early and late 60s, censuses showed that population growth was about 3%, far exceeding death rates. An average of 7 children were born to women reaching 50 years of age and average life expectancy was 40-45 years. Those engaged in family planning resolved to reduce fertility by 50%, with intrauterine devices (IUD) being seen as the best contraceptive method for achieving this. Family planning was to be integrated into public health services and it would be free and voluntary (although costs involved in attending the clinic were not covered, which may account for the relative popularity of longer acting methods, which didn’t involve repeat costs).

The number of clinics had reached 160 by 1970, with the biggest being set up in urban areas, along with some of the more heavily populated non-urban areas. Smaller units and mobile teams operated in less accessible areas (although some of the higher populated areas are not urban, such as in the Western and Nyanza provinces, where population is also dense). The Family Planning Association of Kenya claimed to have 17,000 clients in 1965, of which 70% were urban and 30% were rural. It is possible that independence interrupted progress that had been made in the previous two decades. With a growing population and limited revenue, the government needed to provide the free health service they had promised. But the first 20 years or so of family planning may have set some of the patterns that continued for the two or three decades following, and perhaps still exist. Contraception tends to be far more common in urban areas, among better educated, wealthier, urban dwelling people.

British colonial concern about sexually transmitted infections (STI) dates back at least to the 1920s and by the 1970s resistance to antibiotics and penicillin for the treatment of gonorrhea was already common in rural and urban areas. This may suggest that people with STIs had been able to access health services for some time, but that those services were not able to eradicate the most common infections. It is likely that many people did not return for some lengthier forms of treatment, which could involve a lot of discomfort, as well as considerable expense from travel and other costs. A paper from 1971 mentions ‘selected social groups’ being investigated in the past for resistance, including people in capital cities, harbor areas, ‘special elite groups’ (whoever they may be), foreign soldiers and ‘hostesses catering for them’ (Verhagen, 1971). (These are some of the groups among whom HIV was later found to be highest.) But the authors suggest that these groups are not representative of the population as a whole and exclude the majority of gonorrhea patients. It is hinted that the reason these groups are targeted in Kenya is that they may have been the groups most likely to be infected in wealthier countries, such as the UK, but that the analogy didn’t quite work. It is noted that Mombasa and Nairobi have ‘special VD clinics’, although the one in Mombasa only treats sex workers, whereas the one in Nairobi also treats the general population.

A paper published the following year aims to establish the determinants of gonorrhea in Kenya (it is notable that, out of the few papers available in full, many are about gonorrhea, fewer are about other STIs; also, most studies tended to be carried out in a handful of countries, with Kenya being one of the handful). It uses data from monthly checkups for sex workers at the Mombasa and Nairobi clinics mentioned above (Verhagen & Gemert, 1972). One of the authors, Verhagen (and perhaps some of his contemporaries), is interesting for being a lot less judgmental than one might expect, especially given the deep racism later found in institutions working with HIV. Some questions about sexual behavior were deemed ‘too intrusive’ to ask people in their control group. UNAIDS’ criteria for ‘sex work’ is often inclusive enough to be applicable to almost every sexually active person in the country, and even many people who are not sexually active. The authors also draw attention to the fact that attendance for all medical services increased rapidly when treatment became free in 1965.

Gonorrhea tends to infect people who may be more ‘promiscuous’, such as sex workers and their clients. Simple supply and demand would suggest that sex workers must be fairly small in number, whereas clients need to be plentiful. As sex workers are usually female and clients usually male, gonorrhea may therefore be expected to infect more males than females. Verhagen and Gemert find that the male:female ratio is 2:1 in 1964, rising to 6:1 in 1970 and 8:1 the following year. They note that the ratio for syphilis is usually around 2:1. The authors are not able to estimate incidence of gonorrhea but they conclude that Kenya has relatively low incidence, as the disease globally is said to be currently the most common notifiable disease after measles.

Despite earlier findings that patients with STIs are “found among distinct social groups such as the lower social strata, members of migratory or itinerant professions, and other groups characterized by social instability”, this paper concludes that there is “a striking similarity between patients and controls.” Many of the women were single and unemployed (although many were sex workers) and many people who were married and had STIs spent long periods away from their partner, this being more a feature of urban, rather than rural living. Men with STIs usually attributed their infection to someone other than their wife, while women with STIs were often less well educated, as well as being single and not conventionally employed, which strongly suggests that they were very poor. Even among those deemed to be sex workers, it was ‘the smarter and more expensive girls’ who received the monthly checkup, so they may have been less likely to be infected with gonorrhea and other STIs than other clinic patients.

UNAIDS and the HIV industry have a fondness for identifying (and thereby stigmatizing) multitudes of HIV ‘risk groups’, at least one of which almost everyone falls into at some time. In contrast, Verhagen and Gemert assume “that encounters in bars, brothels, dance-halls, and in the street (termed the BBDS category) were the more casual and usually reflected prostitution and promiscuity”. This must have made it a lot easier to target people at risk of being infected with an STI, or of transmitting it to others. The difference in approach may explain the lack of successful HIV prevention interventions, especially before the widespread availability of antiretroviral drugs. Half of the male patients are said to have been infected by someone they met in a brothel, a bar or a dance hall, with brothels only accounting for 10% of all gonococcal infections; the other half met the sexual partner on the street or near where the partner lived. Although the fairly small number of ‘promiscuous’ females infect a larger number of males, fewer of those males go on to infect another partner, such as their wife. The authors neither conclude that all (or most) men are promiscuous, nor that all (or most) females are. The phenomenon of large numbers of single men and married men who live away from their partner, which was very often the case in cities, and a small group of women to cater for their sexual needs, is identified as a major driver of high rates of STI transmission (as it was later said to be in relation to HIV). Even the ‘breakdown in traditional ethics’ said to result from migration and urbanization, frequently remarked on later, had been noted by authors several decades before.

Generally, far fewer women than men were infected with gonorrhea and other STIs. Quite a number of these women were said to be ‘non-promiscuous’, having been infected by a promiscuous partner. Sex workers are often badly educated, unemployed migrants whose marriage may have broken down and who come from a particular tribe associated with these and other factors. Comparing their study participants with a control group, it is found that many of the males are young, badly educated, unemployed, living in overcrowded conditions and are recent arrivals in the study area. The authors warn that “The self-image of an indiscriminately promiscuous community (which in view of our findings in regard to the regularly married is wrong), ostracism against prostitutes and emotional outbursts blaming a particular sex or group of persons are of no help.” That warning, along with others, was to fall on deaf ears. “No distinct high risk groups were found” in the course of this study.

The above papers are of interest to a history of HIV in Kenya because many sexually transmitted infections are a lot less likely to be transmitted through any other route, such as unsafe healthcare. In contrast, HIV is relatively difficult to transmit sexually and easy to transmit through unsafe healthcare, unsafe cosmetic practices and various skin piercing traditional practices. As I have mentioned in earlier posts, HIV is often correlated with higher wealth, better education, employment (as opposed to unemployment) and urban residence, and prevalence is generally higher among women. Many of the factors involved in the transmission of HIV seem to the opposite of those involved in transmission of gonorrhea and some other STIs.

What about factors for STIs and factors for HIV that seem to overlap, such as involvement with sex work, migration, mobility and the like? The above papers, along with others from the decades preceding the discovery of HIV, suggest that sex workers, immigrants, transport workers, migrant workers and those engaged in certain occupations had long been targeted by STI programs. These programs were most prominent in areas that attracted migrants, cities and areas with high labor needs. Could some of these programs have been inadvertently involved in the transmission of HIV to the groups that were later found to have been infected, as if en masse? What about family planning? Could the use of IUDs have infected many women? There is certainly plenty of evidence that conditions in health facilities were poor, that health facilities were oversubscribed, underfunded, understaffed and not the safest place to go for preventative or curative treatment. Even the connections between population growth and density alluded to by some HIV commentators may relate to the relative success of family planning and STI eradication programs in urban, as opposed to rural areas. Higher levels of education and wealth are generally associated with both family planning and health seeking behavior in general; but while these factors are associated with higher HIV prevalence, the opposite is true of STIs.

The massive increase in HIV prevalence among sex workers found in Nairobi, from 4% to 61% between 1981 and 1985, may have been a result of unsafe healthcare, especially in facilities providing STI and family planning services. Historical and contemporary studies show that HIV is only sometimes transmitted sexually; patterns of infection only overlap to a limited extent with those for STIs. The relative contribution of sexual and non-sexual transmission to Kenya's epidemic remains unknown; until it is known, epidemics like that in Kenya will continue indefinitely. Yet the HIV industry is still happy to accuse those infected of being highly promiscuous, and of being indifferent about transmitting the virus to their partners and infants.

[The list of publications below is short and I will comment on other publications in the next part.]


Fendall, N., & Gill, J. (1970). Establishing Family Planning Services in Kenya. Public Health Reports, 131-139.
Pepin, J. (2011). The Origins of AIDS. Cambridge : Cambridge University Press.
Piot P, P. F.-A. (1987). Retrospective seroepidemiology of AIDS virus infection in Nairobi populations. J Infect Dis, 1108-12.
Verhagen, A. (1971). Diminished Antibiotic Sensitivity of Neisseria gonorrhoeae in Urban and Rural Areas in Kenya. Bulletin of the World Health Organization, 707-717.
Verhagen, A., & Gemert, W. (1972). Social and epidemiological determinants of gonorrhoea in an East African country. British Journal of Venereal Diseases, 277-286.


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