After the civil unrest in Kenya early last year, many Kenyans ended up in camps for internally displaced people (IDP). They went to these camps for immediate security but many have stayed because their security is still not guaranteed and, in many cases, they have nothing to go back to. There are hundreds of thousands of Kenyans in IDP camps, although not all of them are there as a result of last year's post election violence.
Whatever about the conditions in IDP camps, people leaving these camps face acute hardships. They need to find a safe place to live and a way of making money, for a start. For some, cities are considered the best place to find work. If work cannot be found or if the pay is not adequate, some resort to various forms of transactional sex for survival, at least for a while.
Unemployment is very high in Kenya, people are facing high prices for basic goods such as water, food, fuel and accommodation. Therefore, finding work is not always enough. When employers know they can get cheaper, they pay less. The same applies to the clients of those depending on sex for survival. For some time, it has been a buyers' market. Certain bars in Nairobi have noticeably more females than males. The men can find what they want and negotiate a low price and even refuse to pay. There is no one to protect those engaging in survival sex.
This scenario can increase the pressure to have more clients per night and to take more risks, such as agreeing not to use a condom, agreeing to anal sex, group sex, anything that will attract more money. This increases the probability of contracting and transmitting HIV and other sexually transmitted infections (STI). It also increases other dangers that sex workers face because of their increased vulnerability, the increased amount of time spent on the street and numerous other considerations.
To make matters worse, there are extreme food shortages in many parts of the country right now. More and more people are moving to urban areas, especially Nairobi and Mombasa, but also other towns and cities. They are looking for work and access to basic goods. This is adding to the existing flow of people and creating a very dangerous situation.
Something curious happened in the mid 1980s in Nairobi. At this time, there were far more men than women in the city (and there probably still are). But in 1986, rates of HIV (and gonorrhoea) peaked among commercial sex workers (CSW). HIV peaked at 81%, one of the highest rates experienced anywhere. But the reasons why HIV peaked at this time, nearly a decade before HIV incidence (the rate of new infections) peaked in Nairobi, are not clear.
I have yet to hear a plausible explanation of why HIV peaked among CSWs, especially as the figures are for those who were new to sex work. There was very little prevention work being carried out at the time and what work had been done would hardly have had much time to produce results. Is it possible that there was a reduction in the number of CSWs, possibly because of an improving economic climate, and a consequent sellers’ market?
Well, rather than speculate further on that phenomenon, after all, I could just research it, I would like to speculate on what is happening right now in Nairobi and other parts of the country, especially urban areas.
If an increasing number of people are currently depending on survival sex, this could give rise to a huge increase in transmission of HIV and other STIs. Current crises, such as the water, food, fuel and economic crises, all increase vulnerability. An estimated 10 million people face starvation. A huge percentage of the population is extremely vulnerable.
HIV can take ten or eleven years to kill you. But you can die of thirst in a few days. Starvation is pretty quick too. Add to this the fact that you may have children and other dependents and survival sex doesn't seem nearly as dangerous.
Whatever politicians may say and whatever newspapers may publish about biofuels, world economic crises, global food shortages, global warming or any other reasons for current food shortages, around 70% of recently acquired maize has disappeared. Those to whom the maize was entrusted are known to those distributing it, but no one has yet been held accountable. Somewhere in the country, there is either a large amount of maize or a large amount of money.
Kenyan politicians are asking international donors for help, yet help may be closer at hand than they think. Their colleagues may have the maize or the money or they may know where it went to. Politicians raise a lot of questions but they should be closer to the answers than anyone. Ultimately, large stocks of food are under their care. If anyone can answer the questions, it is politicians or their friends and associates, people close to the top.
A survey in 2007 found that HIV prevalence in Nairobi had fallen slightly since 2003 (although it has been increasing in most provinces). In years to come, if HIV transmission is rising right now, it will probably be said that there was a food crisis, a fuel crisis, an economic crisis or any other crisis that has yet to come. But poor people in Kenya have been poor and vulnerable for a long time.
True, these crises make things a lot worse, but HIV is increasing because vulnerabilities are still not being addressed, more than 25 years after HIV was identified. Many social indicators have been disimproving since the 1980s but these issues continue to be ignored. Perhaps politicians can continue to hide behind multiple crises but when has there been a time that there wasn't some crisis, ostensibly beyond their control, that they could blame?
We may have the opportunity, right now, to intervene and prevent a significant number of new HIV infections that are about to occur under our noses. The technology to prevent these infections is well known and widely available. It's called food.
Will the Kenyan government do what it can to reduce the vulnerabilities faced by so many Kenyan people? Or will they just allow them to die and later attribute their deaths to circumstances beyond their control? Not all circumstances are beyond their control.
Showing posts with label World Aids Day. Show all posts
Showing posts with label World Aids Day. Show all posts
Friday, January 23, 2009
Tuesday, December 2, 2008
UNGASS and Others Floating on Top
In May of this year, the NACC (National AIDS Control Council) completed the UNGASS (United Nations General Assembly Special Session on HIV and AIDS) report that purported to indicate how Kenya was doing in the fight against AIDS. The report hails Kenya’s success in halving HIV prevalence, from 10% in 1997/98 to 5.1% in 2006. They report that there is “strong political will and commitment at all levels” and that some of the factors that contributed to Kenya’s success include “the improved harmonization and leveraging of resources with and among development partners and" various other technical jargon.
It was surprising that the UNGASS report should have come to these conclusions because the data to back them up was mostly incomplete or simply not supplied. In July of this year, the KAIS (Kenya AIDS Indicator Survey) found that HIV prevalence had actually increased between 2003 and 2007. Prevalence now stands at 9.2% for women and 5.8% for men, with a national prevalence of 7.8%. Rates are usually higher for women as they more easily become infected with HIV.
People working with HIV, including myself, were unsurprised by the KAIS findings. HIV increased in 6 out of Kenya's 8 provinces. It fell slightly in Nairobi and Central provinces. The biggest increases were in Coast and Rift Valley provinces. Increases, in general, are higher for men than for women, suggesting a real increase, rather than an apparent one.
Of more significance to a place like Mumias and the surrounding towns is the fact that the number of people becoming infected in rural areas is far higher than the number in urban areas (1 million people and 400,000 people, respectively). The percentage of infections is higher in urban areas but most Kenyans, around 75%, live in rural areas. Prevalence is 7% in rural areas and 9% in urban areas.
Even the UNGASS report notes that in Kenya, “rural populations continue to trail behind urban ones in the pace at which infection rates drop”. These authors go on to say that 60% of VCT sites are in urban or peri-urban areas and that ways of addressing that imbalance are presently being ‘promoted’. Whatever being 'promoted' means, I hope that after nearly thirty years of HIV, they will find a way of reaching the majority of the population, the same people who are also denied adequate levels of health, education and other social services.
Considering men are being infected in higher numbers now than they were in 2003, it is worrying that far more women test than men and the increase in testing among men has been disappointing. In fact, in both Kenya and Tanzania, I have talked to people who say that men will often get their wife or partner to test and then get tested themselves if the result is positive. In many couples, only one partner is positive, so these men are playing a kind of Russian roulette.
Similarly, apparently people sometimes ask other people, perhaps their partner, to collect antiretroviral (ARVs) drugs on their behalf. This has more serious consequences when both parties are infected as they then end up sharing the drugs, which runs the risk of drug failure and of building up resistance.
Those who are isolated from testing facilities, many rural dwellers, are also isolated from ARV facilities. Malaha, Shibale and Shianda are just three examples of that phenomenon. Because there is no VCT there, there is no outlet authorised to distribute ARVs.
It is not a well kept secret that many Kenyans live in rural areas, nor is it a secret that most VCTs, indeed most public services, are found in urban areas. The need for more voluntary councelling and testing (VCTs) is pressing but even more pressing is the need for mobile VCTs. That is, unless the government is going to pay for people's transport costs to visit a clinic and perhaps compensate them for loss of earnings. I don't see that happening.
UNGASS claims that there are almost 1000 VCTs in Kenya, but that is not enough for the Kenyan population, in excess of 38 million. Nor are the clinics distributed widely enough to be of benefit to most people. This would be the case even assuming that all VCTs are working to capacity, a very risky assumption.
UNGASS also claim that VCT, ARVs and TB medication are given free of charge in government facilities. But as we have seen in Western Kenya, access to those services and other costs are not free. Nor are the other things that people need when on ARVs or TB drugs, such as treatment for various illnesses and nutritional supplements.
(This is similar to the claim that all children are entitled to free primary and secondary education. There are many costs involved in education which are not met by the government and many children are not going to school or their attendance is not very high.)
World AIDS Day in Mumias was great, insofar as many people turned up. I hope the photographs speak for themselves. There was a number of organisations there of various kinds, a UN organisation promoting the AIDS vaccine initiative, the NACC, a big project in partnership with USAID called Aphia II, a Western Kenya based organisation and SAIPEH. The last two are the closest to the people on the ground, but they don't seem to see any of the millions of dollars that are said to go to Kenya every year. Yet they have been round for longer than most of the others.
There was a temporary VCT clinic and a real mobile VCT clinic. Which is wonderful, except that Mumias is the one place out of the four I visited that actually has its own permanent VCT clinic. Not so many people queued up to be tested yesterday, which is a pity, because I'm sure they had plenty of testing kits this time.
But on the subject of VCT, we have probably all heard about how confidential they are, and that's supposed to protect people against stigma and discrimination. Well, if you go to the VCT clinic in St Mary's Hospital, Mumias, you will notice that it is a separate building, outside the hospital compound. Everyone passing can see who is waiting in line outside the clinic and there is only one thing to go there for.
Eileen Stillwaggon, in her excellent book AIDS and the Ecology of Poverty, makes the point that when HIV and AIDS are seen as separate from health and welfare in general, this contributes to the stigma and discrimination suffered by people who are known to be HIV positive. In fact, there are many health conditions that have little or nothing to do with HIV, but that make people more susceptible to HIV.
Stillwaggon suggests that instead of setting up separate, standalone clinics for HIV, governments could set up clinics that treat others of the many conditions affecting people in developing countries. Only by improving health in general will sexual and reproductive health be improved. And reductions in the transmission of HIV will follow.
But more about this sort of argument another time. The top down approach to HIV in Kenya has failed and needs to be changed radically. There are many people who can advise on what sort of changes need to be made. It's time the government started talking to them.
It was surprising that the UNGASS report should have come to these conclusions because the data to back them up was mostly incomplete or simply not supplied. In July of this year, the KAIS (Kenya AIDS Indicator Survey) found that HIV prevalence had actually increased between 2003 and 2007. Prevalence now stands at 9.2% for women and 5.8% for men, with a national prevalence of 7.8%. Rates are usually higher for women as they more easily become infected with HIV.
People working with HIV, including myself, were unsurprised by the KAIS findings. HIV increased in 6 out of Kenya's 8 provinces. It fell slightly in Nairobi and Central provinces. The biggest increases were in Coast and Rift Valley provinces. Increases, in general, are higher for men than for women, suggesting a real increase, rather than an apparent one.
Of more significance to a place like Mumias and the surrounding towns is the fact that the number of people becoming infected in rural areas is far higher than the number in urban areas (1 million people and 400,000 people, respectively). The percentage of infections is higher in urban areas but most Kenyans, around 75%, live in rural areas. Prevalence is 7% in rural areas and 9% in urban areas.
Even the UNGASS report notes that in Kenya, “rural populations continue to trail behind urban ones in the pace at which infection rates drop”. These authors go on to say that 60% of VCT sites are in urban or peri-urban areas and that ways of addressing that imbalance are presently being ‘promoted’. Whatever being 'promoted' means, I hope that after nearly thirty years of HIV, they will find a way of reaching the majority of the population, the same people who are also denied adequate levels of health, education and other social services.
Considering men are being infected in higher numbers now than they were in 2003, it is worrying that far more women test than men and the increase in testing among men has been disappointing. In fact, in both Kenya and Tanzania, I have talked to people who say that men will often get their wife or partner to test and then get tested themselves if the result is positive. In many couples, only one partner is positive, so these men are playing a kind of Russian roulette.
Similarly, apparently people sometimes ask other people, perhaps their partner, to collect antiretroviral (ARVs) drugs on their behalf. This has more serious consequences when both parties are infected as they then end up sharing the drugs, which runs the risk of drug failure and of building up resistance.
Those who are isolated from testing facilities, many rural dwellers, are also isolated from ARV facilities. Malaha, Shibale and Shianda are just three examples of that phenomenon. Because there is no VCT there, there is no outlet authorised to distribute ARVs.
It is not a well kept secret that many Kenyans live in rural areas, nor is it a secret that most VCTs, indeed most public services, are found in urban areas. The need for more voluntary councelling and testing (VCTs) is pressing but even more pressing is the need for mobile VCTs. That is, unless the government is going to pay for people's transport costs to visit a clinic and perhaps compensate them for loss of earnings. I don't see that happening.
UNGASS claims that there are almost 1000 VCTs in Kenya, but that is not enough for the Kenyan population, in excess of 38 million. Nor are the clinics distributed widely enough to be of benefit to most people. This would be the case even assuming that all VCTs are working to capacity, a very risky assumption.
UNGASS also claim that VCT, ARVs and TB medication are given free of charge in government facilities. But as we have seen in Western Kenya, access to those services and other costs are not free. Nor are the other things that people need when on ARVs or TB drugs, such as treatment for various illnesses and nutritional supplements.
(This is similar to the claim that all children are entitled to free primary and secondary education. There are many costs involved in education which are not met by the government and many children are not going to school or their attendance is not very high.)
World AIDS Day in Mumias was great, insofar as many people turned up. I hope the photographs speak for themselves. There was a number of organisations there of various kinds, a UN organisation promoting the AIDS vaccine initiative, the NACC, a big project in partnership with USAID called Aphia II, a Western Kenya based organisation and SAIPEH. The last two are the closest to the people on the ground, but they don't seem to see any of the millions of dollars that are said to go to Kenya every year. Yet they have been round for longer than most of the others.
There was a temporary VCT clinic and a real mobile VCT clinic. Which is wonderful, except that Mumias is the one place out of the four I visited that actually has its own permanent VCT clinic. Not so many people queued up to be tested yesterday, which is a pity, because I'm sure they had plenty of testing kits this time.
But on the subject of VCT, we have probably all heard about how confidential they are, and that's supposed to protect people against stigma and discrimination. Well, if you go to the VCT clinic in St Mary's Hospital, Mumias, you will notice that it is a separate building, outside the hospital compound. Everyone passing can see who is waiting in line outside the clinic and there is only one thing to go there for.
Eileen Stillwaggon, in her excellent book AIDS and the Ecology of Poverty, makes the point that when HIV and AIDS are seen as separate from health and welfare in general, this contributes to the stigma and discrimination suffered by people who are known to be HIV positive. In fact, there are many health conditions that have little or nothing to do with HIV, but that make people more susceptible to HIV.
Stillwaggon suggests that instead of setting up separate, standalone clinics for HIV, governments could set up clinics that treat others of the many conditions affecting people in developing countries. Only by improving health in general will sexual and reproductive health be improved. And reductions in the transmission of HIV will follow.
But more about this sort of argument another time. The top down approach to HIV in Kenya has failed and needs to be changed radically. There are many people who can advise on what sort of changes need to be made. It's time the government started talking to them.
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