IYAP Kenya's New Blog

Photo: The strong wind that whips up the dust blows for much of the year and residents seem oblivious to it.

Isiolo Youth Against Aids and Poverty (IYAP) now have a blog, so you will be able to follow their activities as they continue to provide their services and introduce new services and facilities.

This week, the IYAP team spent most of the week operating their mobile clinic on the streets in and around Isiolo. At present, the weather is dry and very windy. So there is a cloud of reddish dust everywhere and everything quickly gets covered. But this hasn't put the team off and they tested over 250 people over four days.

A few months ago, IYAP were wondering how they would manage to raise money to continue their activities. But recently, Liverpool VCT (the organisation that trains most of Kenya's voluntary counsellors) have agreed to provide them with payment for the testing work they do and to help them meet some of their other costs. This will allow them to achieve their objectives and the team has breathed a big sigh of relief.

In the next few weeks, IYAP will be finding out what they can do with a blog and they will be launching a small, hosted site, displaying their contact details and the like. I'll make an announcement here when the site is available.

Circumcision for All. Then What?

Male circumcision (MC) as a protection against HIV has been a controversial subject for some time. It is believed to protect against male-to-female transmission of HIV. I shall leave much of the controversy to the experts and consider two questions that the literature, as far as I know, doesn't address:

1) To what extent can Kenya benefit from a mass MC campaign?
2) How feasible is a mass MC campaign in Kenya, under present conditions?

I raise the question of the extent to which Kenya can benefit because rates of MC are already very high in most provinces. The only province with relatively low rates of MC is Nyanza. Just over 50% of men are uncircumcised and HIV prevalence is 15.3%, the highest in the country. Around 20% of men in Nairobi are uncircumcised and HIV prevalence is 9%, the second highest in the country.

That sounds like a strong case for mass MC for those two provinces. However, one would also need to look at other factors in the transmission of HIV, such as population density and demographic balance (between males and females) in Nairobi, say.

One could also look at cross-generational marriages and rates of other sexually transmitted infections, such as herpes simplex virus, in Nyanza. (Cross-generational marriages referring to those where the man is considerably older than the woman.) No doubt, additional factors would also be relevant.

But the other six provinces have high rates of circumcision, standing at over 90% in four of them. Of course, they all have lower HIV prevalence than Nairobi and Nyanza. But in two of them, Rift Valley and Coast, HIV is increasing faster than in any of the other provinces. The absolute numbers involved here are worrying as well, the population of Rift Valley alone exceeding that of Nairobi and Nyanza together.

If a mass MC campaign is beneficial and feasible, quite a substantial number of people could benefit. A liberal estimate would suggest that four million men could benefit directly by being circumcised and another six million could benefit indirectly (these figures being VERY rough estimates). That would be almost one quarter of the population of Kenya.

It would be hard to argue against a campaign that could benefit so many people. Even if I have overestimated the number who could benefit, the numbers would still run into millions.

The second question is more difficult and I would compare it to the question of how feasible it would be to test every sexually active Kenyan, perhaps once a year, and put all those who are HIV positive on ART (antiretroviral therapy).
Similar questions arise: what sort of health service capacity does Kenya have, how many trained health service employees are there and how much capacity will be left for HIV prevention and care for the 75% or so of Kenyans who will neither directly nor indirectly benefit from mass MC?

It may well be the case that mass MC, universal testing and ART are desirable, but their feasibility is still in question once the experts have discussed all the other issues. Preventive medicine is desirable, so is health surveillance and so is treatment. They should all help to reduce HIV transmission.

But general health is also desirable, so are adequate nutrition and food security, water and sanitation, education, environmental protection and many other things. Why spend so much time and effort on something that may protect a minority of people, albeit a substantial minority, and ignore all these things that will benefit everyone?

Ok, I have listed some intractable problems and I agree, let's do something we know how to do rather than despairing about the things we may not know how to do. But I would seriously question the feasibility of safe mass MC in Kenya. Health services, education and other social services have been run down over several decades, the ratio of health personnel to patient is low and even though more health personnel are being trained, this is not keeping up with population growth.

The desirability of reducing transmission of HIV is not in question, but how will it be achieved? Will the Kenyan government build up the health service, develop educational programmes that will support this mass MC campaign and address all the other social conditions that contribute to the transmission of HIV? If so, then we should support such a campaign.

But I suspect these measures are not on the agenda and that mass MC will be rolled out as if HIV were a short term emergency. HIV is not a short term issue, it's been a long time building up and the conditions that allowed it to build up go back many decades. Allow those conditions to persist and HIV will not be eradicated.

Those conditions include structural problems that would make a mass MC campaign very unlikely to succeed without many adverse effects and complications. Circumcision carried out in modern, well equipped, well funded health institutions may suffer few adverse effects and complications but how many hospitals and health institutions meet those criteria in Kenya, and how many will do so in the next five or ten years?

MC is sometimes compared to a vaccine. Indeed, so is education. In fact, neither of them is particularly like a vaccine. People who are circumcised and people who are educated are still vulnerable to HIV, especially in a country with high prevalence. MC is just one more way of reducing HIV transmission, education is another. Combined with all the others, they may even reduce transmission considerably.

Unfortunately MC can be like a vaccine in the sense that those who are vaccinated may think they don't need to be careful. A circumcised man may assume he will not be infected, even if he doesn't use a condom. I have heard this belief many times and I am also aware of how much men dislike condoms and would avail of any argument to avoid using them.

Even if this so called 'risk compensation' behaviour has not been has not been detected yet, it does exist. People soon forget the safety messages or start to ignore them, especially if the death rate from HIV is seen to be dropping substantially.

So I'm not against mass MC if the experts can settle their differences, and there are many differences to settle. I also realise that those arguing for mass MC are not talking of circumcision on its own, that they would include counselling, testing, behaviour change messages, condom provision, STI treatment, etc.

In answer to my first question, I believe that Kenya would only benefit to a certain extent from a mass MC campaign and needs also to avail of all known types of prevention programming.

In answer to my second question, I don’t think a mass MC campaign is particularly feasible in Kenya at the moment. But if the conditions that make such a campaign unfeasible are addressed, the benefits will go far beyond those of a mass MC campaign alone. In fact, the benefits will go far beyond HIV prevention.

Absolutely Brutal Confident Dogma...

...engendering foolishly grotesque hype in blah blah blah.

I have mentioned before that, despite years of hype about HIV prevalence going down in Kenya and about how this was as a result of ABC (Abstain, Be faithful, use a Condom) campaigns, prevalence is actually rising.

It has been rising for three or four years. It went down earlier this decade, primarily, because of a very high death rate. The prevention campaigns only really started in the early years of the decade, when death rates were high. When death rates started to decline, prevalence started to go up again.

The increase in prevention money and campaign capacity was roughly concurrent with an increase in HIV transmission!

Uganda's HIV epidemic is older than Kenya's. The Ugandan government recognised the threat posed by HIV in the late 1980s and launched a multifaceted approach, one that was appropriate to a multifaceted epidemic. When prevention campaigns were at their strongest many people were dying. This reinforced the prevention message.

Foreign money started to flow into Uganda while prevalence was dropping. However, once death rates started to decline, prevention messages began to have less impact. At the same time, foreign money started to come with more explicit conditions.

Ugandan HIV organisations were encouraged (and eventually instructed) to emphasize the 'abstain' part of ABC at the expense of the other two facets. The emphasis on abstinence (or abstinence only until marriage) increased and spread to other countries because of further pressure from certain donors.

Many years ago, it was already clear that HIV was being transmitted by and to people who were not considered to be at high risk of contracting HIV. Married people were considered to be at low risk. This is odd, because it has long been clear that married people are being infected in large numbers. In some places, married people are at greater risk of being infected that highly sexually active, unmarried people.

You would think this would result in different campaigns evolving to support the ABC campaigns that became ubiquitous early this decade. However, as ample evidence showed that earlier hypotheses about transmission of HIV seemed less tenable, a dogmatic adherence to ABC and abstinence only campaigns became even more entrenched.

On the one hand, there are medical and field practitioners, showing that HIV is spreading among people previously thought to be at little risk of infection. On the other hand, there are political and other 'stakeholders' jumping on a moral bandwagon and referring to their approach as 'evidence based', whatever they meant by that.

HIV prevalence in Kenya will probably be higher next year than it was this year. But there have been warnings for several years that gains made in earlier campaigns in Uganda have also started to reverse. More people are admitting to having multiple partners than before, fewer people are reporting using condoms, even during high risk sex.

It would be surprising if HIV didn't start to show increases in transmission in Uganda similar to those that have occurred in Kenya. If it can happen in these two countries, there may be other countries where earlier declines in prevalence are reversed.

This is also a distinct possibility in countries where death rates are presently declining. Death rates decline around 10 years after peak incidence ( peak incidence being the time when the rate of transmission is highest). Even if death rates from HIV are not carefully recorded, HIV prevalence is under the spotlight in every African country. In any country where prevalence is declining, death rates are also high. It shouldn’t be too difficult to spot the countries most likely to experience an increase in HIV prevalence in the next few years.

At one time, people would ask if Uganda's success in fighting the HIV epidemic could be replicated in other countries. Perhaps this is no longer such a wise question. Perhaps, and this is purely speculative of course, but perhaps ABC doesn't really have that much effect.

Well, I think ABC has its place, but ABC on its own doesn't seem to do very much. Even less would abstinence only until marriage work, but we’ve known that for many years.

It has been demonstrated in many ways that HIV epidemics change over time and vary from place to place. At times, more men than women are infected, at times more women are infected. In the early years in Kenya, more men were infected. Later, far more women were infected. But the latest data shows that men are now being infected in higher numbers than before. At one time richer and better educated people were infected in higher numbers but this, too, is changing.

It may well be the case that HIV was, at one time, predominantly spread by high risk sex, involving sex with commercial sex workers, multiple concurrent partnerships and various other circumstances. But that would have been a long time ago. The HIV epidemics in Uganda, Kenya and many other countries have been 'generalised' for many years. This means that HIV is spreading among the general population, as opposed to specific groups, such as commercial sex workers, men who have sex with men, intravenous drug users, etc.

So, if the epidemic is different, why are the campaigns not different? The Ugandan First Lady has said that ABC campaigns will continue. Why? It is recognised that more infections occur in older people and inside marriages. What good will ABC campaigns do, even if they are supported by strategies that target high risk groups?

You can wag your finger at children and tell them to abstain and you may even be 'liberal' enough to tell them about what they are to abstain from. You may even shock the moral fibre of the nation by going on to tell them that they should be faithful to one partner, use condoms and other precautions and even send them off for VCT (voluntary testing and counselling). But can you wag your finger at adults and tell them what to do?

After all, many adults have sex in order to have children. It's something they have a right to and they are sure as hell not going to use a condom. Even if they want to avoid pregnancy they are likely to use a different form of contraception. Ok, you could, if you felt you had the moral authority, wag your finger at them and tell them to be faithful to one partner and they may not tell you where to direct your finger.

Really, you can have as many health campaigns as you want but they need to be based on genuine health issues, not moral crusades and political posturing. If the international community is worried about HIV transmission, they should take an interest in gender inequalities, economic inequalities (yes, poverty, I know how much they hate hearing that it exists), education, public health that is accessible to poor people, exploitation, water and sanitation and many other instances of people's human rights being compromised.

Of course people need to avoid high risk sex and there are ways of reducing risk. Everyone should avoid risky things, shouldn’t they? After all, they are risky. But there are so many more things that can be done, we needn't limit ourselves to the most difficult strategy of all, the vain hope that human beings will cease to engage in human behaviour.

HIV Eradication

HIV eradication means different things to different people. Some have suggested that HIV could be substantially reduced by universal voluntary counselling and testing (VCT) and universal antiretroviral therapy (ART) for those found to be HIV positive. If it were possible to test every sexually active person around once a year in any population in the world, then it may also be possible to put all those found to be positive on ART.

Personally, I think the chances of testing every sexually active person in a country like Kenya, where a sizable proportion of births are not even registered and many people never see a health professional, are slim. Even testing people once has eluded the Kenyan Government's efforts to date and around 80% of people do not know their status.

I have no doubt that, when the people who came up with such a proposal also come up with a plan on how to implement it, the event will be met with the same level of press coverage. But until that time, I'm sure there will be other plans for eradicating HIV. And if you think universal VCT and ART for those found to be HIV positive is crazy, there is a crazier suggestion and it is already being trialled in Kenya.

Many have heard of post-exposure prophylaxis (PEP), something a bit like the morning after pill for HIV. If you think you have been exposed to HIV infection, through sexual assault, needlestick, accidental exposure to infected blood or any other way, you can visit a suitable medical facility and ask for it. That's if you are lucky enough to live in a country with easy access to such facilities, of course. PEP involves a short course of antiretroviral drugs and it can ensure that you do not become infected with HIV.

That's not the crazy suggestion, by the way. The crazy suggestion is called pre-exposure prophylaxis (PrEP). Anyone deemed to be at risk of becoming infected with HIV can be put on antiretrovirals. This should result in them being much less likely to be infected. If they are already HIV positive but don't know their status, PrEP should result in them being less likely to transmit HIV to others.

That's great, but in a generalised epidemic like Kenya's, all sexually active people are at risk of either contracting HIV or transmitting the virus. Of course, commercial sex workers, men who have sex with men and intravenous drug users are much more likely to contract and transmit HIV. These are known as 'vulnerable groups'. But most HIV here is found among the general population. A relatively small percentage of the country's HIV positive people are members of those groups.

For some, the very idea of providing expensive drugs to commercial sex workers instead of providing them with an alternative to sex work could obscene. And there are other, less radical, harm reduction programmes that could be of use to intravenous drug users.

But another group of people who may be offered PrEP if its trials are successful is 'discordant couples'. Only one member of a discordant couple is HIV positive. Often, the HIV negative partner remains HIV negative for many years, even though the couple may have unprotected sex.

HIV is much more likely to be transmitted in the first two or three months after infection and in the last few months or years, after the progression towards AIDS has started. The period in between can be 10 or 11 years and during this time, HIV positive people are less likely to transmit the virus. Of course, this is a long period of time, and HIV positive people may have many sexual experiences. They may also have other sexually transmitted infections, for example, that could make them more likely to transmit HIV.

The potential for PrEP seems obvious, except that we have not always been very good at assessing what the most important factors are in the spread of HIV. Some point the finger at multiple partners, some say poverty is the main problem, genetic differences in Africans or people of African origin have been blamed, tribal practices, commercial sex work and all manner of things have been blamed.

The problem is that all of these could be important factors and all could play a greater or lesser part in different places and at different times. If we are not very clear about exactly how HIV spread in various countries, that is, the history of the virus's spread, we may not be in a position to make predictions about its future.

At present, people are not always good at taking drugs regularly. Sick people, though, are likely to be better at taking drugs than people who are not sick. That's only a guess, but I can see problems with many people remembering or even bothering to take drugs when they are not sick. The drugs may even have side effects or interfere with other drugs they are taking.

Taking drugs for a large part of your life requires certain changes in lifestyle that many may not like to make, if it were even possible for them to make those changes. Drugs can also fail for various reasons. And resistance can develop among people using a drug for a long time, especially if they don't always stick to the recommended regime.

PrEP, if it is ever practicable, will be a very expensive and dangerous shot in the dark if we are not able to predict what the major trends are in each country and, indeed, in each part of each country. But then, some people are unworried by danger when lots of money is involved. Especially if the danger affects other people, far away from home.

And if HIV is eradicated? Well, then we can go on to other transmissible diseases, non transmissible diseases, poverty, malnutrition, food insecurity, fuel insecurity, exploitation, water and sanitation and, well, there are just too many things to list. These, I would suggest, are some of the underlying conditions that allowed HIV to spread in the first place. In Kenya, many of these are getting worse; we are losing sight of them as we allow ourselves to be distracted by grand proposals for the eradication of HIV.

Of course, we could try to deal with some of those other problems first or at the same time as trying to prevent the transmission of HIV. And then, by the time transmission of HIV is reduced as substantially as the mathematical models predict it will be, we may truly have something to celebrate.

(For further discussion of PrEP, see my other blog, pre-exposureprophylaxis.blogspot.com)

Centres and Peripheries

The trip back from Mumias to Nairobi was long, hot and often bumpy. But there were no incidents, flat tyres, etc. Only the usual poorly surfaced roads and traffic jams in Nairobi. It’s only about 350km so nine hours is slow, but not the worst.

Infrastructure is a big problem in Kenya and East Africa in general. So many projects assume a certain level of telephone, mobile, rail and internet connections and quickly run into difficulties.

For example, there are hundreds of internet cafes in Nairobi but try to find one where you can do everything you need to do online and you may have difficulties. I tried today for three and a half hours and just as I was about to compromise and try to achieve only some of my objectives, there was a power failure throughout the city. How long it will last is anyone’s guess.

There is a tantalising possibility that the poor roads in Kenya, Tanzania and other countries played a part in protecting many people from becoming infected with HIV early on in the epidemic. People in more isolated areas were not infected in large numbers in the early years.

However, that is not the case any more. As mentioned in the last few days, people in rural areas and more isolated areas in both Kenya and Tanzania are being infected now in greater numbers than before. They are not receiving the prevention education that is sometimes found in towns and cities and testing facilities are scarce or non-existent.

Countries with relatively good infrastructures sometimes have much higher HIV prevalence than Kenya or Tanzania. Examples of this phenomenon are Zimbabwe, Malawi, South Africa and Botswana. Of course, there are probably other reasons why HIV prevalence is so much worse there, but demographic balance, mobility and circular migration play an important part in the transmission of HIV.

One of the reasons why urbanization may be so strongly associated with high and fast transmission rates of HIV is the high number of males in urban populations. Botswana, one of the richest countries in Africa, with one of the highest rates of HIV in the world, has also experienced rapid urbanization, economic growth, population growth, high levels of income inequality, a history of mobility and high levels of commerce with surrounding countries.

Botswana's economy depends to a large extent on extractive industries and they, typically, employ large numbers of men who live in all-male accommodation. This results in high levels of commercial sex and a consequently increased risk of contracting and spreading HIV and other STIs.

Employees are not just from Botswana, so when they return home, they can transmit HIV and other conditions to their home countries, which are often poor, with high unemployment rates.

Ok, Kenya doesn’t have a lot of mining, certainly not on the same scale as Botswana. But there are industries that give rise to circular migration and the resulting demographic imbalances and consequent spread of HIV and other diseases.

Kenya’s number one product is tea. As mentioned, Mumias is dominated by the sugar industry. Some coastal areas grow little but sisal. And there are natural resources here, such as soda and uranium. Other examples are the massive cut flower businesses around Lake Naivasha and the fruit and vegetable growing farms.

All these industries depend on large supplies of casual labour, very often for only part of the year. People arrive and stay for as long as the work lasts and then go back to their homes. Many of these economic migrants are male and they live away from their families for much of the year.

This kind of circular migration, often driven by rural poverty, is common in developing countries and is associated with many health hazards, for example, TB. Labour practices in South African diamond and gold mines result in similar conditions and again, the HIV related effects were transmitted to surrounding countries that suffered worse HIV prevalence than that of South Africa.

Eileen Stillwaggon, in AIDS and the Ecology of Poverty, talks of the “circular migrant streams” that are fuelled by mines, factories and plantations and the consequent slums and shanty towns with their poor sanitation and high rates of disease and malnutrition. It must also be noted that circular migration transmitted HIV from urban to rural regions in earlier years but later the transmission was in both directions.

John Iliffe, in A History of the African AIDS Epidemic, cites the “male predominance in urban populations” in East Africa as one of the reasons why levels of infection were higher there than in western equatorial Africa. In the early 1990s, “Kigali had 50 per cent more men than women aged 20-39” (page 21). In Nairobi in 1979 there were 138 males for every 100 females, the imbalance was even higher among adults and many of the males were unmarried.

A high male to female ratio in the population does not just affect urban dwellers. Fishing communities in rural areas around Lake Victoria were predominantly male and HIV rates there are very high. Nyanza province has the worst HIV rates in Kenya. Rural dwellers are also affected by these imbalances because the migration is temporary and people come and go, perhaps for much of their working life.

There are also certain occupations that involve high levels of mobility. Iliffe mentions urban immigrants, truck drivers, alluvial miners, their female partners and labour migration as examples of particularly mobile groups. Towns along trade routes often have higher rates of HIV than other towns.

This problem is especially prominent at borders. Border controls are very slow moving and truckers often have to spend several days in border towns because of slow administrative procedures. It can be cheaper for them to stay with a casual partner there than to put up in a hotel, so it’s an ideal place for commercial sex workers to look for business.

These are all major factors in the history of the transmission of HIV in Kenya and East Africa in general. They crop up constantly in the literature and mobile people were among the first ‘vulnerable groups’ to be studied, along with commercial sex workers.

It was Zimbabwe's “excellent transport system” and circular internal migration between urban and rural areas that transmitted HIV out into rural areas, according to Iliffe (page 39). In the case of Malawi, Iliffe makes a further connection between higher education and greater mobility, perhaps elucidating the phenomenon of higher HIV prevalence sometimes being associated with higher levels of education.

Iliffe tracks the transmission of HIV from Western Equatorial Africa to East Africa, Southern Africa and West Africa. He makes it clear that mobility is the chief driver of the epidemic at the regional level.

Indeed, obstacles to mobility from east to west is one of the possible reasons Iliffe suggests as to why West Africa's epidemic was less severe than that of some other African regions. Where HIV rates were high in West Africa, one of the principle drivers was mobility, especially among commercial sex workers.

Tantalising as it is to suggest that poor infrastructure reduces the spread of HIV, it is not really true. It is true, but trivially so, that complete isolation is a protection against HIV and any other transmissible disease. In reality, people are not completely isolated, even in the most remote parts of Kenya.

Isolation explains why HIV spread slowly to rural areas and more quickly and earlier in cities and densely populated areas. It also demonstrates the critical situation that many towns, villages and rural areas are in, right now.

The situation is critical because we really don’t know what HIV prevalence is in more remote areas. People there are less exposed to HIV prevention publicity, they have less access to health and other social services and especially, to voluntary counselling and testing centres.

The further people are from urban centres, the more isolated they are, the less we know about HIV rates in those areas. The difference in prevalence between urban and rural areas may be merely apparent.

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.

Thirty eight million divided by a few hundred...

HIV was first identified in Kenya in 1984. However, it has probably been present there since some time in the 1970s. The political response to what may then have been only a potential epidemic was generally one of denial. There is still a lot of denial, though it is now often cloaked in politico-technical jargon.

The HIV epidemic appeared to decline from the late 1990s, from a prevalence of 10.7% in 1997 to around 6.6% in 2004. However, much of this decline may have been due to a high death rate. Recent figures suggest that HIV prevalence began to increase again after 2004 and stood at 7.8% in 2007.

Much of the HIV prevention work carried out in Kenya started in the late 1990s and early 2000s. This could suggest that the prevention work has been of little benefit. Of course, that is just my analysis. But through this blog, I hope to be able to say why I think that Kenya has so far failed to control the HIV epidemic.

I’ll return to historical details at various points, but first, I’d like to concentrate on this week, National Aids Week, 2008, here in Mumias, Western Kenya. This is where my interest in HIV began, way back in 2002.

Mumias is a very typical town, surrounded by many other smaller towns and villages. (I hope my photographs bear witness to this.) Much of the HIV awareness, prevention, treatment and care work is carried out by an organisation called SAIPEH (Support Activities in Poverty Eradication and Health).

On Thursday, we went to a town called Malaha (pictures on Picasa). There was music and drama to raise awareness about HIV. SAIPEH volunteers went from place to place, asking people if they knew about HIV and getting tested. A mobile VCT clinic (Voluntary Counselling and Testing) was set up for the day.

So far, so good. Over 100 people turned up to be tested. But there were only 100 testing kits. A car was sent off for more testing kits but they were not available at such short notice. After mobilising hundreds of people who were willing to be tested, only around 120 people were tested.

So the mobile VCT could come back next week? Well, yes and no. The Kenyan Government sets up VCTs but they are only just realising that a few hundred clinics is not adequate for nearly 40 million people. Let’s not do anything hasty, VCT clinics have only been around for nearly 20 years.

The government is also just realising that about 80% of people live in rural areas. Most VCTs are in towns. Malaha is less than half an hour from Mumias, where the nearest VCT clinic is. But the return journey costs around 200 shillings, about 2.5 dollars. That would buy more than three kilos of maize flour, the staple food.

Maybe a few days without food for yourself and your family is a small price to pay for knowing your HIV status, but if you are sexually active in an area with high HIV rates, you need to be tested regularly, perhaps every year. But I don’t see anyone choosing to be tested if it means spending scarce cash that could be used for food.

SAIPEH put forward a proposal for a VCT clinic to be set up in Malaha, but it was turned down. SAIPEH is expected to pay some of the costs and supply some of the labour to carry out the government’s work, but if they mobilise people and can’t provide the testing facilities as well, people will know all there is to know about HIV except whether they are positive or negative.

And if someone is positive? Eventually they will need to go on ARVs (Anti Retroviral Drugs). These are free. Well, the drugs are free, if you can get hold of them. Sometimes, the supply doesn’t move from central areas, such as Nairobi, to more remote areas. Sometimes, supplies don’t move at all, such as during a civil disturbance. And when the supply of ARVs does move, it stops in Mumias.

Back to the isolation problem. Malaha is not that far from Mumias but people there find it hard to meet the costs of going there for a test. Even harder to meet the costs of travelling there regularly for fresh supplies of drugs. This is not even counting the cost of special dietary requirements for people on ARVs, drugs for other illnesses, time taken off work, etc.

If there was a VCT in Malaha, ARVs could also be distributed from there. I don’t think I am the only one to question the Kenyan Government’s commitment to fighting the HIV epidemic.

Ok, Malaha is just one town. On Friday we went to Shibale (photos). Shibale is not as far from Mumias and it is a very busy place with a bustling market. Mumias is known throughout Kenya for one thing, sugar. You can drive a long time in the region and see little but sugar cane. Everywhere there are bits of chewed cane because people become addicted to sugar from a very young age.

But it’s not just the people that become addicted. Once an area commits itself to a monoculture, it’s hard to get away from it. A market and infrastructure develops around the sugar industry. The Mumias Sugar Company is, pretty much that market. They can provide the transport, fertilizer and anything else you may need. Sounds ideal, till you come to get paid for your sugar and find out how much those all cost!

But why whinge, the Mumias Sugar Company is in Shibale. So the people there are rich? Well, no, there are rich people working for the company but most people in the town do casual work. They dependence is not just on sugar but on the single employer for many miles around. But given all the wealth in sugar, there is a VCT clinic in the town?

No, there is no VCT. Being close to Mumias, a mobile VCT that could test and distribute drugs would be ideal. So SAIPEH turn up and make music and merriment. People come and talk. Free condoms are distributed. Demonstrations are given on how to put on and take off condoms. People exchange views and enjoy the activities. But some ask for a test, having expected a mobile VCT and they are told to wait or to go to Mumias.

Saturday, SAIPEH are in Shianda, it’s a market day. We drive around, the musicians and performers in the back of a truck, shouting, singing, stirring up curiosity. And when the band starts playing, many people turn up to watch and enjoy. More condoms, more demonstrations using the wooden dildoes.

And more people asking for a test. Friday is market day in Mumias. I met a woman there who said she was afraid to be tested because she didn’t know how she would cope if she turned out to be positive. She was within easy walking distance of the Mumias VCT. But this is why SAIPEH volunteers go around mobilising people and persuading them to be tested. There are many reasons why people are reluctant and SAIPEH have spent nearly 14 years addressing these problems.

This same woman turned up and said she had decided to be tested. She was just one of the many people who was disappointed to find that there was no mobile testing unit. But she said she would go to be tested anyway. She is mobile, she can go to Mumias on a market day. As for those who can’t afford to travel, maybe SAIPEH will be able to organise for them to be taken to a VCT or arrange a mobile VCT visit.

Even if there were 1000 VCT clinics in Kenya and even if they were in isolated as opposed to urban and semi-urban areas, this would not be enough to achieve universal testing. Of course, universal testing depends on many things aside from an adequate number of testing facilities. Even unlimited mobile facilities would not persuade people to be tested if they don’t want to be tested. But it would be a start.

How many VCTs, mobile and otherwise, would be required for Kenya? I don’t know. But I will write to Dr X (I'll reveal the identity another time). Dr X is an advocate of universal testing and universal roll out of ARVs. The former is a prerequisite for the latter. Maybe it would be possible to indicate how far away Kenya is from reaching even those who will willingly be tested. If I get a reply, I’ll post it here.