Kenya gets ready for PrEP roll-out

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Francis (not his real name) is a gay Ugandan sex worker living in Nairobi, Kenya. He moved to the Kenyan capital last year after fleeing for his life: he says he was twice arrested and tortured for being openly gay in Uganda.

“In” 2014, Uganda introduced a new anti-homosexuality law, which proposed life imprisonment for ‘aggravated homosexuality’. Although the bill was later struck down by the country’s Constitutional Court, a number of lesbian, gay, bisexual and transgender (LGBT) Ugandans have escaped to Kenya for fear of persecution.

“I was arrested for the first time in 2009 together with my fiancée who is still serving a 10-year jail term,” Francis tells Equal Times. “The police wanted us to give them a list of all the gay people we knew in Kampala but we refused. In the process I was tortured badly and was admitted to hospital but I managed to escape,” he says.

After two years he moved back to Kampala but was re-arrested after a few weeks. Friends paid a bribe for his release. It was at this point that Francis realised life in Uganda was too dangerous for him. In 2011 he moved to Kenya, where he now makes a living as a sex worker.

“I charge at least US$5 per client per session but some pay more,” says Francis.

Earlier this year, his friend Brandon Kimani – a sex worker and peer educator with Liverpool VCT (LVCT), a Kenyan HIV prevention charity – recommended that he enroll for pre-exposure prophylaxis, more commonly known as PrEP.

PrEP is an antiretroviral (ARV) drug treatment which, when taken daily, helps people at high risk of getting HIV drastically reduce their chances of infection. Users take Truvada, a HIV/AIDS combination therapy drug, approved for HIV treatment in many countries around the world.

Last year, the World Health Organization recommended Truvada as a PrEP drug for HIV prevention in combination with other safe sex practices like condom use. Studies have shown that it can reduce one’s HIV risk by as much as 99 per cent.

So far only a handful of countries, such as the US, Canada, France, Israel and South Africa, have approved daily oral Truvada for HIV prevention amongst high risk groups like young women, serodiscordant couples (where one person is HIV-positive and the other is HIV-negative), men who have sex with men and sex workers.

 

Prevention is better than cure

There are an estimated 1.6 million people living with HIV in Kenya making it home to the joint fourth largest HIV epidemic in the world (alongside Mozambique and Uganda). In addition, there are an estimated 200,000 commercial sex workers in Kenya, 15,000 of whom are men (even though same-sex sexual relations are illegal in Kenya and can carry a prison sentence of up to 21 years).

HIV prevalence amongst gay men is estimated 18.2 per cent, compared with 6 per cent of the general adult population. Meanwhile, according to research done by the Sex Workers Outreach Program (SWOP), female sex workers have an HIV prevalence of 30 per cent. Amongst male sex workers that figure is a staggering 40 per cent.

The Kenyan government has been relatively active in the fight against HIV. It has promoted the use of condoms since 2001, increased the distribution of free condoms and HIV testing, as well as voluntary medical male circumcision, amongst other measures.

Dr Martin Sirengo, Kenya’s deputy director of medical services at the National Aids and STI Control Programme (NASCOP) says that because it is the most at-risk communities which account for more than one-third of all new HIV infections in Kenya, in order for the country to reach its goal of reducing new HIV infections by 75 per cent by 2019, it must implement appropriate and high-impact prevention interventions.

“It is cheaper to prevent HIV infections than to put infected persons on antiretroviral treatment for life,” Sirengo told Equal Times.

That’s why Kenya is expected to roll out PrEP for large-scale use before the end of this year, becoming only the second country in Africa to do so after South Africa. Costing between US$525 and US$830 per person per year, it is expected that the treatment programme will be subsidised by the government and its NGO partners such as the Melinda Gates Foundation.

NASCOP and the National Aids Control Council (NACC) have partnered with various NGOs to implement trials involving over 1,700 people. They have also incorporated new guidelines on PrEP into existing prevention and treatment programmes to ensure PrEP’s efficient integration into existing health services.

 

“Sex work is risky business”

With regards to the trials, SWOP currently provides 600 male and female sex workers with daily doses of Truvada in Nairobi and Kisumu, Kenya’s third largest city. LVCT is conducting its own trials with 1112 gay men, young women and female sex workers in Nairobi, Kisumu and Homa Bay in western Kenya.

Brandon has been using PrEP for the last nine months. The 25-year-old sex worker says it has had a positive impact on his life.

“Sex work is a risky business. There are times when I meet clients who offer to give me more money if I have unprotected sex, which I do. And other times you meet clients who are too rough and the condom bursts. In such cases, the chances are you have exposed yourself to HIV,” says Brandon, who has also mobilised 60 gay sex workers to enroll for PrEP treatment.

Before PrEP, Brandon would take post-exposure prophylaxis (PEP) – a four-week course of ARVs recommended for emergency situations only.

Francis says he is also happy with the drug, although he does have some concerns about the stigma. “The colour should be changed from blue to white because people assume it is an ARV drug and clients can easily mistake you as a HIV positive patient,” he says.

Caroline, 28, is a female sex worker in Nairobi who takes PrEP drugs every morning. The mother-of-two, who started sex work three years ago because she was unable to find any other work, says she learnt of PrEP through SWOP.

“It has worked well for me because I have had unprotected sex many times and when I go for HIV tests, the results are negative,” she tells Equal Times.

Critics of PrEP have expressed strong concerns that it could encourage sexually risky behaviour, reduce condom use, and with that, increase the spread of other sexually-transmitted diseases.

But Nelly Mugo, the principal research scientist at the Kenya Medical Research Institute who is helping to lead the PrEP roll-out in Kenya, says it is important to remember that PrEP should be combined with other safe sex practices such as condom use.

“PrEP is also not a method to be used by everyone but for those at high risk. There is, however, a need to create awareness and educate people about PrEP”.

 

Confronting challenges

According to Dr Jordan Kyongo, a research manager at LVCT in Nairobi, all sex workers must undergo medical screening before they are enrolled in the trials as PrEP only works for those who are HIV-negative.

He said that issues raised by participants are addressed where possible: “The issue about the color of the pill is a major concern for users and has been directed to the drug manufacturers, but they say the colour is not likely to change at the moment since Truvada is primarily a treatment drug, not a prevention drug,” says Dr Kyongo.

Paul Sore, a PrEP field officer at SWOP in Nairobi says one of the challenges with the trials is the slow enrollment of sex workers into the program because of misconceptions about the drug and the stigma attached to HIV treatment.

“Most people don’t understand what PrEP is. Most people think it is a drug only meant for the HIV positive patients,” he says, adding that a lot more awareness campaigning is required to educate people about PrEP before it is fully rolled out later this year.

“PrEP is safe and works to prevent HIV infection, but only if taken effectively as directed by the health service provider,” said Wanjiru Mukoma, executive director of LVCT. “The public needs to get as much information as possible prior to using the drug”.