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Final Report for the
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A. Introduction The epidemic of HIV and subsequent AIDS is well established in Kenya. By the early 1990s, HIV seroprevalence rates were increasingly affecting a wide segment of the general population. HIV prevalence in the adult population in Kenya was estimated to be 3.1% in 1990, and then rose on average 1% per year, to 8% in 1996. In February 1992, the USAID Mission to Kenya requested priority country status for Kenya based on seroprevalence rates and projections, including socio-economic projections on the future course of the epidemic. In September 1992, USAID/Kenya was designated an AIDSCAP priority country. The Kenya AIDSCAP program was developed in collaboration with the Ministry of Health, USAID/Kenya and international donor agencies. The program was designed to fit into both the Medium Term Plan (MTP) for AIDS Control in Kenya; existing donor-funded programs and the USAID Mission's overall objective of integration. The goal of the AIDSCAP program in Kenya was to reduce the incidence of sexually transmitted HIV. The purpose was to reduce high-risk sexual behavior in target populations in selected sites. Three strategic approaches were used to reduce sexual transmission of HIV including changing high-risk sexual behaviors through multiple channeled and mutually reinforcing communication programs; improving the diagnosis, treatment and prevention of sexually transmitted diseases (STDs); and expanding condom promotion, distribution and effective use. The primary target populations were men and women in the formal workplace; men and women seeking STD services at clinics; and men and women seeking services at maternal/child health and family planning (MCH/FP) clinics and outreach programs. The populations were targeted in peri-urban and urban areas in Nairobi, Mombasa and Eldoret which are high-prevalence areas along the trans-Africa highway through Kenya. Of these sites, the program is most comprehensive in Eldoret. The selection of these target populations was based on potential epidemiological impact, gaps in programming, the Kenya MTP II priorities, opportunities to build on established USAID programs, and potential economic impact. The Kenya AIDSCAP program worked on both national and regional level interventions. Regional level interventions were primarily concerned with reaching the target groups (men and women at worksites, STD patients, family planning clinic attendees, and students at institutions of higher education) with interpersonal prevention education interventions and training for health care providers. National level interventions provided a supportive framework for AIDSCAP's intensive prevention activities within targeted geographic areas and included promotion of policy dialogue, support for mass media, activities in capacity building and sustainability, and behavioral and operations research. Interventions were implemented for the most part by private and public agencies, NGOs and church related organizations under subcontract to AIDSCAP, which provided substantial technical guidance and support. It was felt that working through institutional structures (churches, worksites, and institutions of higher education) would provide easier access to target audiences and would likely result in the greatest multiplier effect. Several aspects of the AIDSCAP/Kenya plan were unusual. First, there was a strong emphasis on policy interventions. Second, no direct condom social marketing projects were included, since this activity was funded by USAID through a separate, pre-existing contract with Population Services International (PSI). Third, there was a strong interest in integrating HIV/AIDS into family planning activities, reflecting the Mission's lead role in supporting family planning interventions in Kenya since the 1970s. Fourth, there was an emphasis on working with the private sector, and on exploring cost issues related to sustainability at the national and implementing agency level. Activities began in 1993 with four transitional projects, in the bridging year between AIDSTECH and AIDSCAP. These were followed in early 1994 by the start of the major sub-project activities. A list of the major activities implemented by AIDSCAP/Kenya is included in Attachment A. B. Country Context Kenya, a country with an estimated population of 27.6 million (1995 estimate) has seen a rapid increase in the spread of HIV. The first case of AIDS was diagnosed in 1984, and since then the epidemic has grown from an adult seroprevalence rate of 3.1% in 1990, to a 1996 rate of 8%, an increase of roughly 1% each year. For every 13 adults, one is infected. In urban areas, this is one out of every eight adults, and there are areas in urban Kenya where prevalence is already 20-30%. 200,000 cases of AIDS have been diagnosed and it is estimated that 1.2 million people have the virus. 75% of cases occur between the ages of 20-45, with the peak ages for AIDS cases being 25-29 for females and 30-34 for males. However, young women in the age group 15-24 are twice as likely to be infected as males. In major hospitals, approximately 50% of beds are occupied by people with HIV/AIDS and HIV/AIDS/TB, with a somewhat lower rate in small hospitals. The number of TB cases has been rising rapidly. STD rates have also been high in Kenya. In 1991, STDs were among the six most common causes of morbidity in Government of Kenya health facilities. Nationally, health services are provided through a public system including a national referral hospital, several district and provincial hospitals, health centers and dispensaries, and a system of community-based health care workers to provide local outreach. Kenya's health service is also notable for its active family planning program, which has been successful in reducing the total fertility rate from 8.1 in 1977/78 to 5.4 in 1993. Kenya is bordered by Tanzania, Uganda, Sudan, Ethiopia, and Somalia, with the Trans-African Highway route running from the port of Mombasa, to Lake Victoria, and Uganda in the West and on to Rwanda and Zaire. Many of the major towns, including Nairobi, Eldoret, and Kisumu are on this route. The country is rapidly urbanizing, but about 80% of the population still lives in the rural areas. Therefore, though the estimated HIV prevalence in urban and peri-urban sites is as high as 13-14%, the total number of HIV-infected people is larger in the rural areas. Eighty percent of the population is Christian, with a significant minority of Muslims, the major religion at the Coast (Mombasa and environs). The national languages are Kiswahili and English, but numerous local languages are also spoken, the most important being Kikuyu, Dhluo, dialects of Luhya, and Kalenjin. The diverse local cultures and communities play a significant role in shaping the social norms that govern sexual behavior, particularly in the rural areas. The Country Program was developed in collaboration with the Kenya National AIDS and STD Control Programme (NASCOP) which has been coordinating HIV/AIDS/STD interventions throughout the country since its inception in 1985. Funding Until the recent World Bank loan was assumed by the Government of Kenya (GOK), external donors funded most of Kenya's AIDS control efforts. USAID has been among the largest and most consistent of donors. The prior Overseas Development Administration (ODA) of the British government contributed funding for condoms and provided technical assistance and in 1996 approved a large integrated HIV/AIDS prevention and care project with a three-year budget of US $9 million. The Belgium government has supported STD prevention efforts and both an STD and an IEC advisor to NASCOP and funds STD and IEC work in Kisumu and Kajaido districts. In addition, the Kenyan government negotiated a $40 million loan from the International Development Agency of the World Bank for STD and HIV/AIDS prevention and care. Implementation of that project was designed to fit into the decentralization reforms being undertaken by the Ministry of Health. In fact, the STI project, as it was commonly known, facilitated the reform process by taking a lead to negotiate with the Treasury to include line items within the national budget for district-level HIV/AIDS prevention initiatives. According to Ministry of Health sources, it had taken six years to gain a line item for the NACP (i.e. a direct budget allocation); the STI project was able to acquire fifteen district line items in a few months. Other donors included UN agencies. UNDP supported the preparation of the Seventh National Development Plan (1994-1996) which included a chapter devoted to the social and economic impact of HIV/AIDS. UNICEF continues to provide support for understanding the impact of the epidemic on children, to community-based prevention and condom distribution, and to AIDS education in school. UNAIDS appointed a resident representative to Kenya in 1996, and made support for the preparation of MTP3 a priority. WHO/GPA provided significant financial and technical support, in diminishing annual amounts, until it was dissolved in 1996. Government Policy and Implementation Initiatives In 1994, the Government initiated a process of writing, revising, consensus-building and bureaucratic consultation for a national policy. The process of approval was somewhat slow as the Sessional Paper on HIV/AIDS was approved by Parliament in September 1997. The delay in producing the Sessional Paper was of concern to many organizations who looked to the government for guidance on HIV/AIDS issues. What needs to be acknowledged, however, is that this particular government paper has been more participatory than the earlier versions, with input from the NGO sector, in which the Kenya AIDS NGOs Consortium was extensively involved. Political/Government/Institutional Responses Prior to the early 1990s there was strong official denial that AIDS represented a serious threat to the Kenyan people or social institutions. However, as epidemiological data became more available, officials of the Ministry of Health became quite outspoken about the epidemic and could have provided reasonable leadership for the country. The Attorney-General's office seemed prepared to address legal aspects of the epidemic and has gone on record to support adolescents' rights to reproductive health services. The Vice President (as Minister of Finance and Planning) spoke about the socio-economic impact of HIV/AIDS, and the Ministry of Education, with UNFPA and UNICEF support, prepared family life education (that included sexuality and AIDS in the curriculum) for school children. In spite of these positive developments, in the absence of an articulated national policy, it was easy for special interests to disrupt HIV/AIDS prevention impetus. This occurred on several occasions in the first half of the 1990s when various religious, medical and academic authorities questioned the efficacy of condoms. It happened again in 1996 when a university professor announced he had a cure for AIDS--later amended to suggest the drug cured opportunistic infections associated with HIV/AIDS. A ban on this drug, "Pearl Omega," was only effected ten months later, after thousands of people had been treated by its inventor, in spite of the scientific and medical communities having disassociated themselves from the drug. "Pearl Omega" is currently dispensed as a herbal remedy. Additionally, due to opposition from some religious and parents' groups to discussion of sexuality with youth and to condom promotion, "family life education" in schools was withdrawn before it was adopted into the official school curriculum. Some extreme groups also organized demonstrations against youth sexual education and condom promotion, publicly burning condoms and HIV/AIDS information on several occasions in the mid-1990s. In late 1995, all government-run radio and TV stations ceased broadcasting or accepting commercial and "public service" advertisements for condoms and condom use promotion. However, one of the two privately owned radio stations resumed advertisements for the USAID-funded "Trust" condom in 1997. The transmissions are currently limited to the Nairobi area. Media Response For its part, the media gave extensive attention to HIV/AIDS. The three major English language daily newspapers provided regular coverage of HIV/AIDS events. One could argue that the press was fairly objective, as they gave equal attention to both pro-AIDS prevention and anti-prevention views. There was, however, little critical analysis of the various responses to the epidemic, although over ten editorials urging greater governmental and public attention to HIV/AIDS were published in the early and mid-1990s. As mentioned above, the withdrawal of condom advertisements was a major setback to prevention efforts. It should be noted, however, that both the Kenya Television Network (which is private) and the Kenya Broadcasting Corporation (State owned) continued to broadcast spots with messages which suggested condom use ("avoid casual and unprotected sex") but which never mentioned condoms by name. Grassroots Response Behind these national-level trends, NGOs and religious groups implemented hundreds of HIV/AIDS prevention and care interventions. In 1989 a consortium, the Kenya AIDS NGOs Consortium (KANCO) was formed of NGOs and religious groups concerned about and/or involved in HIV/AIDS prevention and care issues. Among the emerging issues was the desire to improve relations between government and non-government entities and to assist in the coordination of NGO interventions. In fact, KANCO members were often the most outspoken about the difficulties of designing and implementing interventions in the absence of guiding national policy or strategy. As a result, KANCO received support from AIDSCAP to design and implement a policy development process that would solicit district and provincial level concerns and views and shape them into a set of policy recommendations that would be placed before the appropriate authorities including government, religious groups, businesses, and NGOs themselves. By 1997, it was widely acknowledged that KANCO had played a "most significant role," in the words of one UN observer, in giving voice to numerous constituents who had felt excluded from decision-making around HIV/AIDS issues, and in raising the level of discussion and attention to those issues within policy circles. Several HIV/AIDS networks emerged or were greatly strengthened in the mid-1990s. The largest was that associated with KANCO, whose membership grew from about 50 to over 300 at the national level, with 26 associated district-based network branches. The Kenya Christian AIDS Network (Kenya-CAN or KCAN) was nurtured by the Medical Assistance Project (MAP) International into over 20 branches with clergy and lay membership. Kenya Ethical and Legal Issues Network (KELIN), a network dealing with law and ethics issues related to HIV/AIDS, was formed to increase awareness and solidarity for legal reforms to address the epidemic. Business/Private Sector Response For the most part during the 1990s, the business community ignored HIV/AIDS as an issue of concern to their operations. It was widely assumed that many companies tested potential employees for HIV/AIDS, but no confirmation was forthcoming. Applicants for life insurance were tested, which was a way for companies to acquire knowledge about the HIV status of their employees. A handful of larger companies offered STD treatment for employees. Many life insurance policies carried riders that limited payments to beneficiaries of people who died of AIDS. However, when offered assistance to provide information within the workplace, an increasing number of companies responded positively, although few were willing to make the financial commitment to sustain the activities over the long term. The lack of a national guideline on matters relating to HIV/AIDS was consistently cited as a major obstacle to policy formulation. Conclusion In summary, Kenya has moved a long way during the period of AIDSCAP's involvement in the country. Some of that can be credited to the strategic sub-agreements developed between AIDSCAP and skillful implementing agencies. Some of it can be ascribed to the relentless expansion of the HIV/AIDS epidemic, which has not abated. Some of it can be accounted for by a variety of organizations and individuals who have used information and influence to move agendas. The result has been a much stronger focus on HIV/AIDS as a national problem, the commitment of significant resources to address aspects of the problem, and the mobilization of communities across the country to confront the epidemic. Several observers noted early in 1997 that the structures and foundation had been created to permit an effective national response in the years ahead. |
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