BY SOILA KENYA
When 23-year-old Ashley Nicole* first found out about her HIV positive status in 2013, she was still in high school.
“I started getting sick and I was in a boarding school. When I came home for treatment, my mom insisted I should test for HIV. It was traumatizing. I hadn’t had any engagements with any guy so I was confused,” she said.
It turned out that her mother had transmitted the virus to her and all her siblings through breastfeeding when they were babies.
This is just one of the ways that HIV can spread from one person to another, but all this has mostly become common knowledge now.
As of 2019, the Joint United Nations Programme on HIV/AIDS (UNAIDS) reported that between 1.3 and 1.7 million people are living with HIV/AIDS in Kenya.
Ever since the first case of the Human Immunodeficiency Virus in Kenya was recorded in 1984, the country initially experienced a steep increase in the number of new infections.
However, due to the increased use of Antiretroviral drugs, the number of new infections decreased from 170,000 people in 1990 to 42,000 people in 2019.
20-year-old Anne Carol Kibuthia first got a fever and a few symptoms of flu in early June, but she thought nothing of it. By that time, the number of recorded COVID-19 cases in the country was nearing 3,000.
“I also started getting headaches and lost my sense of taste and smell,” said Anne Carol.
One day when she was at work at a cafe in Kangemi, her aunt called her with some bad news. “She told me my sister had tested positive for COVID-19 so she came to collect me and my colleague so we could go get tested too at KEMRI [the Kenya Medical Research Institute]. I was so scared,” she said. Her colleague’s results came out negative, but she wasn’t so lucky.
Anne Carole and her sister are part of the 35,020 Kenyans, and counting, that have caught COVID-19. The COVID-19 infection rate had a slow start but rose steeply in late June and has continued to rise since the first case was reported in March 2020.
As the virus has spread within the country, several public service announcements have been aired on TV, in newspapers and on radio, giving guidelines on how to protect yourself and others. This came in conjunction with the daily COVID-19 updates from Health Cabinet Secretary Mutahi Kagwe. There have been varied reactions to this with most people taking the extra precautions while others dismiss its seriousness or even question whether the virus exists at all.
At a glance into the past, Kenya has been tackling the HIV pandemic for more than three decades. In this time we have achieved relative success in containing the disease.
In February 2020, the Ministry of Health released the Kenya Population-based HIV Impact Assessment (KENPHIA) 2018 survey indicating that Kenya’s HIV prevalence now stands at 4.9%. During the event, Chief Administrative Secretary (CAS) Dr. Rashid Aman said, “Today we celebrate that over 96% of people who know their HIV-positive status are on life-saving treatment. More than 90% of those on treatment have controlled the HIV virus and therefore pose a very low risk of HIV transmission.”
This success has been achieved through concerted efforts by the government and its partners. It proves that the country can deal with a deadly disease.
HIV/AIDS and COVID-19
Before HIV/AIDS, Kenya has faced Smallpox, Spanish Influenza, Bubonic plague and Cholera epidemics. Other than COVID-19, HIV is the most recent large-scale epidemic that has struck and is similarly causing fear and stigma within communities.
Currently, a big concern for people living with HIV is their increased risk of getting COVID-19 due to their suppressed immune systems. The lockdowns and restrictions also prevented some HIV positive patients from getting their medication.
“When COVID came around, it really affected the kind of work we do to carry out testing among the population,” said Dr. Philip Masaulo who is the Western Kenya Director of LVCT Health, a non-profit organization that works to reduce new HIV infections.
According to the KENPHIA 2018 survey, the top five HIV high-prevalence counties with a prevalence of more than 9% are Homa Bay, Kisumu, Siaya, Migori and Busia.
Dr. Masaulo, who carries out his duties from his Kisumu office says this is due to an already highly infected population in the area that continues to spread the virus, the border with Uganda and a high concentration of sex workers and men who have sex with men, who are key drivers of the spread of HIV.
In recent months, fewer people have been doing walk-ins into hospitals to get tested due to fear of catching COVID-19 or possibly being detained in one of the isolation centres. “We had expected to have a 25% increase in the amount of testing we carried out between March and September but we have only managed 13% by the end of June,” said Dr. Masaulo.
To ensure testing continues, LVCT Health adopted the strategy of spreading people’s appointments throughout the day so that fewer people are in the clinics at any given time to observe social distancing regulations. They have also ramped up their use of phone technologies such as Whatsapp and SMS to follow up with patients who test positive for HIV.
This situation in the long term means there will be a higher number of HIV positive people who do not know their status. It also means that for people who already know their status, they might face interruptions to their medication schedule due to fear of contracting COVID-19 by visiting hospitals. These people will become a risk to others due to high viral-loads which makes it easier to spread HIV. This could mean the country will face a surge in new HIV infections driven by the COVID-19 pandemic.
Self-testing kits, which are usually used in order to increase access to testing within counties and rural areas, were in short supply in the country by the time the COVID-19 restrictions began. The kits are usually used as a screening method especially for those who fear facing stigma by visiting a clinic. Those who test positive are then required to visit a clinic to confirm their status. “KEMSA (Kenya Medical Supplies Authority) buys the kits and distributes them to the counties. They are funded by the PEPFAR Program,” said Dr. Masaulo.
The President's Emergency Plan for AIDS Relief (PEPFAR), is an initiative of the U.S. government started in 2004 to support the fight against HIV/AIDS around the world. Due to COVID-related lockdowns, the kits were not able to be shipped into the country.
Based on a modeling study published by UNAIDS and WHO in August 2020, it was discovered that a six-month interruption in HIV treatment in sub-Saharan Africa would cost 500,000 additional deaths in the first year. The report also noted that decades of progress in the fight against HIV/AIDS would be lost in just one year.
Victor Odallo* is a 22-year old living with the HIV virus. He is also a Facility Youth Advocate for people living with HIV and counsels adolescents living with HIV. When COVID-19 arrived in Kenya, he became extremely paranoid, washing his hands several times a day and avoiding contact with others as much as possible. “I’ve ever contracted TB. So what about COVID where I’m even hearing that very young children are dying. What about me who already has one of the worst diseases, what will happen to me?” asks Victor.
He also admits that going to the nearest clinic to get his medications to reduce movement and subsequent exposure to COVID-19 is not an option for him. “Leaving your primary facility of care is quite hard. I’ve been going to the same facility for my medication for the past 13 years,” he said, afraid that people he knows could discover his status.
The counselling services he offers to teens living with HIV have also been greatly affected. Due to physical distancing regulations he has to sit far apart from them and with the addition of mask-wearing sometimes he is unable to offer his clients the needed care during the consultation. “I cannot hear them properly when they speak as they have to wear masks. And when I ask them to speak louder, they refuse or run the risk of someone outside the room eavesdropping on our conversation,” he says.
To protect health workers who work with HIV patients, the Ministry of Health provided a guideline to “ensure continuity of antiretroviral treatment and other essential HIV services for the over one million people living with HIV (PLHIV) while maintaining a safe environment for other clients and service providers.”
The guidelines range from protocols where all people living with HIV must have their temperature taken before entering clinics and hospitals to providing people living with HIV with 3-month supplies of their medications at every visit to reduce clinic attendance and drug pick-up frequencies.
What can Kenya learn from the HIV epidemic?
“Because of COVID-19, it became a bit difficult to follow the agreed-upon protocols [when dealing with HIV patients] so the fact that the government gave guidance on how to still provide adequate services to PLHIV gave us a bit of leeway and made the delivery of HIV services easier,” said Dr. Florence Njenga the Clinical Lead at the Mater Hospital Comprehensive Care Clinic in Nairobi that serves PLHIV from all over the country.
She confirmed that in the clinic there was a 10% drop in walk-ins. Most patients have also been able to collect medications that last them a longer time with the exception of those who have started treatment recently, those who are pregnant and those who are failing treatment due to high viral load or low immunity.
The biggest challenge the clinic was facing was that there was a limitation of the tests for viral-load monitoring in patients. This is because the National HIV Reference Laboratory (NHRL), a government laboratory that does the HIV viral load test for free, is also a COVID-19 testing site. Before the pandemic, the Mater Hospital Comprehensive Care Clinic used to do an average of 250 tests per week. At the height of the pandemic from April to July, the number was reduced to less than 20 tests per week as directed by the National AIDS and STIs Control Programme (NASCOP).
On August 24th, NASCOP retracted these changes and health care providers were instructed to go back to the initial protocol that is followed to treat HIV positive patients and testing limits were lifted. “Right now the labs are back to testing at full capacity though they have told us it may take longer to get results,” said Dr. Njenga.
Those living with HIV and the health workers that care for them across the country can draw on the lessons learnt from the decades-old fight against HIV.
“One of the first things we should focus on is public information. Giving people accurate information, making this information regularly and easily accessible just as we did with HIV/AIDS will go a long way in stopping the spread of COVID-19. And just as we did with HIV/AIDS, we must also address stigma which is also a big problem with COVID-19,” she says.
Anne Carole*, who found out her COVID-19 status while working at a cafe went into isolation with her sister. They were the only two in the family who caught the virus. None of their neighbours is aware of their condition. Reason? Carole and her sister are worried about the stigma from fearful neighbours about the virus and how it spreads.
Currently, government messaging about COVID-19 has been around numbers of new cases and demands that people should take precautionary measures. The only faces we see are of those who have died from the disease. In rare occasions, the stories and images of those who have recuperated from the disease have been shown. In the campaign to reduce HIV stigma, one of the most effective ways of addressing stigma was to amplify the voices and experiences of those living with the disease, joint and collaborative advocacy and public education campaigns done by the government, mainstream media and on social media. Stories of recovery represented by a cross section of Kenyans irrespective of celebrity, political or social status could help in the fight against stigma. Those speaking about their experiences with COVID-19 are a big help. Celebrities who have recovered such as Jeff Koinange, Bonnie Musambi, Stephen Letoo, Robert Burale and Bishop Margaret Wanjiru on social media while commendable reinforces the myth that the disease is impacting on those of a higher social standing than the average Kenyan and does little to deter the stigma.
Celebrities and politicians' stories of recovery may be inspirational; they have done little to disabuse ordinary Kenyans of the mistaken belief that the virus cannot affect them. “I have not heard of anyone in my neighbourhood, or even anyone in my circles or even friends of friends talk of anyone they know who has caught the virus or even been put in quarantine on suspicion of having the virus. This disease is for the rich,” says Mungai Nzioka, who works as a delivery truck driver at Kawangware food market says, Nzioka observes the guidelines—frequent handwashing and the wearing of a facemask when he makes his deliveries at the market. He says none of his customers or even the farmers where he collects vegetables for sale know anyone who has been infected, making COVID-19 testing easily accessible to all citizens will also help in reducing the spread, create awareness and reduce stigma. Dr. Njenga draws comparison with HIV testing. Announcements and the offer to test people for HIV is done at many social gatherings such as churches, hospital entrances and schools. Due to the lockdown, these gatherings were suspended and even though the regulations have been eased, the government has yet to exploit these forums to educate the public or even offer the tests. This ease of access to testing helped demystify HIV and could also be done for COVID-19.
Over the years, the HIV test has evolved and improved over three decades to become quick and easy and can be taken for free at any VCT clinic. The COVID-19 test, though simple to carry out, costs anywhere between Ksh 8,000 and 13,000. This is compounded by the corruption allegations against KEMSA’s procurement and distribution of PPE in the country.
For those living with HIV, the care offered is comprehensive— psychosocial support, counselling, nutrition advice, even tips on how to live with HIV in the home. Dr. Njenga says HIV is a social disease - it affects not only your body, but also your mind. All-round support is offered to PLHIV to the extent where community health workers even come to your home to help you address issues even at the family level. This one-stop-shop approach could be adopted with COVID-19 rather than having several different people all dealing with one patient, while others are even left with little or no support. This has already been observed in the treatment of COVID-19 where patients are recovering through home-care based treatment interventions.
Contact tracing has also been thoroughly practised with HIV patients. Over the past ten years, Dr. Njenga says health workers caring for PLHIV have almost become experts at it. The same practices can be used when dealing with COVID-19 patients to avoid anyone slipping through the cracks.
There is also a lot of care offered to PLHIV to make sure they stick to their treatment. From SMS reminders to phone calls to physical tracking. Within facilities, there is also counselling offered. Before starting treatment PLHIV are taken through extensive training on how to take their medication, how the drugs look like, what their names are and what side-effects they might encounter and what to do in case that happens. There is also a follow-up to see if you are following their prescribed regiments. This is something that is absent in the treatment of all other diseases.
“I know a big concern with COVID has been that people are sick but they’re not letting other people know and they’re not isolating themselves. So there’s a lack of adherence to the treatment guidelines. That’s something I think the COVID management can borrow from the HIV management,” said Dr. Njenga.
After dealing with the COVID-19 pandemic, the Mater Hospital Comprehensive Care Clinic will continue to utilise phones in conducting adherence counselling and support. Constantly adapting their approach to HIV/AIDS healthcare as the COVID-19 pandemic runs its course has highlighted the need for “creativity and flexibility.”
The lessons that Kenya has learnt as it deals with HIV cannot be ignored as being totally separate from the novel coronavirus. In the UNAIDS response to COVID-19, they said, “The experiences learned from the HIV epidemic can be applied to the fight against COVID-19. As in the AIDS response, governments should work with communities to find local solutions.”
Though the two diseases have hardly anything in common other than that they are both viruses, managing the care and treatment of patients can be adopted across the board just as Ebola provided public health management services with a learning curve in the Central and West African countries that battled the outbreak. Even as we learn how other countries are handling the pandemic, Kenya can rely on its in-country experience in handling HIV/AIDS to tackle COVID-19.
This report was supported by the Africa Women Journalism Project (AWJP) in partnership with the International Center for Journalists (ICFJ)