In response to a recent blog post on the history of the HIV epidemic in South Africa, I would like to provide a brief history of the HIV epidemic in Kenya.
Kenya had a very different history from South Africa. In fact, the histories of most African countries may share similarities but are also subtly different. Therefore, each country is now experiencing very different HIV epidemics and need different sets of HIV prevention interventions.
Following independence in the early 60s, Kenya under Kenyatta saw many changes, some good and some bad. Spending on education, health, infrastructure and various social services increased. The country underwent a transformation and enjoyed a level of prosperity that was unmatched, before or since.
The early independence period was not perfect, of course. Some gained, some remained in the position they had always been in. In general, many people were employed and social and economic indicators showed improvement. But at the same time, those in the Kenyatta government had already started the process of enriching themselves from the public purse.
It is important to note an advantage that Kenya had over some other African countries. They opposed the soviet regime and were well rewarded for the part they played in the cold war. Kenya continues to support the current ‘war against terror’ and appears to be generally sympathetic to US aggression. It is probably not an accident, therefore, that they currently receive the tenth highest share of US aid money.
So, while health, education and other social infrastructures were being built up during the 70s, politics and governance were taking shape to eventually undermine many of the earlier gains. Kenyatta died and was replaced by Moi in 1978. (The current president, Mwai Kibaki, held senior cabinet posts in the Kenyatta and Moi regimes, so there is a high level of continuity between the early independence years and the present decade.)
HIV probably first reached Kenya in the late 1970s, coming from the Western Equatorial region via Uganda and perhaps via Tanzania. This was still some years before it would be identified, though some health professionals working in Kenya at the time retrospectively noted an unusual health situation characterised by acute versions of relatively common conditions.
1980: retrospective tests of blood samples from Nairobi commercial sex workers (CSW) show zero HIV prevalence (the percentage found to be HIV positive), but a sexually transmitted infection (STI) programme was established. So the virus may well have already been present in other areas because in 1981, retrospective tests show a prevalence of 4%. Around this time the US Center for Disease Control (CDC) noted a new disease that affected gay men.
Kenya had been receiving loans from the International Monetary Fund (IMF) and the World Bank for some years but it was in the 1980s that these institutions started to build conditionality into its loans. ‘Structural Adjustment Policies’ (SAP), which resulted in reduced spending on education, health, infrastructure and social services, had an enormous impact on the country. When HIV prevention efforts started, belatedly, they were seriously curtailed by these SAPs.
These SAPs continue to this day, sometimes under different names. This is despite clear evidence that their effects are almost entirely destructive. They play a major part in what can only be described as retrogressive development and the sooner they are reformed the better. As long as developing countries are compelled to reduce health, education and other services, they will be unable to develop or, therefore, to reduce the spread of HIV.
1982: AIDS is named and vertical (mother to child) and heterosexual transmission are recognised. The following year a virus is identified that is suspected of causing AIDS. It is later named HIV and World Health Organisation (WHO) HIV surveillance starts. In 1984 the first case of HIV in Kenya is identified and in the following year the National AIDS Committee is established.
For the whole of the 1980s and 1990s, even into the 2000s, Kenyan leaders persisted in denying the existence of HIV. There was plenty of evidence that HIV was a serious problem in Nairobi because prevalence among CSWs there peaked at 81%. Prevalence subsequently declined, despite the fact that HIV prevention efforts were not very widespread until many years later. In fact, it remains unclear why prevalence peaked so early among CSWs and then declined.
1987: the WHO formed the Global Programme on AIDS. The following year, Kenya’s Ministry of Health issues guidelines stating that patients should be told their HIV status. In 1989, President Moi is said to have ordered the quarantining of people with HIV/AIDS but the order was quietly ignored. By 1990, there were an estimated 7.5 million people living with HIV, globally.
Without the Kenyan government substantially moving from their position of denial, HIV incidence (the number of new infections per year) peaked at 2%. Prevalence in one province, Rift Valley, peaks at 14% in the same year. At this time, Moi publicly refused to admit that the HIV epidemic had become national in scope. Prevalence peaks in Western Province at 17% in 1994 and the government as a whole recognises HIV as a critical issue.
But in 1995, the Kenyan government still seems uninterested in the epidemic. Donor funds are not distributed or go missing and, although the countries blood stocks are found to be unsafe, the government denies that this poses a major problem. At this time 17.5 million people are living with AIDS, globally. Prevalence in Nairobi peaks at 17% and national prevalence is estimated at between 10 and 14%.
1996: Highly Active Anti-Retroviral Therapy is developed (HAART). In the same year, a Kenyan cardinal condemns the use of condoms to prevent HIV infection. The following year, HIV prevalence peaks. Early prevalence figures were subsequently revised and it is now thought that HIV prevalence peaked at 9 or 10% in the late 1990s.
1997: UNAIDS (Joint United Nations Programme on HIV/AIDS) is formed. The Kenyan Parliament approves a 15 year national AIDS policy and forms the National AIDS Council. Moi bows to election year pressure from religious leaders and shelves sex education plans.
1998: incidence is thought to have peaked globally at around 3.4%. A large number of Kenyan public sector employees die as a result of AIDS. The Great Lakes Initiative on AIDS (GLIA) is established. The following year, HIV in the last of Kenya’s provinces peaks; North Western Province peaks at a relatively low rate, 6%, although this and other figures are often questioned.
In the same year, Moi declares AIDS a national disaster but is still reluctant to do anything about it. He says he feels it would be improper to encourage the use of condoms in schools and colleges. However, the National AIDS Control Council was formed and is still in operation.
2000: an estimated 27.5 million people are living with AIDS, globally. Kenya develops a five year National AIDS Strategic Plan and plans AIDS education for all schools and colleges. The Millennium Development Goals (MDG) are adopted by the international community and reducing the spread and impact of HIV are include in this initiative.
2001: the Global Fund to Fight AIDS, TB and Malaria (Global Fund) is formed by the World Bank. Moi, in the run up to another election, publicly expresses reluctance to spend public money on condoms. He recommends abstinence as protection against AIDS. Christian and Muslim leaders join him in opposing condoms.
2002: the new president, Mwai Kibaki, declares ‘Total War on AIDS’. However, the following year, Global Fund grants are withheld because of corruption allegations. Widespread corruption, misuse and disappearance of funds are discovered and, unusually, some people are held accountable.
2003: Kenya’s prevalence is found to have dropped to 6.7% and the death rate peaks at 120,000 per year. These are highly significant milestones. As HIV incidence peaked in 1993 and declined thereafter, it would follow that prevalence would peak some years later, around the end of the 90s, say. A few years after that, it follows that many people would die of AIDS and prevalence would drop dramatically. The first wave of the HIV epidemic ended in the early 2000s.
2005: globally, 37 million people are living with HIV. AIDS deaths peak at around 2.2 million. Kenyan prevalence is said to stand at around 6.1%. A new five year strategic plan, due to run up to 2010, is published. The following year, Kenyan prevalence is said to have fallen again, to around 5.1%.
2007: global prevalence is revised downwards as a result of improved reporting methods. HIV figures are confusing, but data collected in Kenya suggest that prevalence had been rising since 2004 and had reached 7.8%. This is despite the previous assumption that prevalence had been falling continuously since the late 90s and had dropped to about 5.1%
The data published in 2008 show rising prevalence and my interpretation is that this may indicate a ‘new wave’ of the HIV epidemic. On the other hand, it may indicate no such thing. Estimations are very imprecise and predictions are dangerous. Some say HIV in Kenya is declining, some say otherwise. Personally, given the apparent connections between the spread of HIV and the country’s history, I would suggest that that Kenya is in a worse state now than it was in the 1980s and is therefore experiencing another serious HIV epidemic.
Holding a pessimistic position when everyone wants something to be optimistic about is hazardous; people want you to be wrong. But, as I have said elsewhere on this blog, I too would like to be wrong. I am not an epidemiologist, I could well be ignoring many factors and exaggerating the effects of others. No doubt it will be some years before the true picture is known. It is to be hoped, in the meantime, that some effort is made to improve health, education, social services and governance. These are in serious need of attention, regardless of what the HIV epidemic is doing at present.