The World Bank Global HIV/AIDS Program (GHAP) Global AIDS M&E Team (GAMET) Kenya Modes of Transmission Study 2008 Analysis of Prevention Response & Modes of Transmission Presented by L. Gelmon Modes of Transmission Study Team 2008 Kenya HIV Prevention Summit Safari Park Hotel, Nairobi

Background  Kenya has a mixed epidemic: National prevalence ranging from 6.7% (KDHS2003) to 7.4% (KAIS 2007); Casual heterosexual sex (CHS) contributing 2/3 new infections; substantial gains made in roll out of ART. Great regional variations, ranging from almost 1% (Northeast Province) to above 12% (Nyanza Province, and up to 30% in some fishing communities of Districts adjacent to Lake Victoria area).  Most prevention resources (almost ¾) go toward VCT, PMTCT, and ABC.  Over time, proportion of total funds allocated to prevention has been decreasing (<25% of total).  95% of HIV/AIDS funding comes from external sources.

Synthesis process Understanding of current & past transmission intensity Policy & Programme Realignment Comparative investments in prevention activities Adequacy of prevention targeting to sources of infection Alignment resource allocation & epidemiological evidence

Introduction  Key questions about the epidemic the study aimed to answer. magnitude? trends and phase, character & potential? transmission dynamics & sources of most new infections? do the national strategic priorities, investments & interventions, match the major drivers of transmission? Do interventions reflect proven approaches & global best practice? Is established wisdom and thinking being challenged? Can the conclusions be aligned with the realities of the current policy environment?

Introduction Cont.  Leadership of country process Study conducted December 2007 – July 2008 Team of three: epidemiologist/team leader (L. Gelmon), prevention (P. Kenya), modelling/data (F. Oguya) Coordinated & supervised by UNAIDS-M&E-Kenya (G.Haile) and NACC Policy Research and M&E (B. Cheluget). Kenya MoT Technical Team – (KMoTTT) established to provide leadership, technical advice, review progress, provide suggestions, clear reports. Others included NACC officials, MoH, CDC, KEMRI, National M&E Committee, UNAIDS, Univs. Nairobi and Kenyatta, research insts. in Nairobi, Mombasa & Kisumu. Regular briefings to NACC Board, ICC & Advisory Comm.

Methods  Incidence Modeling tool modified to introduce additional categories for clients of sex work “Long Distance Truck Drivers & partners”, “Migrant Farm Workers & partners” and “Other’ Clients & their partners” Two new groups - Fishing Communities and Prison populations.  Because of heterogeneity of the epidemic, the team produced one national model and three sub-national models to strengthen the analysis.  Not included in the model - refugees, women who have been subjected to sexual violence, etc. partly because of a lack of specific quantitative data.

STATUS OF THE EPIDEMIC – decreasing incidence – 0.5% - (NACC, 2006) New trend is being observed: UNAIDS Incidence Modeling estimates close to 90,000 new infections in 2007 (Kenya MoT study).

STATUS OF THE EPIDEMIC – geographic heterogeneity – Nyanza has 30% of national prevalence

The National Incidence Model 2008

Adult Risk Behaviour Percent Incidence NationalNairobiCoast Nyanza Injecting Drug Use (IDU) Partners IDU Sex workers Clients of Sex Workers Long distance truck drivers  Partners of truck drivers Migrant farm workers  Partners of migrant farm workers "Other" clients  Partners of "Other" clients

Adult Risk Behavior Percent Incidence NationalNairobiCoast Nyanza MSM Female partners of MSM Prison population (male)  Partners of prison population Casual heterosexual sex Partners CHS Fishing community Steady partner heterosexual No risk 0.00 Medical injections Blood transfusions

KYR - The Prevention Response  Kenya policy promotes IEC to the general population (abstinence, condoms, safe sex)  Increase in VCT sites, but only 24% (15+ years) know their HIV serostatus  Prevention with Positive (PwP) programmes not widely implemented.  Condom distribution very erratic and less than half the target (120m/10mpm/5-6mpm)  No national level intervention programmes being implemented for MSM, SWs and IDUs  Youth-oriented programmes claim less than 5% of prevention resources.

Key findings  HIV response is mainly national with few Sub- nationally-driven programmes.  Programmes focussed on specific most-at-risk populations are few and far in between.  2/3 of new infections are through heterosexual contact, partners and fishing communities.  IDUs and MSM combined contribute up to 15% of new infections.  Highest proportion of new infections in western part of Kenya (Nyanza Province) 30% – most likely linked to lack of circumcision.  There is evidence of increased risk of HIV transmission in regular partners of sex workers, and regular partners of sex worker clients.

Recommendations  Kenya needs to conduct evaluations and more research on the: Effectiveness of the abstinence, PMTCT and VCT programmes to determine their contribution to prevention. Behaviour and mapping of most-at-risk, cultural issues requiring behaviour change, utilisation of services  Re-engineer the national response for a more rigorous and evidence-based prevention agenda that would ensure informed investment, address variations of epidemics in regions. reform policies to ensure maximum coverage of the response.  Re-focus and strengthen the prevention agenda to couples/partners, youth, MSM, IDUs, fishing communities, SWs and other most-at-risk populations as well as programmes that target prevention with positives.  Strengthen partnerships for consolidation of resources and capacities as well as the “Three Ones”

‘Asanteni Sana!!’