HIV Prevention in Kenya: Lessons Learned from the 2007 Kenya AIDS Indicator Survey Carol Ngare KAIS TWG Member, NASCOP-MOH Prevention Summit 2008 HIV Prevention in Kenya: Lessons Learned from the 2007 Kenya AIDS Indicator Survey

2 The Kenya AIDS Indicator Survey 2007  Nationally-representative HIV serosurvey  ~18,000 individuals from nearly 10,000 households  Includes older adults age  Prevalence of HIV, HSV-2 and syphilis  Coverage of HIV services

3 4 Components of KAIS  Household Questionnaire  Individual Questionnaire  Blood Draw  Return of Result

4 Differences from KDHS 2003  KAIS allows –examination of older adults years old –comparisons of persons’ perceived HIV status to actual HIV status –HSV-2 –Return of results –CD4 counts measured  KAIS-KDHS comparisons restricted to men and women 15-49

5 HIV PREVALENCE IN KENYA 2007

6 HIV PREVALENCE IN KENYA AGETOTALFEMALESMALES Total (15-64) Total (15-49) Roughly 1.4 million Kenyan adults are living with HIV

7 HIV peaks for younger women and older men, but remains an issue across age groups

8 Dramatic disparity in HIV prevalence across provinces National Prevalence: 7.4%

9 Nyanza & RV are home to over 50% of all HIV infected persons in Kenya

10 Rural areas have witnessed an increase in HIV prevalence Ages 15-49

11 From Prevalence to Prevention: From Prevalence to Prevention: Assessing Key Domains of Prevention Efforts in Kenya

12 Key Concerns of Current Prevention Efforts  HIV testing  Knowledge of HIV status and disclosure between partners  Partner HIV discordance  Male circumcision  HIV awareness and knowledge  Youth sexuality  Older adults

13 HIV TESTING  Prevention Relevance –Increase accurate knowledge of status, and reduce transmission/acquisition risk  Prevention Goal –Increase the number of persons testing, particularly among those at higher risk of HIV transmission/acquisition

14 Testing has increased in recent years, especially among women

15 …but we are far from the 2010 target of 80% universal CT coverage 68% Gap 48% Gap

16 Increased testing among women is likely a result of increased ANC testing

17 Testing rates show little difference across provinces... Ages 15-64

18... but should testing rates differ given HIV prevalence?

19 Testing: Summary  Trend is improving, but long way to go from testing target  ANC testing has increased among pregnant women  Acceptability of home testing is high  Testing among men and in rural areas lagging  Gap in testing among older adults  Testing gap in high prevalence provinces

20 Knowledge of HIV Status & Disclosure  Prevention Relevance –Knowledge of serostatus and proper disclosure to sexual partners can help reduce new infections  Prevention Goals –Increase knowledge of serostatus –Increase disclosure between sexual partners –Increase condom use when serostatus is unknown

21 82% of HIV+ adults do not know they are HIV infected Never Tested Believed themselves uninfected based on last test Correctly reported HIV positive Did Not Report Status year olds who were KAIS laboratory-confirmed HIV infected, n= %

22 Most people do not know their partners’ status 89%  Never tested: 89% do not know partners’ status 60%  Tested and believe themselves negative: 60% do not know partners’ status 36%  Reported HIV positive: 36% do not know partners’ status

23 Consistent condom use is low with partners of unknown HIV status

24 Knowledge of Status & Disclosure: Summary  Most HIV+ persons do not know they are infected.  Most persons do not know the HIV status of their partners.  Consistent condom use is low.  Those who know they are HIV+ are more likely to know HIV status of partners.

25 HIV Discordance  Prevention Relevance –Long-term discordant couples are at higher risk of HIV transmission/acquisition due to frequency of sexual contact  Prevention Goal –Increase awareness of discordance between couples –Promote safer sex practices among serodiscordant couples

26 6% of all married/cohabitating couples are HIV discordant Nearly 400,000 discordant couples in Kenya (200,000 in Nyanza and RV) Nearly 50% of all married/cohabitating HIV+ men and women have an HIV uninfected partner Discordance in Kenya

27 Condom use with married/cohabitating partners is highest among positives who correctly reported their HIV status

28 Male Circumcision  Prevention Relevance –Research suggests that male circumcision is associated with substantially lower HIV acquisition for men.  Prevention Goals –Increase awareness of potential benefits of circumcision –Promote voluntary circumcision among adult men –Encourage parents to have male children circumcised

29 Circumcision is associated with lower individual HIV risk among men Among men age who are not circumcised 30% are HIV infected

30 HIV Knowledge & Attitudes  Prevention Relevance –Increased knowledge of HIV should help promote risk-reducing behaviors –Reduced stigma will support secondary HIV prevention through care and treatment of infected individuals  Prevention Goals –Increase HIV knowledge in general public and high risk populations –Decrease stigma of HIV throughout population

31 Radio is the most common source of HIV information Top 5 sources of information, 15-64

32 Knowledge Questions  9 questions on general acquisition/transmission –“Can people reduce their chance of getting the AIDS virus by using a condom every time they have sex?” –“If a woman has the virus that causes AIDS, does her sexual partner always have the AIDS virus, almost always, or only sometimes?”  3 questions on mother-to-child transmission pathways –“Can the virus that causes AIDS be transmitted… during pregnancy?”

33 School education is associated with comprehensive HIV knowledge  Of the 12 major questions –56% –56% of men and women answered 9 or more correctly –40% –40% answered 5-8 items correctly –4% –4% answered fewer than 5 correctly  Educational background was an important determinant of comprehensive HIV knowledge –19% –19% of those with no primary education answered fewer than 5 items correctly, compared to –1% –1% of those who completed primary school or beyond

34 Increase in PMTCT knowledge among women, 15-49

35 Comprehensive HIV knowledge is not associated with differences in prevalence

36 Attitudes Questions  70-90% agreed with the following individual statements –“I would buy fresh vegetables from a vendor who has HIV” –“I would not want the status of an HIV-positive family member to remain secret” –“I am willing to care for a relative with HIV at home” –“I believe an HIV-positive teacher should be allowed to continue teaching”

37 Among women there is an increase in accepting attitudes Percent agreeing with all 4 items, ages 15-49

38 Knowledge & Attitudes: Summary  Radio is the most common means of reaching people with HIV information  Comprehensive knowledge was low, especially among those with little formal education  HIV knowledge alone is not associated with reduced HIV infection  PMTCT knowledge is growing for women  Stigma remains a challenge, but improvements are evident among women

39 Youth Sexuality (age 15-24)  Prevention Relevance –Delayed initiation and safer sex during early sexual development can help reduce HIV acquisition  Prevention Goals –Increase age of sexual initiation –Increase condom use among youth

40 Marriage and early sexual initiation are associated with higher HIV prevalence among young women Very few young men were married (n=228). Youth, 15-24

41 Some declines in age of sexual initiation evidence

42 Youth Sexuality: Summary  Marriage at young ages is strongly associated with HIV prevalence  Some decline in proportion of men having sex by age 15  Few young women have sex with men 10 or more years older

43 Older Adults: A New Prevention Area (50-64 year olds)

44 HIV in Older Adults  85% of older adults have never tested for HIV  88% of older adults do not know the HIV status of their marital/cohabitating partners  Condom use is very low –Less than 2% report consistent condom use with marital/cohabitating partners

45 HIV in Older Adults (cont.)  Older women have higher proportion of undiagnosed HIV infection  HIV is almost 3 times higher among formerly married older adults (widowed, separated, divorced) than those currently married

46 Lessons Learned  Know your status; know your partners’ status –Need for ‘repeat’ testing and disclosure –Condom use remains low  Re-evaluate common perceptions of ‘high risk groups’ –Married couples –Uncircumcised men  Older adults need to be targeted as much as our focus on youth

47 Acknowledgements  MOH-NASCOP  NACC  KNBS  NPHLS  NCAPD  KEMRI  PEPFAR through CDC & USAID  UNAIDS/WHO  All TWG Members