AIDS treatment group breaks cultural taboos

NAIROBI, Kenya-It has trained 70 percent of Kenya’s voluntary counseling and testing personnel. It helped to set up more than a quarter of the country’s operational VCT sites, treats 5 percent of the country’s HIV-positive population with anti-retrovirals, has written the manual for post-rape counseling and broken a number of taboos doing so.

Yet for a non-governmental organization with this many accomplishments, made in the relatively short period since its establishment in 1998, Liverpool VCT Care & Treatment seems purposefully unassuming.

Its busy offices in Nairobi are functional, its staff casual, but its mission is, in one word, enormous. As a public health NGO specializing in the prevention and treatment of HIV/AIDS, it has shrugged off the protection of easy consensus in pursuit of, in the words of the woman who leads it, Dr. Nduku Kilonzo, a public health imperative to “respond to the reality of HIV/AIDS” in Kenya. What this means concretely, at least for LVCT, is to tread where others sometimes fear to tread, ruffling feathers, sometimes stirring up controversy on the way but always - perhaps in contradiction to the nature of its work - in a non-confrontational way.

LVCT’s programs have helped shine the light on ambiguities and dark corners that most unaffected Kenyans would prefer to ignore. Specifically, Liverpool has delved into the parallel worlds of homosexual sex, prostitution, rape, sexual violence and exploitation, and their intersection with the wider HIV/AIDS pandemic in this East African nation, asking questions but at the same time raising important new ones.

For a reflexively prurient and patriarchal African society, such questions are simply not raised in polite company, their implications are explosive. But HIV/AIDS has challenged African health systems and societies in profound ways. How to explain the fact that two-thirds of the people living with HIV/AIDS are female? How can the spread of this disease be halted if most people still do not have the information they need to protect themselves? How useful is that information if even those who have it often seem unable to apply it in their intimate relations?

Clearly trying to answer those questions will change the way Kenyan society works. Liverpool, for its part, has worked methodically to strip the veil of complacency off such unpleasant realities as same-sex intimacy in prisons.

LVCT’s advocacy work has led to important changes in public policy and procedures related to, for instance, the police’s procedures on post-rape reporting. Far from advancing a foreign agenda, as is often suggested of NGOs stirring up controversy, LVCT’s programs are rigorously grounded in careful research and data analysis. Even its activities targeting “vulnerable” groups such as men having sex with men (or MSM) and sex workers are in line with the official Kenya National HIV/AIDS Strategic Plan. Still, one indicator of how sensitive the topic remains is the fact that LVCT is still one of only a handful of organizations operating MSM programs in Kenya.

Kenya’s HIV/AIDS crisis

According to official estimates, at its peak in 2003, the HIV/AIDS pandemic in Kenya was killing more than 300 adults a day. Other estimates suggest mortality on the order of 700. Yet as the disease emerged and took hold in Kenya during the 1980s and ‘90s, the authorities seemed indifferent or resigned to its proliferation. The gap created by official neglect was fertile ground on which rumor and prejudice flourished. The lack of information and the associated stigma discouraged frank discourse and helped the disease to spread.

By the late 1990s, this slow but relentless disaster began to look like a threat to the Kenya’s economy - as well as other economies in Africa and around the world. Death and sickness had cut down a swathe of Kenya’s most productive citizens. Worse, the effects were being felt in essential public services such as health and education and in the private sector. The year 1998 may be seen as a turning point; that year, sentinel surveys from the Kenyan Ministry of Health showed adult HIV prevalence rocketing into the double digits, eventually peaking at 14 percent in 2000. In the hardest-hit parts of the country, the burden of increased mortality and ill health was eroding family ties, the foundation of social cohesion and solidarity in both rural and urban Africa. Phenomena that had long been unheard of - such as child-headed households and the breakdown of extended family support - went in line a decline in public services and the overall economy.

The government dramatically, albeit symbolically, declared the HIV/AIDS pandemic a national emergency. More concretely, it created the National Aids Control Council (NACC) to lead the national response to the disease and its social consequences. In 2003, it launched the “Total War on AIDS” campaign. Its acronym, TOWA, means to “remove” or “take out” in Swahili.

Ten years on, this year’s UNAIDS Global Report on the AIDS Pandemic highlights Kenya as one of the countries making the fastest progress turning the tide. Mortality rates have declined sharply as a nationwide treatment program was rolled out. The rate of new infections has, at least until recently, been declining.

Mortality and new infections remain high. According to NACC, there are some 1.1 million Kenyans living with HIV/AIDS. Under the official best-case scenario, this number would remain stable as both mortality and new infections decline. But the latest Kenya AIDS Indicator Survey showed prevalence rising again after years of decline, casting doubt on the sustainability of past achievements, such as the reduction of the HIV/AIDS prevalence in adults by more than half within 10 years.

Breaking barriers

These difficulties Kenya has had in making durable progress reducing the prevalence of HIV/AIDS illustrates an important point: The core driver of every HIV/AIDS pandemic is the fact that HIV/AIDS is an incurable sexually transmitted disease, and a sustained reduction of infection rates require lasting changes in sexual behavior. This, in turn, requires clear-eyed analysis of what in the sexual behavior and mores of Kenyans continues to favor the spread of the disease.

The statistics themselves shed some light on the issues. Female seropositivity rises sharply among early teens, peaking in young women in their mid-twenties. Seropositivity in males rises more slowly, peaking in males in their late thirties to early forties. This is not coincidental: Women often have their first sexual experience with considerably older men who have multiple sexual partners and are the main propagators of the disease.

But frank discussions about the vulnerability of young women and older men are rare. Other areas, especially male-to-male sexuality and sex workers, are similarly shunned. Above all, sexual violence, which touches on the balance of power in intimate relations, is still cloaked in deep secrecy, shame, denial and female disempowerment.

NACC works with many indigenous and foreign partners, but among Kenyan NGOs, Liverpool’s outreach to vulnerable groups stands out for its scope and ambition. LVCT runs five major programs targeting vulnerable groups: men who have sex with men, survivors of sexual violence, the deaf, youth, and sex workers.

Established in 1998 as a research project of the Liverpool School of Tropical Medicine, LVTC was incorporated in 2001 as a Kenyan NGO specializing in HIV prevention and treatment. It has since grown into a large organization by Kenyan standards, with more than 250 staff. Its biggest visible impact has been in the rapidly growing VCT sector, where LVCT has trained more than 70 percent of the 3,600 VCT counselors and helped set up about a quarter of the VCT sites operating in the country.

In some cases, reality has helped to overcome public hostility to Liverpool’s causes. Its prisons program is a case in point. MSM activity is behind the high levels of HIV/AIDS in Kenya’s prison population. Research conducted by LVCT in Kenyan prisons revealed a world where sex between inmates - whether coercive, consensual or transactional - is shockingly routine. For their part, prison rules explicitly recognize that sex between inmates happens; the punishment for being caught is an extended prison sentence.

This reliance on simple-minded repression has helped to fuel the HIV/AIDS crisis in Kenyan prisons. Faced with a rising tide of infections and apparently powerless - or unwilling - to stop it, the Kenya Prisons Service has changed tack by establishing AIDS Control Units and encouraging prisoners and staff to get to know their HIV/AIDS status. Liverpool has partnered with the Prisons Service’s AIDS control units to offer VCT services to prisoners and prison workers, a move that has been well received by staff and prisoners, according to Lorna Diaz, LVCT’s MSM program manager.

Reaching out to men having sex with men is a clear, pragmatic health imperative, Diaz said. Kenya, like other countries, has a significant and sexually active MSM community, and research by Liverpool and others suggests high levels of ignorance about the risks involved in certain sexual practices and, consequently, high levels of infection.

For instance, a survey carried out in Mombasa, Kenya’s main port, showed a HIV prevalence of 43 percent among men having sex with men. Moreover, the majority of such men were married or had girlfriends, meaning they formed a bridge from a high-risk group to the rest of the population, undermining the effectiveness of prevention. UNAIDS suggested in a 2008 report that the direct and indirect contribution of MSM activities to the overall HIV/AIDS pandemic in Africa is greatly underestimated.

Addressing these issues is difficult in a country where homosexual acts are illegal and carry severe sanctions, and where public opinion extends to most health workers. For Liverpool, it means that outreach and information efforts targeting men having sex with men must proceed gingerly, Diaz and LVCT Director Dr. Nduku Kilonzo agreed. Both emphasized that their work is not aimed at stirring controversy for its own sake. Liverpool’s priorities are dictated by its research and are fully in line with the Kenya National HIV/AIDS Strategic Plan, they said. Diaz stressed that the MSM category encompasses more than people who identify themselves as gay.

Sexual violence is perhaps an even harder issue to confront. Victims are likely to be exposed to the virus, particularly if they experience injuries. Police statistics show ever-rising numbers of rapes. For instance, in 2004 the police reported 2,908 cases of rape, almost 30 percent more than the year before. However, given the stigma and fear of victims, this is very likely a woeful underestimate of the problem.

Sexual violence is a serious social crisis and is far more widespread than commonly acknowledged, Kilonzo noted. A variety of factors contribute, all involve power imbalances between genders, according to the doctor.

In general, sexual violence is tied up with stubborn traditional notions of intimacy and masculinity, compounded by rapidly changing economic and social circumstances, Kilonzo argued. In many indigenous cultures present in Kenya, “disciplining” one’s wife is often considered the “right” of a man. The idea that a wife could refuse sexual relations with her husband is utterly alien. Moreover, common Kenyan notions of masculine sexuality emphasize aggression and domination.

In an increasingly urbanized and complex society where men and women of different origins interact and where new notions of gender relations are forming, gender violence can take on sometimes extreme forms. An example is the alleged violent gang rapes by police officers sent into Nairobi’s vast shanty towns to stem political riots.

Perhaps more conventionally, men who are unable to assert their headship by being the sole provider might resort to violence against their spouses out of frustration at their own perceived masculine inadequacies. Some acts of sexual violence might thus be a backlash against women who are increasingly empowered. On the other hand, sexual violence can be an act of war; gangs targeted women, girls (and boys) from “rival” communities during Kenya’s post-election crisis in early 2008.

Because Kenya is a patriarchal society, the sexual transgressions by men are tolerated, even encouraged. Thus no consensus has emerged, for instance, on what constitutes sexual violence, particularly in the domestic context. The country is still in the early stages of confronting this challenge, Kilonzo noted.

Still, Liverpool sees progress. For instance, LVCT has worked with the police and Ministry of Health to reform post-rape management and make it easier for victims to report assaults. It has helped to produce new national guidelines for post-rape care with the Ministry of Health and a manual for rape counselors in Kenya.

Diaz said she has observed a greater willingness of stakeholders to talk about homosexuality. Indeed, NACC recommended in March that the government decriminalize homosexual acts as well as prostitution.

And to some of the most marginalized people living with HIV/AIDS, Liverpool has given truth to its motto “You Shall Never Walk Alone.”