There has been a gradual decline of new HIV cases overall in Kenya – from a high of 230,000 new infections in 1992 to 33,000 in 2020. But there are particular population groups that are at higher risk of contracting HIV than the general population. In these groups, new HIV cases remain unacceptably high.
This is especially true among gender and sexual orientation minorities, including men who have sex with men and transgender women. Transgender women – individuals assigned male gender at birth, but who currently identify as female – have been documented to have the highest risk for HIV infection globally.
Data from sub-Saharan Africa on transgender women remain limited. But recent findings from Kenya, Nigeria and South Africa provide corroborating evidence of increased risk of HIV infection in transgender women.
The increased risk for HIV infection in transgender women is driven by a combination of factors. The mismatch between their current identity and government issued documents makes transgender women more likely to be unemployed, engage in sex work, and face violence from clients or even law enforcement.
Additionally, receptive anal sex has previously been shown to be an independent predictor of HIV acquisition. Stigma and criminalisation of same-sex relationships makes it difficult for either transgender women or men who have sex with men to seek preventive services in public healthcare facilities. This further compounds their risk for infection with HIV.
Since 2017, the Health ministry in Kenya has been promoting use of pre-exposure prophylaxis (PrEP) as part of HIV prevention efforts. These preventive medicines are recommended for use in both the general populations and those at increased risk for HIV acquisition. Transgender women and men who have sex with men would be ideal candidates for PrEP use.
However, recent data from Kenya demonstrated subdued uptake and adherence to PrEP in men who have sex with men. Additionally, retention in PrEP care for those who take it up is reduced with high rates of loss to follow-up.
In our recent study, my colleagues and I set out to explore the opinions of healthcare providers, leadership of community-based organisations and current PrEP users. We wanted to find out what they thought about Kenya’s PrEP programme. We sought to understand the perceived or experienced barriers to joining and staying on PrEP programmes. We were also interested in their views on how to improve PrEP provision.
What we did
Data were collected between February 2018 and April 2019 in coastal Kenya. Healthcare providers working in an HIV clinic at a public hospital were invited to participate in two focus group discussions, at the start of PrEP rollout at the facility and again a year later. The leaders of community-based organisations that have programmes for either men who have sex with men or transgender women were invited to separate focus group discussions. Finally, we invited transgender women and men who have sex with men to in-depth interviews. They were either currently on PrEP or had defaulted.
The discussions and interviews explored for PrEP knowledge, perceived or actual challenges to PrEP uptake and retention in care, and how to improve PrEP programming. Data from all three sources were used to paint a complete picture of the PrEP provision landscape in Kenya.
What we found
Four major themes emerged out of the analysis.
First, healthcare providers admitted to feeling ill-prepared for the massive PrEP roll-out in Kenya. They felt bombarded with targets without enough training or consideration of the increased workload. A year later they seemed less combative, but more passive about PrEP programming. Rather than proactively driving demand, they preferred that potential users present themselves to the facility and ask for PrEP. One said,
While the research may have been done and it showed that PrEP works, we are lacking follow-up systems … I feel like we were not ready for the implementation.
Second, we found differences in motivation for PrEP uptake between men who have sex with men and transgender women. Transgender women seemed to be strongly motivated by recognition of their increased risk for HIV infection and desire to remain HIV negative. A transgender woman said,
I wish to remain HIV negative. I know that being a trans is putting me at risk for HIV. So, when I heard that PrEP was available here (hospital), I was among the first to ask for it.
For men who have sex with men, the motivation to use PrEP was to facilitate condomless sex. One of the men remarked:
… before I knew about PrEP, I had two partners. When I started using PrEP, I added two more (partners), as I felt protected (by PrEP). Now I have four partners.
Third, healthcare providers did not consider transgender women to be at any increased risk for HIV infection. And they did not understand a need to give transgender women additional attention. This was reflected in the view of one healthcare provide:
… they (transgender women) are just at the same level as anybody else exposed to HIV … They are not at a very high risk of acquiring HIV.
Fourth, all respondents seemed to agree that the public hospital was not an ideal venue for PrEP provision. A leader of one community-based organisation felt PrEP uptake and retention would be better if there were additional incentives.
There are some specific needs like those hormones, therapy, legal, because it is very expensive … that can be a plus for us.
PrEP is available. But access continues to be limited. The limited access is due to a combination of healthcare provider attitudes and the sentiment among men who have sex with men and transgender women who feel unwelcome in public health facilities. There is an urgent need for alternative PrEP dispensing environments. These must be spaces where men who have sex with men and transgender women can feel free to access comprehensive HIV prevention services.
Healthcare providers need to be trained to accommodate the needs of these populations. Programming guidelines must recognise transgender women as an at-risk population.
Working with community-based organisations may help create tailor-made solutions that are available to the populations that most need them.