HIV Vaccine Research in Kenya Yields Better Healthcare, Less Stigma and Empowerment for Men Who Have Sex with Men
Men who have sex with men (MSM) in Kenya are a highly stigmatized population and constitute a disproportionate percentage of both existing and new HIV infections. They face discrimination including denial of services by doctors, physical violence and hate speech, alienation by family, expulsion and/or suspension from public schools and losing the right to raise their own children1. Vaccine research by IAVI and partners is helping to raise awareness and slowly change these realities.
In 2003, the International AIDS Vaccine Initiative (IAVI) and the KEMRI Wellcome Trust Research Program, funded in part by USAID, began a collaboration to identify people or groups of people at higher risk of acquiring HIV. Research with those individuals would allow researchers to estimate the annual incidence of new HIV infection, provide prevention counseling, characterize the evolution of HIV infection over time, and prepare clinical research sites for future vaccine efficacy trials. In 2005 researchers began working with MSM and Female Sex Workers (FSW) in coastal Kenya. Over the past ten years this effort has steadily evolved into a more holistic response to the HIV/AIDS epidemic among these groups. Through a wide range of advocacy, policy and community engagement activities, services for Kenya’s vulnerable MSM population have begun to improve. Research efforts are indeed contributing to efforts that build social and political support and acceptance.
Nationwide, roughly 6 percent of adults in Kenya are infected with HIV2 though much of those infections are clustered in specific regions and groups of people, including MSM. Although awareness of HIV and AIDS is comparatively high in Kenya, MSM in general, and those living with HIV in particular, face high levels of social stigma and rampant discrimination. This reality has compounded the challenges in reaching this vulnerable group and made them less likely to seek out health services including antiretroviral therapy (ART), sexually transmitted infections (STI) treatment, health education and psychosocial support. Their acute health care needs are often further exacerbated by substance abuse, high rates of violent assault and barriers to health care access. This story has been all too familiar among Kenyan MSM whose sexual behavior is still considered illegal and whose HIV rate is more than three times the national average. In 2010, HIV prevalence among MSM was an estimated 18.2 percent3.
In 2015, this difficult day-to-day reality for Kenyan MSM is slowly realizing some bright spots of change, in part as a result of those HIV vaccine research studies that began in 2005. HIV vaccine research is an investment that realizes benefits beyond the promise and potential benefits of a preventive HIV vaccine. As HIV vaccine science in Africa is contributing to an array of research-driven discoveries, efforts by IAVI and partners are also incrementally empowering MSM to write a new narrative that extends their voices from the halls of healthcare facilities to the halls of Kenyan government.
Beginning in 2005, IAVI clinical research center (CRC) partner the KEMRI-Wellcome Trust Research Programme at the Center for Geographic Medicine – Coast (CGMR-C) received approval to develop the first MSM HIV clinical trials in Africa. For the first time, previously invisible MSMs emerged from the shadows to shed light on both behavior and epidemiology among this high-risk group. To date, CGMR-C has tested more than 1,500 MSM, and enrolled 950 in studies that look at HIV incidence and disease progression. Both studies have contributed significantly to knowledge about transmission and immuno-pathogenesis that is now frequently referenced around the world. At a national level, this research has helped inform public health policy and practice towards most-affected populations. For those involved in this research, it has also meant increased access to counseling and testing, prevention options, STI treatment and basic healthcare and referral.
IAVI-sponsored research data has been used by both IAVI and CGMR-C to highlight the needs of MSMs in Kenya within the Ministry of Health’s National AIDS & STI Control Programme (NASCOP). This work has helped influence the inclusion of MSM issues in Kenyan national strategies, guidelines and policies including NASCOP’s Most at Risk Populations Surveillance Report (2012), the HIV Prevention Roadmap (2014 - 2030), Kenya National AIDS Strategic Framework and a global best-practice guidance document, Respect, Protect, Fulfill, (RPF) outlining the challenges and opportunities for conducting HIV research with MSMs (developed in collaboration with amfAR, Johns Hopkins University and the United Nations Development Programme (UNDP)). RPF has also been adopted by the Joint United Nations Programme on HIV/AIDS (UNAIDS) and the World Health Organization (WHO) to inform their community engagement for the on-going Ebola vaccine clinical trials in Africa.
The strong commitment of IAVI and partners to influence government policy toward those most affected by HIV/AIDS is also evident through their work with community grassroots organizations. IAVI partners with the Gay and Lesbian Coalition of Kenya (GALCK), Kenya’s national Lesbian, Gay, Bisexual or Queer umbrella organization, to work on issues of rights, health and social welfare. The list of IAVI- and CGMR-C supported MSM empowering activities continues to grow. IAVI helped support Kenya’s first ever national consultative forum on MSM/ Lesbian, gay, bisexual, transgender and intersex (LGBTI) research partnership meeting and develop the G-10, a LGBTI Kenyan national research advisory committee that has helped define the LGBTI research priorities for Kenya in collaboration with leading researchers. IAVI supported the first ever national MSM/LGBTI research partnership forum and a 2012 MSM symposium that led to the formation of the GMT HIV Prevention Network Kenya (GHPN-Ke). IAVI-sponsored work with MSM has been used to provide training on the use of evidence-based research for advocacy to local organizations and NGOs.
The KEMRI-Wellcome community engagement program, including community advisory boards (CABs), has worked to engage religious leaders, local authority representatives, law enforcement experts, people living with HIV, medical professionals and MSMs. Researchers have brought these stakeholders together to both inform them and ensure that research safeguards the rights of participants while reflecting the interests of the community. In so doing, they have helped sensitize community leaders about issues faced by MSM on the coast, helping to build a base of support to recognize the need for improved access to services and care. This community support has fueled significant change in peoples’ thinking and is critical to allow research to continue.
IAVI and CGMR-C continue to partner to refine community engagement mechanisms to ensure support and involvement of the MSM community in research studies. Representatives from MSM communities have been invited by CGMR-C to take part in research activity discussions that ranged from research design and study protocol development through publication to ensure their meaningful Community Engagement and Ownership in research. With the formation of national and local research advisory groups, MSM organizations have been able to more actively participate in research implementation. Most recently the Coastal group, Utafiti Pwani, was invited by CGMR-C to co-author a paper in KEMRI Bioethics Review Newsletter: “Collaborating with GMT organizations on HIV prevention and care research in Coastal Kenya.”
CGMR-C has also worked successfully to facilitate safe access to healthcare for the MSM community. In 2011, IAVI supported CGMR-C, in collaboration with the Kenya National AIDS and STD Control Program (NASCOP), to develop most-at-risk populations (MARPS)-Africa (develop www.MARPS-Africa.org), a first ever modular on-line training tool that provides awareness and sensitivity training to healthcare workers about MSM health issues. To date, nearly 1200 healthcare workers (including over 500 government employees) have completed the training. And, recent studies say it is working to reduce homophobic attitudes, open a dialogue on how to best treat MSM and initiate first ever MSM support groups4.
IAVI and CGMR-C have generated important evidence, provided services and helped build advocacy capacity, while also empowering another vehicle for change in Kenya via the LGBTI community itself. These individuals continue to put themselves on the frontline of struggle for over a decade to ensure, among many things, more tolerant healthcare. In a recent interview with IAVI, a brave Kenyan MSM described the progression of his work:
“Beginning with my own encounter in the streets during 2004 – alone, scared and in hiding– I was invited to learn more about health – my health. A visit to a newly established clinic gave me counseling, condoms and lubricants – as well as somewhere to turn – someone to talk to as many of my peers were sick and dying. At the very first National AIDS Control Council gathering in 2005, I remember their surprise to see actual MSM ready to be counted as part of this epidemic. Finally, our faces emerged from the shadows to be seen. In 2006 I became a trained organizer in the community where in the field I would hand out condoms, lubricants and information while urging my fellow MSM to come to the clinic to find safe spaces and for the first time, lifesaving healthcare. Person by person we help change the lives for MSM- one clinic visit at a time. As part of the National AIDS Strategic Plans 3 and 4, I watched the MSM health conversation evolve from one line in the plan to an entire paragraph in plan 4 (2013.) Now – even care in government run hospitals is possible. With IAVI’s help, networks continue to form, policy changes are implemented, and care for MSM in Kenya becomes more tolerant.”
More than 30 years into the pandemic, it is clear that a vaccine is essential to achieve and sustain the end of AIDS. Fortunately, clinical research does not exist in a vacuum and these efforts are already producing dividends that extend beyond the immediate search for an HIV vaccine. While IAVI’s mission is the development of a safe, effective preventive HIV vaccine, the development process itself also offers immediate benefits to those most in need.
1The Outlawed among us by Kenya Human Rights Commission 2011
2Kenya HIV Estimates Report, MoH, 2014 and MOT 2009
3Sanders, E.J. (2007) ' HIV-1 infection in high risk men who have sex with men in Mombasa, Kenya' AIDS 30(21):2513-2520
4van der Elst EM, Smith AD, Gichuru E, Wahome E, Musyoki H, Muraguri N, et al. Men who have sex with men sensitivity training reduces homoprejudice and increases knowledge among Kenyan healthcare providers in coastal Kenya. J Int AIDS Soc. 2013;16(4)