With PrEP, I am Covered

By Geoffrey Njenga and Catherine Ndungu

Nairobi, Kenya—In the outskirts of Nairobi is the sprawling Kangemi informal settlements. The slum is bustling with people; some cooking outside their shacks, others burning charcoal to sell or busying themselves with their food stalls. The sky is overcast and the air is cold. At the hall hired for the day’s outreach, bedsheets serve as makeshift partitions. This outreach is unique: Here, for the first time in Kenya, eligible clients will have access to pre-exposure prophylaxis (PrEP). PrEP is a pill taken once daily by HIV-negative people who are at continuous risk for HIV infection. In Kenya, Jhpiego—through the Jilinde project—is scaling up the use of PrEP into a large-scale public health response. Over 20,000 people at continuous risk of HIV infection will receive oral PrEP, which will be integrated within existing HIV combination prevention services. Today’s outreach gives clients access to HIV testing and counseling services, anti-retroviral therapy and PrEP. Among those getting their first dose of PrEp is Cynthia, a warm and candid 25-year-old sex worker. Born and raised in Nairobi, Cynthia was introduced to sex work as a teen, after the birth of her daughter. “My father deserted us and my mother struggled to take care of my siblings and I,” she explains. At 15, she dropped out of school to look for a job so she could feed her baby. When no opportunities arose, her cousin, a sex worker, told her how she could earn earn between 2,000-3,000 KES per night (the equivalent of about $20 to $30), and $5,000 KES ($50) on weekends. Most of the clients are men 35 and older, from wealthy neighborhoods surrounding Kangemi slum. Too good to be true? Conventional protection isn’t always easy or even possible, Cynthia says: “Sometimes, clients pay extra for condom-less sex and sometimes a condom bursts.” She has also been forced to have sex with policemen to buy her freedom when arrested. When Cynthia first heard about PrEP from a Jilinde-trained peer educator, it sounded like a scam, too good to be true. “My first thought was, there is no cure for HIV, so how could there then be a pill that prevents HIV?” Only when she saw PrEP in the media did she begin to believe it was a real drug and seek more information. The Jilinde project is scaling up the use of PrEP in Kenya within existing combination prevention services to people like Cynthia who are at high risk of HIV. More than two million people acquire HIV infection globally every year. In Kenya, in 2015, 71,034 people aged above 15 years and 6,613 aged 0-14 years got infected with HIV. This translates to 77, 648 Kenyans requiring lifelong antiretroviral treatment to keep them alive and prevent further transmission of HIV. The Jilinde project is set to demonstrate the incredible potential of PrEP by generating evidence that population-level PrEP interventions are feasible and effective in low-and middle-income countries which bear the brunt of the world’s HIV burden. For Cynthia and so many others like her, the time for PrEP is now. “I don’t like the sex work and hope that one day I can start my own food business,” she says. “But for now, PrEP gives me peace of mind because I know that I can keep HIV at bay.”  

Hard Pill to swallow

By Geoffrey Njenga

Hard pill to swallow Nairobi, Kenya- It’s a lazy afternoon and 23-year-old James is done with classes- he is taking a course in accounting and hopes to be an entrepreneur in the future. James is a male sex worker and this is a closely guarded secret. “I have a straight life and a gay life. I even have a girlfriend whom I use to cover up my gay life.” He says. On average he has 3 clients in a week in the many hotspots he frequents in the central business district of Nairobi. James was introduced to PrEP by one of his peers and he made the decision to take it. However, after one week, he discontinued using it because the side effects were severe. “I couldn’t deal with the side effects. I had stomach aches, started vomiting and diarrhea” says James. Unbearable side effects, peer pressure, myths and misconceptions are some of the factors undermining retention in PrEP. For PrEP to be effective, one is required to commit to taking the pill daily, but for some clients they do not see the sense in that “Why should I take the pill daily and I am not having sex daily? Sometimes I can go up to two weeks without having sex” says James. After 2 weeks, James attended a peer support group and was encouraged by his peers to continue taking PrEP and that the side effects would fade away. “I asked myself am I a coward? so I decided to come back and take it again.” The doctor reassured James that with time, the side effects would disappear. “What has motivated me to take it for 9 months now, is that I know I am at risk and I would like to maintain my negative status. In as much as I always use condoms, sometimes they break and one is at risk of infection so PrEP is a backup.” Says James. He however wishes scientists would speed up the injectable PrEP he has heard so much about.

Lured By Money Saved By PrEP

By Geoffrey Njenga

Migori County, Kenya – 22-year-old Millicent stared at the ceiling trying to process what the doctor was telling her. “This can’t be possible” she said looking perplexed. For the first time in her life, Millicent Aaoko had been diagnosed with a sexually transmitted infection and deep in her heart she knew who the culprit was. It was her high school teacher and she has been keeping the relationship a secret because it was inappropriate. It all started one hot afternoon when Millicent was still in high school, in Form 2. She met the teacher during a sports event and thereafter he started offering her remedial lessons in subjects she was weak during school holidays. Initially her mother could pay but she couldn’t afford in the long run. The teacher offered to continue providing the lessons for  free. He would also provide her money to purchase clothes, sanitary towels and supplement her school fees. With time it evolved into an intimate relationship. “Two days before reporting to school I would go to his residence to collect what I needed and of course we would have sex.” Not all that glitters… After one year, Millicent realized that he had several girlfriends but she hang onto the relationship because of the benefits she was receiving. On one occasion she experienced a condom burst and since she did not trust him, she rushed to hospital and was put on post exposure prophylaxis (PEP) and treated for an STI. Despite this experience, she could not deny him sex because he could physically assault her. “You know someone who is supporting you can do anything to you” says Millicent. Millicent was introduced to PrEP by a friend who explained to her the benefits. At first, she was a bit skeptical but she opted to visit a health facility on the insistence of her friend. “At the hospital I answered yes to most of the questions the nurse asked me and when she provided feedback, that is when it dawned on me that I was at risk of being infected with HIV” says Millicent. Millicent has been on PrEP for close to two years now. “I am more at ease now. Before I used to tell myself that I had gone to get HIV whenever I visited his house” says Millicent. Her parents do not know she is taking PrEP. “My mum would quarrel me and I detest that. Only my younger sister knows I am taking PrEP and she encourages me because she understands my situation” says Millicent.  

Successful integration of Oral PrEP at Riruta

By Daniel Kyalo and Geoffrey Njenga

Kawangware, Kenya – As the first rays of sunlight hit the ground, Riruta Health Centre is a beehive of activity. Patients are already streaming in the facility for different types of services. Among these are sex workers who have come for Pre-Exposure Prophylaxis commonly known as PrEP a pill taken daily to reduce HIV infections for those at risk. Since May 2017, Riruta Health Center, a Nairobi County level three health facility has successfully integrated oral PrEP into its routine service delivery and many key populations are at ease seeking services from the facility. Riruta gained an interest in PrEP the minute it was launched as Kawangware is one of the areas highly affected by HIV. The facility used to receive a lot of clients requesting for Post Exposure Prophylaxis (PEP), and most of their clients did not use condoms for various reasons and thus PrEP was coming in to help minimize the risk of HIV transmission.  Wanjiku Kimita the Nursing Officer in Charge says “the desire to see reduction of HIV in the community motivated me to offer the services”. She also explained how they are integrating oral PrEP into routine service delivery. For Riruta, the staff were trained on PrEP service delivery and they had the desire and willingness to offer PrEP services to those at risk of infection. They were sensitized on how to handle key populations. At the beginning only 2 staff had been trained on PrEP however through On Job Training (OJT) and Continuous Medical Education (CME) three nurses, two clinical officers and three HTS counselors have been trained on PrEP service delivery.  They have a monthly plan in place for the service providers, which they use to coordinate PrEP delivery in the facility efficiently PrEP Delivery Riruta Health Centre has integrated PrEP into the existing services and it is offering PrEP at all service delivery points. The facility ensures that not only do clients get PrEP services but also receive family planning, Hepatitis B vaccine, STI screening and management, “We offer a comprehensive care package” says Wanjiru Kimita. PrEP is also part of Riruta’s performance indicators and hence included in daily, weekly and monthly reports. PrEP uptake, adherence and retention has been a major challenge for PrEP rollout in Kenya and Riruta is using different strategies to overcome these challenges. Ownership of PrEP services by the facility, good attitude embraced by health workers and teamwork easing service delivery, integration of the services with all other services offered in the facility, has led to increased PrEP uptake and adherence. Involvement of peer educators in disseminating PrEP information within the community, establishment of a good, strong and effective referral system where the peer educators are the link persons between the facility and the community, and following up clients when their refills are due has ensured retention. The facility has also ensured a steady and constant supply of commodities by monitoring the stock levels, as well as maintaining confidentiality and ensuring short period for clients queueing for the service. Jilinde has supported Riruta by offering PrEP service delivery training, conducting regular CMEs, mentorship, inreaches and regular supervision for the health workers. Pre-exposure prophylaxis (PrEP), should always be used with condoms, safer sex practices, clean injection equipment, and other HIV prevention methods to reduce chances of becoming infected. Since Riruta Health Center has integrated PrEP services into all its’ service delivery departments, it is clear evidence that public health facilities can offer these needed services to people at high risk of HIV infection. This can lead to reduction of HIV transmission which can be done by training health care workers, peer educators and community health volunteers, steady commodity supply and ongoing mentorship through OJTs, CMEs, support supervision and ownership of the service.    

Urembo Wednesday: Creating Demand For PrEP

By Geoffrey Njenga Nairobi, Kenya- Walking up the stairs to the 3rd floor of the wellness center run by Bar Hostess Empowerment and Support programme, my ears are tickled with the sound of warm music and my nostrils are hit with the scent of acetone and fingernail polish. I arrive at the reception and there are young beautiful ladies chatting and watching music videos as they wait for their turn to be pampered in an adjacent room. Every Wednesday BHESP with support from Jilinde hosts Urembo Wednesday where sex workers get a chance to try something new with their nails, change their look and get pampered. However, there is a twist to this event. Not only do the girls get pampered they also get health talks on HIV prevention methods like condoms, Post Exposure Prophylaxis (PEP), and the latest HIV prevention method Pre-Exposure Prophylaxis (PrEP)- a pill taken daily to prevent HIV infection for those at high risk. This is one of the many events that Jilinde in partnership with Civil Society Organizations (CSO’s) is using to create demand for PrEP and health services in general. The receptionist greets me with a friendly "hello" and a smile. “I am here to meet Mercy the Prevention Manager” I say with a smile. “Please have a seat” she tells me. She retreats into one of the offices and comes back to tell me Mercy will be with me shortly as she is wrapping up another meeting. I decide to make new friends in the meantime and I started charting with Gladys a 23-year-old bubbly sex worker and an outreach worker at BHESP. “Why are you here today?” I inquire. “I am here to help with the event and to get myself pampered” she replies. “For you to be a successful sex worker you have to be attractive and be good looking” she continues. She invites me to the room where the action is happening and I am met with young women getting their nails done. In one corner of the room manicurists are busy tending to their clients, in another, there is a condom demonstration happening, there is also a station for snacks for the clients. I notice a health talk going on as they are being pampered. There are posters on the wall reminding clients the need to maintain a negative HIV status and use PrEP daily. After 10 minutes, Mercy comes to where I am and pulls me aside. “Welcome to our Drop in Centre. This is a safe space for female sex workers where they not only get health services but also a space where they can come to catch up with their peers and relax” she says. As we continue talking I find out Urembo Wednesday came about after consultation with the sex workers as a way of creating demand for health services among sex workers and particularly PrEP.  “You see Wednesday is ladies' night and what better way to get your mojo on than to pass by the wellness center and get pampered before proceeding to your hotspot” she says. Urembo Wednesday is usually a hit with the sex workers and its one of the demand creation approach they are using together with Jilinde to ensure sex workers and those at high risk of HIV infection are reached with PrEP information and are able to take PrEP to prevent HIV infection. After talking to Mercy, I walk back to Gladys who was getting her nails done. She had chosen different colors for each of her nails. “I have been on PrEP for 1 year 2 months now and I am satisfied with its protection. I can’t imagine living with HIV” she says. As I walk out of the wellness center I meet more ladies arriving at the facility to get their dose of beauty.