HIV/Aids: The last 12 months

It is precisely 2pm, and Stellar * is busy in the office typing letters for her employer in readiness for a meeting. Her phone rang; it was her house help calling. She ignored the first call thinking it was a usual call. “I knew she wanted to ask me what to prepare for supper. I left the house in a hurry and forgot to instruct her,” she says.

The second time it rang, instinctively, Stellar knew something was off. Especially since her nanny was under strict instructions to only call once unless in the case of an emergency. “I picked the call and heard a cry from the other end… Mama Alicia, mtoto anakufa (mum to Alicia, the child is dying),” she shouted. Her three-year-old daughter was convulsing. Later she would discover that this was because she hadn’t been getting her prescribed medication regularly. “I gave birth to an HIV positive baby but did not tell my house help the importance of giving her medicines at the right time every day. I did not want people to know that my child was HIV positive; they would know about my status,” she told the Healthy Nation.

Her nanny being unaware of the importance of the baby taking her drugs, admitted that she only administered the medicine to baby Alicia when she remembered. Baby Alicia forms part of the data from the National Aids and STI control programme, which states that there were 7,978 new infections in children between the ages of 0 and 14 years. These statistics translate to an estimated 22 children contracting HIV daily and 12 of them dying daily of Aids. As the World Celebrates HIV/Aids day, Baba Alicia constitutes to a recorded data of 1.8 million children who are living with HIV globally, almost 90 per cent of whom live in Sub-Saharan Africa.

On December 1 every year, the world marks World AIDS Day. This year’s theme is “communities make the difference”, in recognition of the essential roles that different stakeholders play in the AIDS response. Accurate information is the key to understanding and preventing HIV and AIDS.

CHILDREN AND HIV/AIDS

Only an estimated 54 per cent of these children have access to HIV treatment; inappropriate, suboptimal treatment options have contributed to low treatment coverage. The vast majority of the massive efforts to roll out antiretroviral drugs have concentrated on adults, not children. Children continue to die of Aids at high rates.

If untreated, it kills 50 per cent of children born with HIV before their second birthday. In Kenya, 120,000 children between the ages of 0 to 14 are living with the virus with over 8,000 new infections, according to UNAids Report 2018. It also revealed that 5,200 children in the same age bracket perished due to HIV related diseases, while over 74,344 children are on antiretroviral drugs. The biggest challenge to access to Aids treatment in Africa is the absence of antiretroviral drugs or their enormous cost. In June this year, medical personnel in Kenyan public hospitals lamented the shortage of the drugs given as prophylaxis in syrup form to newborns to prevent them from contracting the virus. The drugs, nevirapine, and zidovudine, also reduce the viral load. According to the 2018 guidelines on using ARVs for treatment and prevention of HIV, all HIV-exposed babies should receive infant ARV prophylaxis. This consists of six weeks of zidovudine and nevirapine and after that continued doses of nevirapine until six weeks after complete termination of breastfeeding.

Obtaining these drugs is a question of life or death for children. Many children are still not accessing treatment for several reasons. However, access to medicine could improve. An Indian pharmaceutical company Cipla recently announced plans to reduce the cost of new product Quadrimune, a “4 in 1” treatment for young children with HIV, to below a dollar a day. Quadrimune is currently under review by the US Food and Drug Administration (FDA) for use in children between three and 25kg body weight. The drug contains the WHO-recommended ARVs abacavir, lamivudine, lopinavir, and ritonavir, in the form of granules filled in capsules which are easier to administer, store, and have an improved taste. ‘Children living with HIV have been neglected for too long, with the recommended treatment for years consisting of a bitter-tasting syrup with 40 per cent alcohol content,’ said Dr Bernard Pécoul, executive director of the Drugs for Neglected Diseases Initiative (DNDi).

HIV TESTING

Currently, the available HIV testing types globally include antibody tests, RNA (viral load) tests, and a combination test that detects both antibodies and a viral protein called P24 (antibody-antigen test, or HIV Ab-Ag test). Antibody tests detect the presence of antibodies, proteins that a person’s body makes against HIV, not HIV itself. Most HIV tests, including most rapid tests and home tests, are antibody tests. It can take 3 to 12 weeks for a person’s body to make enough antibodies for an antibody test to detect HIV infection. In general, antibody tests that use blood can detect HIV slightly sooner after infection than tests done with oral fluid.

Combination tests look for both HIV antibodies and antigens. Antigens are a part of the virus itself and are present during acute HIV infection. It can take 2 to 6 weeks for a person’s body to make enough antigens and antibodies for a combination test to detect HIV. Combination tests are now recommended for testing done in labs and are becoming more common in the United States. There is also a rapid combination test available. Preliminary studies suggest that diagnosis could be made an average of one week earlier using the Ab-Ag test, compared to antibody testing alone. The test uses a reaction known as “chemiluminescence” to detect antibodies and protein antigen. If either the antibody or the antigen is present, the test reaction emits light that registers on a detector. HIV RNA tests: It detects HIV the fastest by looking for HIV in the blood. It can take 7 to 28 days for NATs to detect HIV. This test is pricey; it costs between Sh3500 to Sh20,000 depending on the hospital. It is not routinely used for HIV screening unless the person recently had a high-risk exposure or a possible exposure with early symptoms of HIV infection.

NEW HIV STRAIN

A new strain of HIV, part of the Group M version of HIV-1, has been detected by scientists hence thrashing the gains made so far in the fight of getting HIV vaccine. According to Abbott Laboratories, which researched along with the University of Missouri, Kansas City, the strain is in the same family of virus subtypes to blame for the global HIV pandemic. HIV has several different strains that change and mutate over time, making it difficult for scientists to detect the disease. According to scientists, it is the first new Group M HIV strain identified since guidelines for classifying subtypes were set up in 2000. “It can be a real challenge for diagnostic tests,” Mary Rodgers, a co-author of the report and a principal scientist at Abbott, said.

 Her company tests more than 60 per cent of the world’s blood supply, and they have to look for new strains and track those in circulation so “we can accurately detect it, no matter where it happens to be in the world.” Dr Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases, said current treatments for HIV are effective against this strain and others. However, identifying a new strain provides a complete map of how HIV evolves. “There’s no reason to panic or even to worry about it a little bit,” Fauci said. “Not a lot of people are infected with this. This strain is an outlier.” For scientists to be able to declare that this was a new subtype, three cases of it must be detected independently. The first two were found in the Democratic Republic of Congo in 1983 and 1990.

POLICIES ON HIV IN KENYA

A report released by UNAids warned that harmful laws and policies in many countries are depriving dozens of national HIV responses of the knowledge, dynamism, and determination of organised communities. It also says that crackdowns or restrictions on many community groups and campaigns are putting their life-saving work in jeopardy. In Kenya, most laws, including workplaces, are against discrimination.

The Employment Act states that no employer shall discriminate directly or indirectly against an employee on the grounds of their HIV status, among others (section 5). The employer shall provide proper healthcare for his/her employees during acute illness. The employer can only discharge this function if the employee notifies the employer of the disease (section 34). The Act implies that there should be no discrimination on the grounds of one’s HIV/Aids status. It states in Section 46 (g) that HIV/Aids does not constitute a fair reason for dismissal or the imposition of a disciplinary penalty on an employee.

Workplace policies and support structures

The HIV and Aids Prevention and Control Act, 2006, gives guidance to review of HIV and Aids workplace policies, making specific reference to HIV/Aids concerning the provision of education and information in the workplace, discrimination, privacy, confidentiality, and personal rights.

Confidentiality at work?

Section 7 further notes that such information to be provided shall cover issues of confidentiality in the workplace and attitudes towards infected employees and workers. To promote privacy, Section 13 states that no employee shall be compelled to undergo an HIV test unless he/she is charged with a sexual offence under the Sexual Offences Act (2006). Section 22 prohibits the disclosure of an HIV test result or any detailed assessment result of another person without his/her written consent.

AT-RISK POPULATION

Women are disproportionally affected by HIV in Kenya, and the latest research from UNAids reveals that of the 1,600, 000 adults with HIV, 910 000 (65 per cent) were women. New HIV infections among young women aged 15 to 24 years were more than double those among young men. From the data 11, 000 new infections among young women, compared to 5,000 among young men. The 2018 Kenya Aids Response Progress Report shows that young women aged between 15 and 24 now account for one-third of the 44,789 new HIV adult infections.

Ms Angeline Siparo, the National AIDS Control Council (NACC) Board chair, says that women account for more than half the number of people living with HIV worldwide. She added that young women (10-24 years old) are twice as likely to acquire HIV as young men the same age because of vulnerabilities created by unequal cultural, social, and economic status. “Unaccommodating attitudes towards sex outside of marriage and the restricted social autonomy of women and young girls can reduce their ability to access sexual health and HIV service,” she said. Ms Siparo said that safe spaces for women are shrinking, and the country needs to have discussions around that ensure that the number reduces.

STIGMA

Myths and misinformation increase the stigma and discrimination surrounding HIV and AIDS. Ms Angeline Siparo, the NACC board chair, says that many people who are vulnerable face stigma prejudice and discrimination in their daily lives. “This pushes them to the margins of society where poverty and fear make accessing healthcare and HIV service difficult,” she says. She says that the lack of information and awareness combined with outdated beliefs lead people to fear getting HIV. Additionally, many people think of HIV as a disease that only certain groups get.

This misinformation leads to negative value judgments about people who are living with HIV. A healthcare worker at National AIDS and STI’s Control Programme (Nascop) says that the most affected in this area is critical populations such as sex workers and men who have sex with men. “They are not comfortable seeking treatment in all facilities and would go to where they are comfortable; this then makes them susceptible because they are most likely to miss out on even other options such as PreP,” he said. Pre-exposure prophylaxis (PreP) is a dose of HIV drugs taken by HIV-negative people to protect them against HIV infection.

ARVS

An estimated 1.6 million Kenyans are living with HIV, yet only 68 per cent of people living with HIV were on treatment. A recent UNAids report reveals 91 per cent of pregnant women living with HIV accessed antiretroviral medicine to prevent transmission of the virus to their baby. However, with 11,000 new HIV infections among newborns, the country is far from achieving its target of having 90 per cent of all people with HIV put on treatment.

Additionally, of all adults aged 15 years and over living with HIV, 69 per cent were on treatment, and 61 per cent of children aged below 14 years living with HIV were on medication. The number of children below 14 not on treatment is worrying, especially with reports early this year that the prophylaxis given to newborns to prevent them from contracting the virus was unavailable. A worldwide shortage of an active pharmaceutical ingredient was the reason behind the antiretroviral (ARV) medication shortfall across the country, the ministry of health confirmed. However, the issue of funding is yet another setback in the availability of HIV drugs in the country.

FUNDING

Financial statements on the National Aids Control Council (NACC) website reveals that donors such as the Ford Foundation, Avenir Health, and Australian High Commission have cut back drastically on funding. Kenya is part of over 100 countries that rely on the Global Fund partnership designed to accelerate the end of Aids, tuberculosis, and malaria as epidemics.

Global Fund grant portfolio growth to Kenya currently stands at US$895,647,494 with the country so far receiving disbursements worth US$697,304,446 since the funds’ payment, which began in 2002.  The most significant cut, however, comes from the President’s Emergency Plan for Aids Relief (PEPFAR), which introduced unprecedented cuts to country programmes in Sub-Saharan Africa, including Kenya.

This move has seen planned spending in Kenya fall from $505 million in last year’s Country Operational Plan to $350 million in next year’s plan. Health Cabinet Secretary Sicily Kariuki said that the donor support shrink is something that they are grappling with, and Kenya is committed to ensuring every Kenyan’s right to quality. “In this regard, the Ministry of Health’s budget has been increased by more than 50 per cent over the last two years. For the start of the 2020 financial year, the ministry has set aside funds within the ministry of health budget to plug donor cuts in antiretroviral therapy and essential services. This is in addition to increased counterpart financing,” she said.

PEPFAR funds are distributed in three ways, and the majority of it goes toward the procurement of commodities such as test kits and drugs, to the civil society, and towards the national data system. Dr Nduku Kilonzo, the CEO of NACC, said the procurement of therapy and commodities would remain unchanged, and there is no need for panic among Kenyans. “The funds will definitely diminish there is no question about it, and as soon as we found that...we looked at ways to ensure that there are no gaps in service delivery. This is not a threat to the major gains made in the fight against HIV,” she said.