Confronting STI in Kenya: Linking key populations to care

In Kenya, a recent TV advert promoting condom use was withdrawn after stirring sharp controversy [1]. The advert, sponsored by Kenya’s National AIDS and STI Control Programme (NASCOP) portrays a woman discussing an extramarital affair with a friend who advises her to use condoms. The advert was launched after a recent national survey revealed that up to 30% of married couples in Kenya have concurrent partners, but that the majority of them do not use condoms [1]. According to WHO figures, sexually transmitted infections (STI) and their complications rank in the top five disease categories for which adults in limited-resource countries seek health care [2]. Although these statistics raise some fundamental questions, discussing STI in public is not done.

Self-treat of STI

Due to limited access to laboratory facilities, STI control programmes in restricted-resource settings have largely been dependent upon a syndromic approach to the management of symptomatic STI [3]. Yet the majority of patients who acquire an STI do not experience symptoms [4]. When patients do experience symptoms, as commonly in male urethritis, men often opt to ‘self-treat’ by buying medication directly from chemists or pharmacies. Chemists offer the advantage of long opening hours, accessibility and widespread localization. In addition, small pharmacies attract clients because of anonymity and a perceived lack of stigma associated with attending a chemist. Small pharmacies, however, are not trained to promote HIV testing among clients, or to refer patients who purchase medication for STI. Hence they lack clinical expertise and tend not to comply with national guidelines. This was illustrated in a recent study assessing STI treatment practices in pharmacies in Coastal Kenya: only in 10% of simulated visits of male clients buying treatment for Chlamydia trachomatis or Neisseria gonorrhoeae, the most frequent causes of male urethritis, the correct treatment was provided. That is, the recommended antibiotic at the recommended dosage and duration was sold[5]. While bacterial STI are important cofactors for HIV transmission, the same study also showed that HIV testing was only recommended in one in ten male simulated clients visiting the pharmacy to purchase STI treatment [5].

High risk populations

Those who are most prone to become infected with an STI often belong to high risk populations such as female sex workers (FSW) or men who have sex with men (MSM). Engagement of these patients is the key to successful STI prevention programmes, but vulnerability and marginalization cause these men and women to avoid public health facilities. As a consequence, those who are most at risk are commonly hardest to reach. Kenya was among the first countries in sub-Saharan Africa (SSA) which, in Coastal Kenya, started screening and testing MSM and male sex workers for HIV-1 [6]. High risk MSM report both male and female partners and most of them participate in transactional sex. MSM who practice receptive anal intercourse have a very high risk of becoming HIV infected, in particular when they have sex with men exclusively (MSME), sex is unprotected, group sex is reported, or a symptomatic gonorrhoea infection was present in the six months before seroconversion [7].

Current practice

The 2010 constitution of Kenya recognizes the right of all consumers to access health care services. In spite of this national right to care, homosexual acts under Kenyan law are punishable by up to 14 years of incarceration and, as a result, anal sex is a taboo subject. Conducting a sexual risk assessment, however, is paramount to diagnosing STI. Cohort studies of MSM and FSW showed that of the symptoms experienced around the time of HIV seroconversion, fever was most prominent [8, 9]. Yet strikingly, most patients who acquire HIV are treated for ‘malaria’ when seeking care for fever [9-11]. These findings illustrate the importance of considering other causes than malaria, such as STI or HIV, in patients seeking health care for fever, especially if they engage in high risk behaviour. In this context, a recent audit assessing current practice regarding the management of febrile adults visiting one of five clinics in Coastal Kenya showed that in none of the 66 reviewed clinical cases a sexual risk assessment had been conducted [12]. In a subsequent focus group discussion health care workers reported that they found it difficult to broach the topic of sexual risk behaviour and that they did not feel confident questioning patients whether they had practised penile-vaginal or anal sex.

Training

Perhaps unsurprisingly, health care workers in Kenya typically receive little or no training in understanding the health care needs of MSM and other key populations reporting anal sex. In 2012 an e-learning programme for health care workers focusing on MSM sexual risk practices, HIV prevention and health care needs of MSM was launched in four districts along the Kenyan coast (www.marps-africa.org). Re-assessment of 71 of the 74 participants regarding course knowledge and homoprejudice (using a 25-item homophobia scale) three months post-training showed not only an increase in knowledge relevant to clinical practice, but also a self-perceived improvement in capability to provide appropriate and nonjudgmental health services to MSM clients, as well as a 14% reduction in mean homophobia scale score [13].

SEXUALLY TRANSMITTED INFECTIONS AND THEIR COMPLICATIONS RANK IN THE TOP FIVE DISEASE CATEGORIES FOR WHICH ADULTS IN LIMITED-RESOURCE COUNTRIES SEEK HEALTH CARE

Barriers to care

Availability of health services tailored to individuals engaging in high risk sexual behaviour, including anal sex, is likely to improve access to care. Currently the highest barriers to care are faced by MSM. Adherence and retention, presumably as a consequence, are generally poor in this group. In a recent analysis of challenges to antiretroviral therapy (ART) adherence in a cohort of most at risk populations in Coastal Kenya, participating MSM were less likely than FSW to have disclosed their HIV status, to have had ART counselling, or to have ever taken ART in the community prior to enrolment, indicating a low level of engagement with health services [14]. Other studies also suggest that MSM suffer from poor access to HIV-1 testing and prevention services, fear of health care seeking, and denial of care [15].

Public debate

The past year was filled with optimism about the possibility to achieve what US Secretary of State Hillary Clinton has called ‘an AIDS-free generation’ [16]. However, without addressing STI as a major public health concern such optimism might prove premature. STI, whether symptomatic or asymptomatic, cannot be ignored. As of today at risk populations, MSM in particular, continue to be disproportionally affected and co-infection with two or more STI, including HIV, is common. These populations are key to the dynamics of the STI epidemic as well as the global HIV pandemic and, therefore, are key to the response to it.

Perhaps it is still too early to bring up extramarital affairs on national television, but at least the condom advert sparked widespread public debate. In terms of linking to care key populations and provision of sensitized health services, however, there is still much to be done.

References

Full list of references can be obtained from the authors.

1. British Broadcasting Corporation Africa. Kenya condom advert pulled after religious complaints. Available at: http://www.bbc.co.uk/news/world-africa-21859665. Accessed 13 April 2013.
2. World Health Organization. WHO Factsheet on Sexually Transmitted Infections 2011. Available at: http://www.who.int/mediacentre/factsheets/fs110/en/. Accessed 13 April 2013.
3. Meheus AZ. Practical approaches in developing nations. In: Holmes KK, Mardh PA, Sparling PF, Wiesner PJ, ed. Sexually transmitted diseases. New York, McGraw-Hill, 1983. 40 p.
4. Sanders EJ, Thiong’o AN, Okuku HS, et al. High prevalence of Chlamydia trachomatis and Neisseria gonorrhoeae infections among HIV-1 negative men who have sex with men in coastal Kenya. Sexually transmitted infections. 2010;86(6):440-1. Epub 2010/07/27.
5. Mugo PM, Duncan S, Mwaniki S, et al. Cross-sectional survey of treatment practices for urethritis at pharmacies, private clinics and government health facilities in coastal Kenya: many missed opportunities for HIV prevention. Sexually transmitted infections. 2013. Epub Publication in progress.
6. Sanders EJ, Graham SM, Okuku HS, et al. HIV-1 infection in high risk men who have sex with men in Mombasa, Kenya. AIDS. 2007;21(18):2513-20. Epub 2007/11/21.
7. Sanders EJ, Okuku HS, Smith AD, et al. High HIV-1 incidence, correlates of HIV-1 acquisition, and high viral loads following seroconversion among MSM. AIDS. 2013;27(3):437-46. Epub 2012/10/20.
8. Lavreys L, Thompson ML, Martin HL, et al. Primary human immunodeficiency virus type 1 infection: clinical manifestations among women in Mombasa, Kenya. Clinical infectious diseases : an official publication of the Infectious Diseases Society of America. 2000;30(3):486-90. Epub 2000/03/18.
9. Sanders EJ, Wahome E, Mwangome M, et al. Most adults seek urgent healthcare when acquiring HIV-1 and are frequently treated for malaria in coastal Kenya. AIDS. 2011;25(9):1219-24. Epub 2011/04/21.
10. Bebell LM, Pilcher CD, Dorsey G, et al. Acute HIV-1 infection is highly prevalent in Ugandan adults with suspected malaria. AIDS. 2010;24(12):1945-52. Epub 2010/06/15.
11. Serna-Bolea C, Munoz J, Almeida JM, et al. High prevalence of symptomatic acute HIV infection in an outpatient ward in southern Mozambique: identification and follow-up. AIDS. 2010;24(4):603-8. Epub 2009/12/19.
12. Prins HAB, Mugo PM, Sanders EJ. Diagnosing acute HIV infection in adults seeking care for fever: a literature-guided review of current clinical practice. 2013. Manuscript in writing.
13. Elst EM van der, Gichuru E, Omar A, et al. E-learning supported by group discussions on MSM behaviour in Africa increased knowledge and reduced homoprejudice among health care providers in Coastal Kenya. Seventh IAS Conference on HIV Pathogenesis, Treatment and Prevention; 30 June 2013 – 3 July 2013; Kuala Lumpur, Malaysia 2013. Poster MOPE200.
14. Graham SM, Mugo PM, Gichuru, et al. Adherence to Antiretroviral Therapy and Clinical Outcomes Among Young Adults Reporting High-Risk Sexual Behavior, Including Men Who Have Sex with Men, in Coastal Kenya. AIDS and behavior. 2013. Epub 2013/03/16.