Backgrounder No. 40
One-month-old baby girl Karen, whose HIV status has not yet been determined, is carried by her sister Margaret, 13, while their HIV-positive mother attends the Baraka Health Centre in Nairobi, Kenya (AP Photo/Ben Curtis).
Gender inequality in Sub-Saharan Africa is visible in the feminization of the HIV epidemic, with women having higher prevalence rates than men in most population based studies across the continent. In Kenya, the HIV prevalence rate for adult women is almost double that for men. This represents a female-to-male ratio of 1.9 to 1.0, the highest in Africa (KNBS and Macro, 2010). For young people, the difference in HIV prevalence between males and females is even more pronounced. The 2008-2009 Kenya Demographic Health Survey showed that the HIV prevalence rate for young women was four times the rate for young men in the same age group (KNBS and Macro, 2010).
Despite the significantly higher prevalence rate among women in Kenya, however, the data also show that more men are sexually active than women (KNBS and Macro, 2010). This trend is particularly pronounced for 15 to 19 year girls, 37 percent of which have had sex and carry an HIV prevalence of 2.7 percent, compared with 44 percent of boys who have had sex with a rate of less than one percent (KNBS and Macro, 2010). This gendered differential demonstrates concerning sexual health issues that expose girls and young women to HIV at a much earlier age and higher rate than boys and young men. This backgrounder will examine the Kenyan government’s policy response to these issues and suggest how it can be strengthened across multiple sectors.
In Kenya, the nation-wide HIV prevalence is estimated to be 7.4 percent among the general population — a steep decline from the estimated 14 percent in 1999, the year the government declared HIV to be a national crisis and formed the National AIDS Control Council (NACC, 2009). The epidemic in Kenya is characterised both as generalized, with troubling rates in the overall population, and concentrated, with higher prevalence among at-risk populations and particular geographical areas. Partly due to political support and stakeholder involvement, rates among the overall population have been decreasing and focus has shifted to reducing prevalence among those most at risk (NACC, 2010). The number of new infections among young women, however, is cause for alarm and more concerted policy efforts (National AIDS and STI Control Programme, 2008).
In Kenya, girls are three times more likely to be exposed to sexual violence than boys, with 15 percent of young women reporting cases of sexual abuse (KNBS and Macro, 2010). This abuse — much of which goes unreported — exposes females to HIV at a young age, with the risk of transmission much higher during rape or other sexually abusive activities(DRH, 2005).
Though Kenya’s Children’s Act prohibits early marriage, the 2008 census showed that 25 percent of women between 20 and 24 years had been married by age 18 (KNBS & Macro, 2010). Whether by choice or force, early marriage exposes girls to an early and longer period of exposure to sexual intercourse and childbearing, thus increasing their chances of becoming infected with HIV and other sexually transmitted infections (STIs). Infection rates, in fact, are higher among young married women than among unmarried women of the same age, partly due to young women’s physiology, but also due to their reduced ability to negotiate safe sex within marriage (NACC, 2009; HRW, 2010).
Female Genital Cutting
Although illegal under Kenyan law, female genital cutting (FGC) continues to be practiced, particularly in North East and Rift Valley provinces (HRW, 2010). Even though FGC rates are decreasing, an estimated 27 percent of Kenyan women have undergone the procedure (KNBS and Macro, 2010). FGC is often carried out under unsanitary conditions and can cause complications such as urinary tract infections, vesico-vaginal fistulaes and chronic pelvic infections that have a greater chance of becoming fatal if a woman contracts HIV (NCPD, 2003; HRW 2010).
Though often unreported, unsafe abortions are common among young women in Kenya (Hindin and Fatusi, 2009) and due to the use of unsterilized equipment during such a procedure, there is a greater risk of contracting HIV. In Kenya, it is estimated that the majority of women seeking care for unsafe abortion complications are below 25 years of age and that half of all pregnancies among girls aged 15 to 19 years are terminated each year (DRH, 2005).
Limited Access to Health Information
In Kenya, young people have less access to HIV and AIDS education, condoms and testing, compared to their older generations (DRH, 2005). The 2008 Kenya census shows that 44 percent of girls had never heard of family planning methods, compared to 29 percent of women in the general population, and fewer young women were aware of methods to prevent transmission of HIV to a child. There is also a strong association between early marriage and low levels of education (HRW, 2010), rendering such young women vulnerable to illiteracy and less likely to participate in school-based HIV prevention programs. With limited information and services, young women are also less likely to be tested for HIV, and use methods to protect themselves from contracting the virus or transmitting it to their children.
In response to the disproportionate impact HIV/AIDS has had among its young people, the Kenyan government has formulated policies over the last decade to improve sexual health. The Adolescent Sexual and Reproductive Health and Development Policy, developed in 2003, “recognizes that gender considerations are fundamental to adolescent and youth health because they are important determinants of access to economic resources, social services, education and other opportunities” (NCPD, 2003: 6). The policy describes a link between harmful practices and low levels of education, stressing that complications resulting from these practices cause children to drop out of school. Further, it recognizes that young women experience higher HIV prevalence rates than young men and creates goals to protect the population by keeping young women in school for longer periods of time than has been the trend in the past. Strategic actions in the policy also include HIV/AIDS educational programs and behaviour change communication among youth (NCPD, 2003), including targets to increase the proportion of youth-friendly and reproductive health services.
Recognizing the need for services that are specific to youth in Kenya, the Department of Reproductive Health has also developed National Guidelines for Youth-Friendly Services in Kenya in 2005(DRH, 2005). As the name implies, the policy seeks to avail appropriate health services in order to reduce disease and protect the human rights of young people throughout the country. Significantly, a key objective is to reduce harmful practices that increase young women’s chances of contracting HIV.
The Kenya National AIDS Strategic Control Plan (2009-2013), is another key policy document that prioritizes HIV education for young people both inside and outside school settings. The document states that although the average age of initial sexual experiences is increasing, prevention programs among young women who are already sexually active have failed (NACC, 2009: 6). It also acknowledges shortcomings in previous policies, stating that only 12 percent of Kenya’s public health facilities offer services defined as youth-friendly, a far cry from the 85 percent target identified in the 2003 policy on adolescent sexual health (NCPD, 2003; NACC, 2009: 8). The plans calls for more sustained efforts in the coming years to offer ‘youth-friendly’ and specific ‘girl-friendly’ sexual health services (NACC, 2009: 8).
The relationship between socioeconomic deprivation and social exclusion is also recognized in government plans (NACC, 2009). Using the example of widows and orphans who may take on risky activities such as transactional sex work to escape destitution, they call for “equity and rights-focused approaches” that require “interventions to promote social inclusion” (NACC, 2009: 8).
Despite acknowledging the need for rights-focused approaches to combat socioeconomic deprivation (and thus reduce HIV prevalence), the government’s 2009-2013 strategic plan did not allocate substantial funds towards achieving this goal. Over five years, only 0.1 percent of the overall national budget was allocated to creating an “enabling environment.” Community policies and guidelines account for most of this meagre budget, while funding for women’s and human rights is even smaller (NACC, 2009: 35). The only youth-specific allocation was to increasing prevention education for in and out of school-aged children, which accounted for 2 percent of the budget.
There is a demonstrable need for youth interventions to be scaled-up at the national level. The policies for adolescent sexual and reproductive health in Kenya acknowledge the vulnerability of young people generally, as well as the socioeconomic factors that place young women at a higher risk of contracting HIV. Greater commitment from the national government is needed in order to provide enhanced resources and coordinate a multi-sectoral effort that includes components on health, youth, gender, education, economic development and legal services. Existing plans and policies are currently under revision, which is timely as programming and budgetary re-orientation are needed to protect vulnerable girls and young women and create an enabling environment where they are empowered to make healthy sexual decisions. It is also imperative that substantial efforts in health and social programming are made to ensure the implementation of such policies across the country, so that all young Kenyans — male and female — are able to live healthy lives and reach their full potential with dignity.
DRH. (2005). National Guidelines for Provision of Youth-Friendly Services (YFS) in Kenya. Nairobi: Division of Reproductive Health (DRH), Ministry of Health.
Grimes, D. A., Benson, J., Singh, S., Romero, M., Ganatra, B., Okonofua, F. E., et al. (2006). Unsafe abortion: the preventable pandemic. The Lancet, 368(9550), 1908-1919.
Hindin, M. J., & Fatusi, A. O. (2009). Adolescent Sexual and Reproductive Health in Developing Countries: An Overview of Trends and Interventions. International Perspectives on Sexual and Reproductive Health, 35(2), 58-62.
HRW. (2010). “I Am Not Dead, But I Am Not Living”: Barriers to Fistula Prevention and Treatment in Kenya. July 2010. New York: Human Rights Watch (HW)
National AIDS and STI Control Programme. (2008). The Kenya AIDS Indicator Survey: KAIS 2007. Preliminary Report, July 2008. Nairobi: National AIDS and STI Control Programme, Ministry of Health.
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Khan, S., & Mishra, V. (2008). Youth Reproductive and Sexual Health. DHS Comparative (No. 19). Calverton, Maryland: Macro International Inc.
KNBS, & Macro, I. (2010). Kenya Demographic and Health Survey 2008-2009. Calverton, Maryland: Kenya National Bureau of Statistics (KNBS) and ICF Macro.
NACC. (2009). Kenya National AIDS Strategic Plan 2009/10 - 2012/13: Delivering on Universal Access to Services. Nairobi: National AIDS Control Council.
NACC (2010). UNGASS 2010 - United Nations General Assembly Special Session on HIV and AIDS: Country Report - Kenya. Nairobi: National AIDS Control Council (NACC).
NCAPD. (2005). Adolescent Reproductive Health and Development Policy PLAN OF ACTION, 2005–2015, Republic of Kenya. Nairobi: National Coordinating Agency for Population and Development, Ministry of Planning and Development & Division of Reproductive Health, Ministry of Health.
NCPD. (2003). Adolescent Reproductive Health and Development Policy, Republic of Kenya. Nairobi: National Council for Population and Development (NCPD), Ministry of Planning and Development & Division of Reproductive Health, Ministry of Health
UNAIDS. (2010). Analysis from the national AIDS strategic plans on HIV and young people. Geneva, Switzerland: Global Interagency Task Team on HIV and Young People, UNAIDS.
Laura Lee is a Ph.D. student in interdisciplinary studies based at the Liu Institute for Global Issues at the University of British Columbia. Her research focuses on perspectives of public health, social medicine, anthropology and gender with a focus on marginalized children and youth.