EDITION 47 NEPHAK Weekly Bulletin 24th November 2019

Kenya Needs a Catch-up Plan with Priority on Men and Boys to Deliver on the 90.90.90 targets by next year

Participants at the Community-led Forum on Men and HIV in Nairobi last week.

The community-led Forum on HIV and Men announced earlier by NEPHAK: https://mailchi.mp/4512cc41c550/e see also https://www.iasociety.org/ was eventually held last week in Nairobi bringing together over 55 participants drawn from civil society and community networks and men-led organizations, including ten representatives of the agencies working to promote the health and wellbeing of men. The community-led advocacy forum was inspired by the Men & HIV Forum convened by the International AIDS Society (IAS) and partners ahead of the 10th International Conference on HIV Science (IAS 2019) in Mexico in July and which provided an opportunity to bring together diverse scientific, political and community interests to discuss current opportunities and challenges for increased prevention, diagnosis and treatment of HIV for men and boys.

The multi-stakeholder consultative process with civil society partners and representatives from community-based organizations drawn from those focusing on supporting general population – men discussed what community-led advocacy and demand creation to reach men with health services, including but not only HIV services) should entail and what is needed to make it happen including whether Kenya “men’s health strategy” is adequate for improving the uptake of HIV services by men. Partners from the LVCT Health; AIDS Healthcare Foundation – Kenya; the National AIDS Control Council (NACC); the National AIDS and STIs Control Program (NASCOP); the Centre for Disease Control and Prevention in Kenya (CDC – Kenya); the Joint UN Program on AIDS (UNAIDS) and; the PEPFAR-Kenya coordination office attended the forum.

The main plenary saw the sharing of the latest Kenya AIDS Response Programme Report highlighting HIV outcomes for men and which corroborated the earlier assertion by the UNAIDS publication Blindspot: Reaching out to men and boys, which acknowledges that men are disproportionately less likely than women to know their HIV status, less likely to access and adhere to HIV treatment and more likely to die as a result of AIDS-related illnesses. The fact that men are being left behind in the response to HIV was demonstrated using the performance and outcomes of the country’s latest data on the progress towards the delivery of the 90.90.90 HIV prevention targets. The same position was shared by the PEPFAR and the UNAIDS representatives.

The forum also deliberated on the barriers and structures that have led to poorer outcomes for men and especially living with HIV, including a presentation by the CDC-Kenya team on the results of potential programs for men that need upscaling. Here, the CDC team that included a Behavioral Scientist shared on the lessons emerging from the interventions designed under the PEPFAR’s recent Strategy for Accelerating HIV/AIDS Epidemic Control (2017-2020) which emphasizes the need for an “acceleration of optimized HIV testing and treatment strategies particularly to reach men under age 35”. Coming after an opening that painted a bleak future for men and boys, this plenary presentation by the CDC provided some hope that at least something was being done and is working. The impression is that such interventions need to be replicated and up-scaled.

The plenary sessions resulted in a debate on what the next steps are to ensure greater uptake and access of HIV services among men in Kenya and which later led to an inspiring panel discussion by discussants with hands-on experience in engaging and working with and for men. The panel took a keen focus on the issue of men and HIV and how to ensure that men and boys are benefiting from the HIV and health programs for the improvement of their health and well-being. The panelists included a young man from the BLAST; the Director of MMAAK; the technical Manager from the LVCT Health; UNAIDS Fast Track Advisor; a HIV Prevention Technical Focal Point from the CDC and the Country Director of the AIDS Healthcare Foundation in Kenya (AHF-Kenya).

Although presenting different views and perspectives, the collective agreement among the panelists is that those managing HIV and health programs must do things differently. In short, Kenya must come up with a catch-up plan to enable boys and men to be part of the 90.90.90 targets set for delivery by next year. The catch-up plan will need to start with the review of the Male Engagement Guidelines developed by the NACC and which many of the participants acknowledged they have neither heard of nor seen. The forum called for community-led consultations to unveil a new Male Engagement Strategy and an accompanying implementation plan and which should focus on both HIV and the broader health issues to make sure that men are also not left behind in the roll-out of universal health coverage.

With detailed technical presentations from the plenary and the panel discussion, the forum participants ventured into group works to agree on the next steps which included setting priority agenda for men and drafting a work plan to guide the engagement and work with and for men. The group work for action planning focused on advocacy and communications, including policy and programming; capacity building and resource mobilization. The fact that Kenya at the moment working on the Kenya AIDS Strategic Framework and preparing for both the Global Fund application and PEPFAR COP 2020 was seen as opportunities for leveraging resources for furthering the men’s agenda. Male engagement Champions were identified to spearhead the next steps. The forum also generated a lot of information about men and HIV that will be shared at the 20th International Conference on AIDS & STIs in Africa (ICASA 2019) in Kigali, Rwanda, 2 -7 December 2019.

Keen to Tackle Mental Health? Increase in Domestic Health Financing.

MoH Ps Susan Mochache and Parliamentary Health Committee Chair at the Mental Health Conference last week

The Ministry of Health last week held the first-ever Mental Health Conference to reflect on the status of mental health in Kenya and to re-commit to the prevention, treatment, and management of mental health in the country. Coming days after the global Mental Health Day, the conference met a lot of expectations. Although such a conference was foreseen in the Kenya Mental Health Policy 2015 – 2030, http://publications.universalhealth2030.org/ref/e5ab9a205fdbd7c811bb895d09e4f81c no such forum has been held before. It is, therefore, inspiring that all partners, including communities who attended the conference, expressed the commitment to join the Ministry of Health in tackling mental health.

For NEPHAK, the conference was a timely reminder of the link between HIV and mental health. As we have always shared through this Bulletin, people living with HIV are more vulnerable to mental health problems than people without HIV. As such, we maintain that the HIV epidemic control goals will not be achieved without addressing the significant mental and substance use problems among people vulnerable to acquiring or living with HIV, which exacerbate the many social and economic barriers to accessing adequate and sustained healthcare and are among the most significant barriers to achieving the 90–90–90 targets. Following this conference, we take this opportunity to remind the Ministry of Health and partners that it will be impossible to significantly ‘end AIDS’ without dramatically altering the approach to diagnosing and addressing comorbid mental health (including substance-use) problems among people living with, at risk of and affected with HIV.

It should be noted that many factors contribute to the high comorbidity of HIV and mental health conditions. People who have (or are at risk of) HIV and who are vulnerable to mental health conditions often face other significant individual, structural, social, and biological challenges to accessing and adhering to HIV prevention and treatment modalities. These factors fall into the domains of socio-demographics, neighborhood and local environmental factors, social structures, individual biology, and intersecting societal stigmas. Structural factors, including poverty, low education, unstable housing, and food insecurity, contribute to increased vulnerability to HIV infection and poor HIV health outcomes.

In addition, biological factors, including comorbid communicable diseases (e.g. tuberculosis, hepatitis) and non-communicable diseases, including diabetes, heart, and bone disease), as well as chronic immune activation, contribute to poorer physical and mental health outcomes. Intersecting social stigmas, and criminalization in some contexts (e.g. sex work, drug use, and same-gender sex) present additional challenges to key populations that are highly affected by HIV, including MSM, transgender women, sex workers, people who use drugs including, PWID and other minorities. These groups experience perceived and internalized stigma as well as enacted stigma such as discrimination that negatively affects mental health, and this relationship is further compounded by the unfortunate stigma of mental illness in society and among patients and providers. It should be noted that 30 years into the epidemic, HIV is still highly stigmatized. Stigma and discrimination is also very rampant for people with mental health problems.

The challenge of mental health and how it relates to HIV is not just about people living with HIV. Mental health disorders play a critical role in HIV acquisition across populations, increasing the risk of HIV acquisition by 4–10-fold. Mental health problems can increase the risk of HIV acquisition through both direct and indirect pathways. Although people with mental health problems tend to be less sexually active compared with the general population, sexually active adolescents and adults with mental health challenges evidence higher-risk sexual behavior, including inconsistent condom use, having multiple sexual partners, trading sex, and drinking alcohol before sex. The risk of HIV infection may also increase with the severity of psychiatric illness.

Mental health problems can also interfere with efforts to prevent HIV infection, including regular HIV testing and adherence to PrEP. Screening and treatment for mental health problems and disorders will be essential to preventing vulnerable populations from acquiring HIV. This is why NEPHAK advocates for the screening of non-communicable diseases such as mental health problems.

We, therefore, agree with the Conference assertion that Mental Health Equals Health and that the universal health coverage goals shall not be delivered if mental health is not properly tackled. Mental health should, therefore, be at the center of primary health care and universal health care. This can only happen with increased domestic financing to the health sector.

Communities and Patients Need Education and Literacy on Antimicrobial Resistance (AMR).

Some of the participants during the Antibiotics Awareness Week in Kiambu County.

With its 4th strategic plan covering the period 2017 – 2021, NEPHAK included Antimicrobial Resistance and committed to work with the Ministry of Health to sensitize and educate communities on what leads to AMR and to seek partnership to respond to the same. And when last week Kenya was honored to host, for the first time in Africa, the regional World Antibiotic Awareness Week 2019 and the organizers of the events to commemorate the week reached out to NEPHAK to join the events and share the communities’ perspective on AMR. For more, see: #WAAW2019

From the engagements, including the interactions at the Antimicrobial Symposium organized by the Ministry of Health and partners, it is clear that communities and patients will need technical capacity building to improve their knowledge and increase their treatment literacy to play any meaningful role in the creation of awareness on antibiotics and ARM. Patients and communities, including farmers, will need to be educated on what AMR is and how it can be prevented and/or managed. With knowledge on AMR, communities and patients through their organizations and networks shall be formidable partners with the Ministry of Health to tackle AMR.

Antimicrobial Resistance (AMR) is a current and increasing threat and challenge to communities with far-reaching consequences. AMR leads to prolonged treatments, longer hospital stays, higher medical costs, increased mortality and loss of productivity. AMR causes additional suffering for patients and financial pressure on health systems. If current trends continue, infections, including Tuberculosis (TB) and malaria, can become untreatable, common surgical procedures, and some complex interventions such as organ transplantation or cancer chemotherapy will become far more difficult or even too dangerous to undertake. It is because of this that NEPHAK prioritized AMR education and awareness.

During the AMR Symposium, it was shared that the Ministry of Health has revised the Kenya Essential Medicines List to include the Access, Watch & Reserve categorization of antibiotics & is in the process of reviewing the Clinical Guidelines to ensure rational use of these precious medicines. This is important as Antibiotic resistance poses a big threat to global health. However, such efforts can only yield positive results if patients and communities are educated and sensitized to adhere to what doctors and clinicians say.