Father takes bold step to protect daughters from HIV and teen pregnancies

When numbers about health are thrown around at community gatherings that he attends in K’akrao in Migori County, John Mbago’s heart skips a beat due to fear. One in five girls under 18 years old (22 per cent) are already teen mothers, according to the latest Kenya Demographic Health Survey.

About 14.7 per cent of the population is living with HIV, the fourth highest in Kenya, according to data from National Aids and STIs Control Programme (Nascop). There are more than 8,000 new HIV infections in Migori each year. 

John is particularly scared because he is a father of four girls, aged between 12 and 25. With three of them in secondary school, and hopeful for what they would be — a nurse, a teacher and a pharmacist— taking care of the girls when pregnant or HIV is not in the grand scheme of things.

After one of the community gatherings, John thought the methods to protect his children from pregnancies and HIV were not sufficient, given the circumstances in the county.

The poverty, he thought, made girls particularly a target.

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Abstinence

‘‘I talk to them about abstinence, sticking with one partner when they marry, and using condoms, but clearly, that is not working because look at the infections, pregnancies and deaths,” John told The Standard.

At 56, John set aside Sundays to connect with the activity his children know most: playing football in his compound. 

“After our chores of slashing the grass, cleaning and farm work, we play football. I want them to see me as their father and friend,” he said. 

One afternoon, while playing football, John saw a young man pass his gate. The young man, John said, had interesting paraphernalia that he was loading in his bag after a meeting with young people from the neighbouring compound.

The young man, Gordon Mito, was a peer educator. Peer educators are young people in the health facilities, and the Department of Health send them to talk to their peers about HIV.  

“He had a wooden toy penis, condoms of all sorts of colours and that made me curious,” John said.   Curious, John invited Gordon to his home.

In the meeting, Gordon patiently explained his role as a peer educator and the information that he gave the youngsters. It was in this meeting that John learnt about pre-exposure prophylaxis or just PrEP. A lightbulb went on his head.  

Perfect pill

“This would be the perfect pill to protect my girls,” he said.  

According to the Centres for Disease Control and Prevention (CDC), PrEP is a medication that people take orally before sexual contact and reduces the risk of getting HIV by about 99 per cent. In 2015, the World Health Organisation (WHO) recommended oral PrEP for people at risk of getting infected by HIV. According to Dr Rose Wafula, the head of Nascop, people at risk include adolescents and young women.

This is how PrEP works, according to the CDC. It is taken before sexual contact, and it interferes with viral infection and its multiplication. It contains the drug Truvada, which is a combination of two medications emtricitabine and tenofovir disoproxil fumarate. 

After learning about PrEP, John took his girls to Migori Level 5 Hospital again.

“They were tested, and when they turned out negative, the nurse educated them about how to take the medicine,” John said. 

John’s fears do not occur in a vacuum.

At their age, below 25, young people cannot negotiate for safe sex.

Several studies that have involved the magnetic resonance imaging (MRI) of teenagers have shown that the prefrontal cortex — the part of the brain that controls impulses and complex reasoning — has not developed. 

Ruth Nduati, a professor of paediatric medicine at the University of Nairobi, has repeatedly said that with brains still developing, teenagers and young people cannot negotiate or choose safe sex.

In 2015, the National Syndemic Diseases Control Council (NSDCC) reported that more than half (51 per cent) of all new HIV infections in Kenya occurred among young people aged between 15 and 24 years. The Ministry of Health reported that in 2022, there were 22,154 new HIV infections. One in five of the new infections (4,464) were in children under 14 years. 

Biological reasons aside, poverty makes it impossible for young men and women to negotiate or choose safe sex.

Take Atieno, 19, for instance. Her father is a carpenter in his 70s, while her mother is a housewife. The situation at home pushed Sharon to look for ways to support her parents and herself where she earned Sh1,000 a month. 

At her place of work, she says, the man of the house turned her into a second wife.  

“I cannot recall how it happened,” she explains. “He just started sleeping with me, and while he did not force himself on me, I did not want it. Also, how could I say ‘No’ yet I needed the Sh1,000 monthly pay to take care of my family back home?” 

Several stories

Although her sexual encounters with her employer were camouflaged as transactional, Atieno, then aged 17, was being sexually abused.

The vice is pervasive in the county. 

John has heard several stories like Atieno’s, and while his daughters would not be in an economic fix enough to drive them to transactional sex, he was aware of coercion. His daughter, Sharon who is in her early 20s, says that her father would never miss a chance to talk to her about HIV.

“After she saw some girls that I went to school being HIV, he became very involved in our lives, doing things he never used to do that shocked us, carrying us on his bicycle to the hospital for HIV test and then the PrEP,” Sharon said as she laughed. 

At the hospital, John learnt that the regimen does carry a risk of side effects that include gastrointestinal complications, mostly nausea. The oldest of the four girls, Sharon took the pills. When she took the pills, her father would ask her, daily, what she was feeling. 

“Dad comes to ask every day about two things, what I am feeling and saying we could bring a boyfriend if I had one,” she says laughing.

There couldn’t have been a better time to reduce PrEP. Like most parts of the world, Kenya is on a path to ending HIV/Aids using two steps: the government is treating those who are already living with the virus and preventing them from transmitting the virus to those who are negative. Targets help, set a to-do list to achieve this goal. The formula from UNAids is a lyrical “95-95-95”.

The figure means Kenya aspires to have 95 per cent of those infected know that they have the virus; once they know, 95 per cent of them should take antiretroviral drugs (ARVs) to suppress their infections; 95 per cent of those taking the ARV suppressing the viruses in their body. Across Kenya, the “treatment trilogy” is an encouraging 94–94–89, according to Nascop.

Prevention is better and cheaper than cure. PrEP augments the other prevention methods that young women like John’s daughters may not have. Besides, studies have shown that the use of condoms, which prevent HIV, pregnancy and other sexually transmitted infections, has been declining in recent years, contributing to an increase in sexually transmitted infections.

Kenya is among the first in Africa to offer HIV prevention through pharmacies

Public health

The government has heightened public health campaigns promoting PrEP. Uptake has been steady but not as fast as the Ministry of Health targets.

In 2016, the government reported, less than 10,000 people were on PrEP. The number increased by more 4,000 per cent, to 438,003 users in December 2023.  

Dr Patricia Ong’wen, a physician and HIV researcher at the Johns Hopkins Affiliate, Jhpiego, said that the queues, the lack of privacy, stigma, and the few staff at the health facilities discourage people from taking PrEP. 

In response, and in another oddity like John’s decision to encourage all his daughters to PrEP, Kenya is considering using private pharmacies to offer PrEP. 

“Pharmacies can sort out the issues of privacy, distance and long waiting times because they are everywhere and they are already part of Kenyans’ health-seeking behaviour, where they buy medicines,” said Dr Ong’wen. As of May 2024, there were 7,425 active registered retail pharmacies in Kenya.

There were 2,391 active registered pharmacists (with a Bachelor of Pharmacy degree) and 9,471 pharmaceutical technologists, adequate numbers that can serve people without the worry about queues.  

Dr Rose Wafula from Nascop said PrEP is now available free of charge in health facilities and Drop-In-Centres —these are clinics where one can pop in and pick PrEP and only serve men who have sex with men and sex workers. 

The use of pharmacies makes Kenya among the first in the continent to adopt the World Health Organisation (WHO) evidence.

Two years ago, seven years after endorsing PrEP, the organisation saw the additional barriers that patients faced seeking PrEP from brick-and-mortar facilities. 

Young women

The hospitals have queues and are not accessible to those who do not identify as a key population but are equally vulnerable to HIV infection such as adolescent girls and young women.

WHO then recommended that countries should deliver PrEP in a way that it meets people whenever, wherever. Pharmacies were floated in technical Working Groups, the little committees of experts that the government gathers to give answers to a particular problem. 

Like all medicine, it is not as easy as decide and offer the next day.

Researchers had to show how the pharmacists would be integrated into the current algorithm of offering HIV care.

Besides, the country’s regulation forbade pharmacists (degree holders) and pharmaceutical technologists (diploma graduates) to prescribe medications. They could, however, screen for HIV and other diseases and provide both prescription and over-the-counter medicines.  

Dr Patricia Ong’wen, who is also the deputy director of a consortium of researchers called PharmPrEP, worked with other researchers and Nascop to test whether pharmacists would offer quality services.

The study which ran from 2022 to 2023 evaluated the effectiveness of using pharmacies to deliver PrEP in six counties with high numbers of HIV: Kiambu, Kisumu and Migori, Homa Bay, Nairobi and Siaya.