Two PhD Fellows from the Sub-Saharan African Network for TB/HIV Research Excellence (SANTHE) are hoping to have their respective findings used to revise Kenya’s national guidelines on the use of PrEP for specifically targeted groups that stand to benefit most from it; and consequently, to reduce the spread of HIV. Pre-Exposure Prophylaxis (PrEP) is daily medication taken by people at very high risk of acquiring HIV to lower their chances of getting infected.
The SANTHE Fellows – Makobu Kimani and Elizabeth Wahome - are based within the HIV research group at the Kenya Medical Research Institute (KEMRI) - Wellcome Trust Research Programme (KWTRP) in Kilifi - an International AIDS Vaccine Initiative (IAVI) supported site, and part of the IAVI Clinical Research Centres (CRC) network. This CRC is well known for its expertise in research and programming with Men who have Sex with Men (MSM) in coastal Kenya, under the leadership of Prof Eduard Sanders. HIV is more common in MSM compared to the general population, and due to the stigma associated with same sex relationships, they are at increased risk for contracting HIV. Furthermore, the illegal status of same sex relationships makes it difficult for them to seek preventive services in public healthcare facilities.
The recent introduction of PrEP to the national guidelines is hoped to slow down new infections. However, a review of these guidelines by researchers at KWTRP revealed a deficit in that they do not specifically address anal sex - an independent predictor to increase the risk for HIV acquisition in MSM. Furthermore, Kimani has identified a small group of transgender women (TGW) who had previously been classified as MSM. This is relevant because research undertaken in 2017 demonstrated a much higher HIV-1 incidence in TGW (26 per 100 persons tested) compared to other MSM (4,5 per 100 persons tested). TGW are currently not recognised as a key population in Kenya but reports from studies in the USA concur that they are at increased risk for contracting HIV.
Consequently, the two SANTHE PhD trainees have on-going study protocols that aim to address these identified service provision gaps and hopefully influence national PrEP policy and guideline revision.
Among MSM followed up in Mtwapa (a small town in Kilifi), the overall HIV-1 incidence has been estimated at 6.9 per 100 persons tested. Moreover, several studies have documented risk factors for HIV-1 and sexually transmitted infection (STI) acquisition. Despite risk reduction counselling, provision of water-based lubricants and condoms, treatment of STI, and provision of hepatitis B vaccinations, HIV-1 incidence has not declined in MSM here over the past 12 years.
Since June 2017, PrEP was made available to individuals meeting HIV-1 risk criteria in the published Ministry of Health (MoH) guidelines. Wahome will assess if PrEP offered programmatically to MSM and FSW in the Mtwapa cohort will lead to reductions in the high HIV-1 incidence in these groups. In order to guide PrEP targeting for MSM, she has developed an empiric risk score based on 5 characteristics including; having sex with men exclusively, receptive anal intercourse (RAI), unprotected sex, group sex and age (18-24 years) [Wahome et al, AIDS and Behavior. 2018:1-10]. This risk score will help Kenyan healthcare providers in discussing HIV-1 acquisition risk among MSM and encourage them to consider PrEP when these risk criteria are met. She is currently comparing the performance of this risk score tool versus the MoH criteria in identifying MSM at-risk of HIV-1 acquisition for PrEP initiation. This is important because incorporating established risk factors for HIV-1 acquisition among MSM, especially RAI (receptive anal intercourse), into MoH guidelines, will enhance the impact of PrEP programming among MSM in Kenya.
Kimani is also running a small PrEP cohort in Malindi, coastal Kenya. Here, he has segregated MSM and TGW to measure uptake and attrition differences between these groups. He is also collecting qualitative data from both PrEP users and public healthcare service providers to identify and understand the barriers to PrEP uptake and provision to MSM and TGW. He also hopes to document what kind of support these groups might need to support uptake, adherence and retention in PrEP follow-up.
SANTHE is a scheme of Developing Excellence in Leadership, Training and Science (DELTAS) Africa, a programme of The African Academy of Sciences being implemented with the support of Wellcome and DFID to train and develop world class researchers and research leaders in Africa. At The AAS, DELTAS Africa is implemented through the Alliance for Accelerating Excellence in Science in Africa (AESA), a funding and agenda setting platform of The AAS and the African Union Development Agency (formerly NEPAD).