Discordant couples, sex workers hit hard as PrEP shortage bites

When Mary Auma (not her real name) decided to get married to a HIV positive husband, she knew there were drugs that would help to cushion her from contracting the virus. Little did she know that things would change one day.

Today, Auma is a worried woman. She fears contracting HIV from her husband, John Ooko.

Since she got married one year ago, she has been relying on the Pre-Exposure Prophylaxis (PrEP). PrEP is a drug taken by an HIV negative person before sexual intercourse to prevent transmission of the virus in case the other partner is HIV positive.

She believed there would be a constant supply of PrEP, and this would enable her to maintain her HIV negative status as she enjoys her marriage.

But when we meet her at Unga village in Kanyamwa Kosewe Ward, Ndhiwa Sub-county in Homa Bay County, Auma looks mentally disturbed.

Her concern is the inability to get PrEP.

At the age of 19 years, Auma is mentally tortured about how she wants to continue with her marriage and avoid HIV infection.

"I got married in early 2024 when I knew that my husband was HIV positive. But our hope has been the PrEP, which has enabled me to be negative to date. But the inability to get the drugs disturbs my mind because I endeavour to be HIV negative and continue with my family at the same time," Auma says.

She says the situation may revive the stigma her parents caused when they opposed the marriage.

"When I shared the details of my husband with my parents early last year, they objected the marriage on the basis of my husband's status," Auma says.

Her parents stopped communicating with her when they realised that she was not ready to quit the marriage as they wanted. But their anger calmed down later.

"I had to overcome their pressure because of PrEP. I love my husband, but I am in a difficult situation today," she says.

Ooko says the use of condoms is not effective for them as a couple.

"We have tried using condoms but they are not effective because we are a couple who will need to get a second baby. Our son is now seven months old. How will it be possible without PrEP?" Ooko asks.

He says the shortage of PrEP is a setback to his family. Ooko believes the drugs are the only way to enable him to fulfill the objectives of his marriage, like couples who are HIV negative.

"Auma showed me true love when her parents wanted us to be apart and I am indebted to her for being a trusted wife. I would not like her to be infected by HIV," he explains.

The 22-year-old man wants the government to revive the proper supply of PrEP in the country.

"As a citizen and taxpayer in this country, I know the government has a role of ensuring Kenyans are healthy. I appeal for an adequate supply of PrEP," Ooko says.

Auma and Ooko's situation is just a case study of the predicament many discordant couples' undergo due to lack of PrEP in various parts of Kenya.

The shortage of PrEP puts the lives of sex workers too at risk. The sex workers depend on PrEP to prevent HIV infection in line of their duties.

Nancy Atieno is a sex worker in Homa Bay Town. Atieno says PrEP is no longer readily available as it was last year.

She says it is difficult for one to get the drugs these days compared to the period before January this year.

"We used to get the drugs in large numbers at various hospitals in Homa Bay Town. But the supply has declined significantly. Only a few maneuver their ways to get it," Atieno says.

She argues that the situation affects her business negatively because she has to turn down some clients who want unprotected sex due to lack of PrEP.

"I have turned down my clients who want unprotected sex when I don't have PrEP. But this has economic ramifications," she says.

But she worries that the shortage of PrEP predisposes sex workers and other members of the key population to HIV infections.

According to Atieno, unprotected sex has more financial returns than the protected one. This makes sex workers susceptible to contracting HIV when they miss the drug.

"Unprotected sex has good returns. Since people are in this business to make money, most of my colleagues end up having unprotected sex even if they have no PrEP and this escalates the risks of HIV infections," Atieno says.

Considering the high cost of living in Kenya, shortage of PrEP makes sex workers more susceptible to HIV infections.

Jael Amondi, a sex worker in Rodi Kopany Township in Homa Bay County, says it is difficult for her to turn down a client who has good money because she does not have PrEP.

Amondi said says the high cost of living leads to high competition in their work. The competition prevents them from choosing who to serve as long as the client has money. Thus, availability of PrEP becomes the least factor for her if the client has what she refers to as good money.

"It is common knowledge that we are in this business to make money. The cost of living has also escalated in manner that if you become so selective with clients, we are likely to lose what we should get. PrEP is very important but at times, circumstances make money influence our decisions to serve clients if the drug is unavailable," Amondi says.

Statistics show that initiation of PrEP has declined in Kenya since the beginning of the year.

Data presented from the Kenya Health Information System showed that PrEP initiation declined by 49 per cent from 55,876 between January and March 2024 to 28,648 between January and March this year in Kenya.

The decline is attributed to funding cuts by the US government including the disbandment of the United States Agency for International Development (USAID) that used to support HIV prevention and treatment.

The gains made in the response against new HIV infections are attributed to initiation of PrEP.

Homa Bay County Department of Health's Research, Learning and Innovation Co-ordinator Justus Ochola says the decline in supply of PrEP is jeopardizing the gains made in the response against HIV infections in Kenya.

Ochola decline in PrEP supply predisposes more discordant couples and sex workers to new HIV infections. And the infection will also spread to other members of the society.

"HIV infection will increase among discordant couples, sex workers and other members of the key population. This will further spread to adolescents and young adults because they are sexually active," Ochola warns.

He urged county governments to make an alternative budget line for purchasing PrEP.

"Health is a devolved function and county governments should put an alternative budget line for purchasing drugs. Failure to do so will escalate HIV infections," Ochola says.

Patricia Jeckoniah, LVCT Health Programmes Manager for Policy, says the government and stakeholders devise mechanisms for generating resources domestically to augment the response against HIV.

"We should not have more people infected by HIV as a country because funding from outside has been cut. This is the time public private partnership framework should work to ensure Kenya has a health system that is responsive to the needs of citizens," Jeckoniah says.

Jeckoniah called for more sensitization among adolescents and young women and to reduce new HIV infections," she says.

The Secretary of Media for Environment, Science, Health and Agriculture (Mesha) Daniel Agan urges stakeholders to join hands to ensure the gains made in the response against HIV are jeopardised.

Agan says they are empowering journalists to sensitise the public on HIV prevention and treatment to enable the country to achieve its goals in reducing the spread of AIDS.

"We empower journalists to sharpen their reporting skills to ensure we achieve the objectives of reducing new HIV infections. Above all, let all stakeholders join hands to put more strategies in place to prevent the spread of the disease," Agan says.

The Co-ordinator of Gender Violence Activities in Homa Bay Michael Ochola urges the government needs to focus more on senitization against HIV spread.

Ochola argues that sensitisation will enable Kenyans to avoid committing acts that predispose them to HIV infections.

"Sensitisation also helps in HIV prevention. Gender based violence also leads to spread of HIV. The government should intensify anti HIV infection campaigns in the community," Ochola says.

He also wants the government to stop relying entirely on donor funds in the spread of HIV.

Ochola opines that Kenya should have internal mechanisms for funding HIV treatment and prevention.

He maintains that the country should learn from the abrupt budget cuts which the US government made early this year.

"It is no doubt that the government should adjust its budget on HIV treatment and prevention. Scrapping of the USAID should be a big lesson to us as a country," he add