Mombasa sex workers hold on to HIV prevention pills as US support wobbles

Prep comes as a pill taken daily. It reduces the risk of getting HIV from sex by about 99 per cent when taken as prescribed.

The first time Fatuma took HIV prevention pills, she had constant diarrhoea.  She also experienced heavy menstrual flow.

“So I stopped,” she says.

She is a sex worker in Mombasa and uses money from her trade to finance her degree at the Technical University of Mombasa, and take care of her nine-year-old daughter.

“From that time, I started insisting on my clients to use condoms,” she says. But not all complied. Some of paid more and had condomless sex.

Female sex workers (FSW) have the highest rate of HIV infection among key populations in Kenya.

In the context of HIV, key populations include sex workers, men who have sex with men (18.2 per cent HIV prevalence) and people who inject drugs (18.3 per cent).

At least 29 per cent of FSW are living with HIV, the National Syndemic Diseases Control Council (NSDCC) says.

That means they are four to six times more likely to be living with HIV than other women.

Omar Mwanjama, a coast regional officer with NSDCC, encourages them to use Pre-exposure prophylaxis (PrEP) pills given freely in public hospitals, on top of condoms.

Prep comes as a pill taken daily. It reduces the risk of getting HIV from sex by about 99 per cent when taken as prescribed.

But few sex workers have taken the advantage despite its proven efficacy. Researchers, who included those from Partners for Health and Development in Africa last year found that  only 24 per cent of sex workers in Nairobi took Prep, and only a third of these took it consistently.

A 2017 study among sex workers in Mombasa indicated that despite their willingness to use Prep, a majority did not because there were concerns about its potential negative side-effects.

NSDCC explains that although some people may experience side effects that include headache, weight loss, nausea, vomiting, and abdominal discomfort, these effects often reduce or stop after a few weeks of taking the PrEP.

One organisation is amplifying the NSDCC message.

The Coast Sex Workers Alliance (Coswa) is a grassroots female sex workers-led organisation that champions human and health rights of sex workers at the Kenyan Coast.

“We are educating our members about the extremely high risks we face and why it is important to protect ourselves,” says Elizabeth Siama, a Coswa director.

Sex workers can collect condoms at the Coswa offices in Mombasa, but go for Prep at the nearby public hospitals including the Tudor Level 4 Hospital.

She says at least 34 per cent of sex workers have reported that they have been violated in their lifetime. The forms of violence include rape, intimate partner violence, and violence by the police especially when they try to report violence.

Female sex workers (FSW) have the highest rate of HIV infection among key populations in Kenya.

Kenya initiated national scale-up of pre-exposure prophylaxis (PrEP) for all persons at high-risk in 2017 Following a WHO recommendation.

June, a 45-year-old sex worker in Mombasa and a mother of two teenage girls, takes her Prep pills religiously.

“It’s also because I have a longterm partner so I need to protect him as well. He knows the work I do, and we agreed I need to protect him,” she told The Star.

NSDCC’s Mwanjama said Mombasa has 54,361 residents living with HIV, Kenya’s seventh highest number after Kisumu, Homa Bay, Migori, Siaya, Nairobi and Nakuru counties respectively.

“As a major port with international shipping links, Mombasa is susceptible to the introduction of new HIV strains. This can lead to the emergence of complex HIV recombinants,” he says.

“The HIV epidemic in Mombasa exhibits both general and concentrated characteristics. This means that the virus is spread throughout the general population, but also within specific groups of individuals, such as key populations like female sex workers.”

Mwanjama explains that Prep does not protect against unintended pregnancies and sexually transmitted infections. “And that is why we encourage sex workers they must use condoms, which can protect against all these risks,” he says.

Last year, Robert Abuga of the County Government of Mombasa, and four other researchers, found that married FSW and their life-partners are particularly vulnerable.  They found that unprotected sex was higher among married than unmarried FSWs, because married FSWs perceive themselves to be at less risk.

Abuga’s study also indicated that many FSWs are engaging in unprotected sex while under influence of alcohol/drugs and having high frequency of sexual intercourse. Few FSWs had tested for HIV within the last three months.

“Interventions to address these modifiable factors such as creating FSWs’ social networks are needed to control and prevent HIV among them,” the researchers advised.

“Social networking among FSWs build peer solidarity/trust and may contribute greatly to condom utilisation, which is one of the key interventions together with pre-exposure prophylaxis used in the fight against HIV/Aids,” Abuga and colleagues said in the study, published by the Pan African Medical Journal in April, 2024.

Prep pills are part of the HIV commodities heavily financed by the US President's Emergency Plan for Aids Relief (Pepfar).

HIV prevention and treatment services in Kenya are now at risk if the US makes good its plan to completely cut funding.

Experts said that makes prevention of HIV a top priority. Kenyans are still accessing free Prep pills courtesy of a 90-day waiver that Usaid issued in February, to ensure that life-saving HIV services, including treatment and prevention, can continue for vulnerable populations.

Pepfar’s annual contribution to Kenya’s HIV services, including ARVs and drugs such as Prep, is Sh8 billion.

The Council of Governors, NSDCC, National AIDS and STIS Control Programme, Kenya Medical Supplies Authority have already appealed to the Kenyan government to plug in the gap in case the US pulls out completely.

These organisations especially made a strong case for HIV prevention services, which help prevent a rise in Kenya’s HIV burden. People with HIV must take ARVs for life, but Prep is not taken for life.

“For now we still have enough Prep drugs in hospitals,” said Mwanjama.

Fatuma is now in second year at the university and has resumed taking Prep. “I am doing it for myself, my dreams, and my daughter,” she said.