KAIS 2007 Collaborating Institutions

National AIDS and STI Control Programme, Ministry of Health, Kenya (NASCOP)
National AIDS Control Council (NACC)
Kenya National Bureau of Statistics (KNBS)
National Public Health Laboratory Services (NPHLS)
National Coordinating Agency for Population and Development (NCAPD)
Kenya Medical Research Institute (KEMRI)
U.S. Centers for Disease Control and Prevention, Atlanta/Kenya (CDC)
U.S. Agency for International Development (USAID-Kenya)
United Nations (UNAIDS and WHO)

Donor Support
KAIS 2007 was made possible through technical and financial support provided by the U.S.
President’s Emergency Plan for AIDS Relief (PEPFAR) through the U.S. Centers for Disease
Control and Prevention (CDC) and the United States Agency for International Development
(USAID) and through technical and financial support provided by United Nations through UNAIDS
and World Health Organization (WHO).

Suggested Citation
National AIDS and STI Control Programme, Ministry of Health, Kenya. July 2008. Kenya AIDS
Indicator Survey 2007: Preliminary Report. Nairobi, Kenya.

Contact Information
National AIDS and STI Control Programme, Ministry of Health, Kenya. (NASCOP)
P.O. Box: 9361 Code: 00202 Nairobi, Kenya
Telephone: +254.(0)20.729.502, +254.(0)20.729.549 Fax: +254.(0)20.710.518
E-mail: headnascop@aidskenya.org Website: http://www.aidskenya.org

2
 KENYA AIDS INDICATOR SURVEY
KAIS ▪ 2007

PRELIMINARY REPORT

NATIONAL AIDS AND STI CONTROL PROGRAMME

Ministry of Health, Kenya

JULY 2008

3
CONTENTS
List of Abbreviations 2

Introduction
1.1 Background 3
1.2 Overview of KAIS 2007 4
1.3 Specific objectives 4
1.4 Timeline 5

Design & Methods

2.1 Geographic coverage and target population 6
2.2 Sampling frame and design 6
2.3 Data collection tools 7
2.4 Survey implementation
Training 7
Community sensitization 8
Fieldwork 8
Supervision 8
2.5 Laboratory logistics 8
2.6 Data processing and analysis 9
2.7 Return of test rsults 10

Preliminary Results
3.1 Response rates 11
3.2 Prevalence of HIV
Overall estimates 12
Estimates stratified by key demographic characteristics 12
Prevalence of HSV-2 and co-infection with HIV 20
3.3 Coverage of HIV testing, care and treatment services
HIV testing 21
Reasons for not testing for HIV 21
Knowledge of status among person with HIV 22
Coverage of cotrimoxazole 23
Coverage of antiretroviral therapy based on CD4 distribution 24

Next Steps
4.1 Dissemination of final results 26
4.2 National programmatic response 26

Glossary of Terms 27

1
LIST OF ABBREVIATIONS
AIDS Acquired immunodeficiency syndrome

AIS AIDS indicator survey

ANC Antenatal care

ART Antiretroviral therapy

ARV Antiretroviral

CD4 CD4 T-lymphocyte

CSPro Census and Survey Processing System

CTX Cotrimoxazole

DASCO District AIDS/STI Coordinator

DBS Dried blood spot

GoK Government of Kenya

HIV Human immunodeficiency virus

HSV-2 Herpes simplex virus-2

IEC Information, education, and communication

KAIS Kenya AIDS Indicator Survey

KDHS Kenya Demographic and Health Survey

KNASP Kenya National HIV/AIDS Strategic Plan (KNASP)

NASSEP National Sample Survey and Evaluation Programme

PASCO Provincial AIDS/STI Coordinator

PMCT Prevention of mother to child transmission

SAS Statistical Analysis Software

STI Sexually transmitted infection

VCT Voluntary counselling and testing

2
 INTRODUCTION
1.1 Background
HIV/AIDS remains a major challenge in Kenya. Substantial regional variations in HIV
infection, low levels of HIV testing, couple HIV discordance, and ongoing epidemics of
sexually transmitted infections (STI) are important challenges in the control and
management of the HIV epidemic in Kenya.

The first identified case of HIV in Kenya was recorded in 1986. Since then, the epidemic and
the government’s mechanisms to monitor it have expanded greatly. While the highest rates
of infection were initially concentrated in marginalized and special risk groups, for more
than a decade Kenya has faced a mixed HIV/AIDS epidemic; new infections are occurring in
both the general population and vulnerable, high-risk groups. In 1999, the Government of
Kenya (GoK) declared the HIV epidemic a national disaster and established the National AIDS
Control Council (NACC) to coordinate the multisectoral response to HIV/AIDS.

Since 1990, Kenya has conducted yearly sentinel surveillance in pregnant women attending
ANC sites and patients attending STI clinics. Other sources of information on HIV/AIDS
include programmatic data from voluntary counselling and testing (VCT), blood donations,
antenatal clinics and tuberculosis clinics, and population-based data from the 2003 Kenya
Demographic and Health Survey (KDHS). In the past four years, Kenya has witnessed
considerable growth in funding of its HIV/AIDS national program from major global
initiatives. The growth and diversification in HIV/AIDS services in Kenya call for an
expansion of HIV and STI surveillance systems. UNAIDS and WHO recommend that a
representative sample of the general population be included in HIV surveillance systems in
countries with generalized epidemics to provide a) reliable measures of HIV prevalence for
women and men and b) information to calibrate the data resulting from the routine HIV
surveillance systems. The HIV epidemic is complex and dynamic, and a number of factors
can impact how prevalence rises and falls, including new infections, mortality due to HIV-
related illness, and availability of care and treatment.

KEY FEATURES OF KAIS 2007

ƒ Provides nationally-representative information about the HIV/AIDS epidemic
ƒ Almost 18,000 individuals from nearly 10,000 households participated
ƒ Includes older adults ages 50-64 for the first time in a national HIV survey
ƒ Prevalence of HIV, HSV-2 and syphilis; CD4 count in those with HIV
ƒ Reports coverage of HIV services including HIV testing and HIV care and treatment
ƒ Allows comparison of 2007 HIV prevalence with KDHS 2003 estimates

3
1.2 Overview of KAIS 2007
The AIDS Indicator Survey (AIS) was developed to provide countries with a standardized tool
for monitoring nationally-representative HIV/AIDS indicators in the general population. The
KAIS 2007 was the first AIS for Kenya and provides the most up-to-date information on HIV
and other sexually transmitted infections. The methods and findings build upon previous
population-based HIV estimates from KDHS 2003.

KAIS data collection included questionnaires, including a household survey and an individual
survey; biological testing based on venous blood samples; and return of test results to
respondents. Incorporating blood testing for HIV and other sexually transmitted infections
in the KAIS makes it possible to link socio-demographic, behavioural characteristics and
household-level indicators to biological outcomes. For the first time, KAIS provides
population-based information about CD4 cell counts among people with HIV. This
information helps to determine HIV/AIDS care and treatment needs. KAIS also partnered
with health facilities and health workers throughout the country to return results to KAIS
participants approximately 6 weeks after blood specimen collection. Participants were
counselled on the meaning of their test results and referred appropriately for follow-up
testing and care at local facilities.

Data from KAIS will be used to evaluate the national response to HIV/AIDS. It will also inform
HIV prevention and treatment efforts coordinated through the GoK.

1.3 Specific Objectives

ƒ Determine the magnitude and distribution of HIV, HSV-2, syphilis and in adults ages
15-64

ƒ Estimate HIV incidence through laboratory testing

ƒ Determine access to and unmet need for HIV/AIDS services

ƒ Describe socio-demographic and behavioural risk factors related to HIV and other STI

4
 Kenya AIDS Indicator Survey 2007 - Timeline
Completion of return
Launch of Successful completion of
of results exercise
KAIS data data collection (interview
KAIS study protocol
collection and blood draw)
approved by relevant Consensus
scientific and ethical meeting with
review boards international
stakeholders

June '07 July Aug Sept Oct Nov Dec Jan '08 Feb March April May June

July: Official release

of KAIS 2007 results
Begin returning test Complete data entry; begin by GOK
Training of interviewers, field data cleaning, merging and
results to KAIS
lab staff, field supervisors and weighting
participants
core lab staff
Begin preliminary
analyses

Figure 1. Timeline of KAIS 2007 activities, June 2007-July 2008.

5
DESIGN & METHODS
2.1 Geographic coverage and target population

The survey was conducted on a representative sample of households selected from the all 8
provinces and covered both urban and rural areas. Sampled, occupied households with a
consenting head of household of were eligible for the household questionnaire. Females and
males ages 15 to 64 who were usual residents of sampled residential households or visitors
present in the sampled households on the night before the survey were eligible to
participate in the study provided they gave informed consent. Potential participants could
consent to the interview and the blood draw or to the interview alone.

2.2 Sampling frame and design

The sampling frame for KAIS was the National Sample Survey and Evaluation Programme IV
(NASSEP IV) created and maintained by Kenya National Bureau of Statistics (KNBS). The
NASSEP IV frame was developed in 2002 and based on the 1999 Kenya Household and
Population Census. The frame has 1800 clusters, comprised of 1260 rural and 540 urban
clusters; of these, 294 rural and 141 urban clusters were sampled for KAIS. The sample
enables calculation of estimates of key indicators for each of the eight provinces, as well as
for urban and rural areas.

The overall design for KAIS 2007 was a stratified, two-stage cluster sample design for
comparability to the KDHS 2003. The first stage involved selecting clusters from NASSEP IV,
and the second stage involved the selection of households for KAIS with equal probability in
the urban-rural strata within the districts. A sample of 415 clusters and 10,375 households
were systematically selected for KAIS in order to achieve the power necessary to make the
estimates at the level of estimation desired by KAIS partners. A uniform sample of 25
households per cluster was selected using an equal probability systematic sampling method.
The sample size took in to consideration the level of non-response in the 2003 Kenya DHS.
Table 1 indicates the sample distribution for KAIS.

Table 1: Distribution of sampled clusters and households by province, KAIS 2007

Clusters Households
Province Rural Urban Total Rural Urban Total
Nairobi 0 58 58 0 1,450 1,450
Central 48 7 55 1,200 175 1,375
Coast 24 22 46 600 550 1,150
Eastern 50 5 55 1,250 125 1,375
North Eastern 23 5 28 575 125 700
Nyanza 54 7 61 1,350 175 1,525
Rift Valley 51 12 63 1,275 300 1,575
Western 44 5 49 1,100 125 1,225
Total 294 121 415 7,350 3,025 10,375

6
2.3 Data collection tools

HOUSEHOLD QUESTIONNAIRE INDIVIDUAL QUESTIONNAIRE

ƒ Household census
ƒ Parental survivorship
ƒ Household characteristics
ƒ Mosquito net use
ƒ Support for sick persons
BLOOD DRAW
ƒ Venous blood:
HIV, HSV-2, syphilis testing;
CD4 for those with HIV
ƒ Dried blood spot:
HIV testing only
ƒ Socio-demographic characteristics
ƒ Reproduction, fertility, and family
planning
ƒ Marriage and sexual partnerships
ƒ HIV/STI knowledge, attitude, behaviours
ƒ Uptake of HIV prevention, care and
treatment services
RETURN OF RESULTS FORM
ƒ Specific test results retrieved
ƒ Individual or couple counselling
ƒ Minors with or without parents
ƒ Referrals provided

2.4 Survey implementation

Training Over 200 skilled interviewers, laboratory
technicians and scientists, and field supervisors were I NTERVIEWER TRAINING
recruited in July 2007 and trained for 2 weeks. The
ƒ Interview technique
training involved both lecture-based and interactive,
ƒ Interview informed consent
with practical applications, mock interviews, and small ƒ Explaining KAIS diseases
group discussions.
ƒ Administering questionnaires
Interviewers were trained in interview techniques,
identifying eligible households and individuals, obtaining
informed consent, educating participants about HIV,
HSV-2 and syphilis, and administering the household L AB TECHNICIAN TRAINING
and individual questionnaires. Field laboratory ƒ Blood draw informed consent
technicians and scientists were trained in preparing ƒ Universal precautions
respondents for the blood draw, and specimen ƒ Sample collection
collection, processing, storage and transportation to ƒ Sample processing
the central laboratory. Trainers emphasized ways to ƒ Return of results vouchers
minimize risks in handling biological specimens. Lab
technicians were also trained to issue the return of results vouchers.

In September 2007, the Ministry of Health/NASCOP conducted intensive trainings for

counsellors/health workers involved in the return of test results. All counsellors/health
workers, regardless of their health care experience, attended. Nearly 200 counsellors were
trained for 1 week in educating participants about HIV, HSV-2, syphilis, and CD4 counts,

7
counselling them on their results and referring them and their partners for follow-up testing
and care.

Community sensitization The launch of KAIS was launched on August 1, 2007

marked the start of the national television, radio and print media campaign to educate
Kenyans about KAIS and the importance of broad participation. Mobilization efforts soon
shifted to interpersonal communications at the village level to raise awareness of KAIS as a
major GoK initiative.

M OBILIZATION AT THE COMMUNITY LEVEL WAS CRITICAL FOR ENSURING HIGH

SURVEY PARTICIPATION RATES AND THUS A REPRESENTATIVE SURVEY SAMPLE .

Fieldwork A total of 29 field teams each consisting of 6 primary data collectors

(interviewers and laboratory technicians), 1 supervisor and 1 driver throughout Kenya
conducted fieldwork over a period of 4 months from August to December 2007. Teams were
given local language questionnaires in addition to instruments in Kiswahili and English to
accommodate respondents not conversant in local languages. Completed questionnaires for
each cluster were packed and delivered to KNBS headquarters through secured courier
services for data processing.

The household questionnaire was first administered to the household heads or the most
knowledgeable members followed by interviews and blood draws among all eligible and
consenting individuals in participating households. Participants received an informational
brochure in two languages on HIV, HSV-2 and syphilis, the association between the diseases
and the value of knowing one’s HIV status.

Supervision Data collection teams were constantly supervised by teams of

coordinators representing KAIS partner agencies. These teams travelled the country to visit
with teams and deliver survey supplies, perform quality checks on questionnaires, assess
mobilization efforts and help address challenges to data collection. Supervision reports were
circulated among KAIS leadership and key issues were attended to immediately.

2.5 Laboratory logistics

Specimens were collected by the field laboratory teams working in different parts of the
country and shipped by secured courier services to the National Public Health Laboratory
(NPHL), three times a week. Each week, more than 600 samples from across the eight
provinces were received at the NPHL, logged into an electronic laboratory information
management database and then screened for HIV, HSV-2 and syphilis. All samples reading
positive for these infections as well as select negative samples were retested for quality
assurance at the KEMRI/CDC laboratory (Kenya Medical Research Institute/U.S. Centers for

8
Disease Control and Prevention, Nairobi, Kenya). NPHL quantified CD4 cell counts for all HIV
seropositive serum samples. Results between the two laboratories were cross-checked and
verified to ensure accurate results were dispatched to the field to share with participants. To
ensure samples collected in remote areas would be delivered to NPHL in a timely fashion,
KAIS partnered with a local airline to fly blood samples from the North Eastern province to
laboratory headquarters in Nairobi. Overall, 98.9 percent of whole blood samples and 99.8
percent of serum samples were of good quality for testing. Only 1.1 percent of whole blood
samples (used for CD4 counts) and 0.2 percent of serum samples (used for determining HIV,
HSV-2 and syphilis status) were rejected for testing.

2.6 Data processing and analysis

Data processing included a number of important steps to prepare the raw KAIS data for
analysis. The initial steps in data processing included: editing questionnaires, both in the
field and at KNBS headquarters, prior to data entry, and complete double-data entry of all
questionnaire responses to minimize error. Data were entered using Census and Survey
Processing System (CSPro) version 3.3. Once all survey responses were transferred to
electronic format, data cleaning began. The first step was to ensure 100 percent verification
between the two data entry databases, using paper questionnaires to resolve any
discrepancies. Next, a series of consistency and range checks were used to identify any
unreasonable responses and to verify that responses adhered to skip patterns. Data cleaning
programs were written in Stata version 8.0 and corrections were entered directly in CSPro.

As the survey data were cleaned at KNBS, a concurrent process of cleaning the raw
laboratory data by laboratory information management specialists was ongoing. The final
cleaned, combined questionnaire database was merged with the laboratory results database
using unique barcodes and study identification numbers to ensure the greatest accuracy.

All results presented in the report are based on weighted data. The weights were used to
correct for unequal probability of selection, to produce results that are representative of the
larger population from which the sample was drawn, and to adjust for non–response. The
final weights were derived from the design weights of NASSEP IV frame and adjusted for
non-response. Three weights were calculated for KAIS analysis: a household weight, an
individual survey weight, and a blood draw weight.

Preliminary analyses were conducted using SAS software version 9.0. SUDAAN and SAS have
procedures to account for the KAIS multi-stage stratified sampling design, and were used to
produce reliable standard errors and confidence intervals. Some data analyses of interest
were verified in Stata version 8.2, to ensure reproducibility across software programs.
Limited preliminary analyses covered response rates, overall prevalence estimates for HIV,
syphilis and HSV-2 (genital herpes); CD4 distribution; HIV testing and correct knowledge of
HIV status; and antiretroviral therapy and cotrimoxazole usage.

9
2.7 Return of test results
Returning test results to the field involved careful coordination between NPHL, NASCOP
officers across Kenya (PASCOs and DASCOs), local health facilities and individual
counsellors. At the time of specimen collection, participants were given vouchers that listed
facilities in the area where they could receive their test results six weeks after the blood
draw. Retrieving results was not required for participation in KAIS, but interviewers and lab
technicians were trained to educate participants on the benefits of knowing one’s disease
status. Results counsellors shared and explained results and also referred respondents who
required follow up to testing and treatment facilities. Tools were developed to capture the
number of participants who came for results and counselling.

KAIS – 2007
Kenya HIV/AIDS Indicator Survey

Your results will be ready for collection at:

1.

2.

Between: &

Time: Weekdays: 9am – 5pm | Saturdays: 9am – 1pm | Sundays: 2pm – 5pm

Today's Date

Male Female Affix Matching

KAIS Barcode
Cluster No.
Here
To ensure confidentiality of your test results, please keep this card in a safe 123456
place. You are encouraged to come with your partner to receive your test results.

Thank you for participating in the 2007 Kenya HIV/AIDS indicator survey

Figure 2. Examples of mobilization and educational materials and the return of results voucher
utilized during KAIS 2007.

10
PRELIMINARY RESULTS
3.1 Response Rates

Overall, participation rates in KAIS 2007 were high. Household response rates were
calculated as the number households consenting to the household interview out of the total
households occupied. Vacant, destroyed, or missing households were excluded from the
study. Individual interview response rates were calculated as the number of completed
interviews out of those eligible for the survey based on the household census. Only those
consenting to an interview could participate in the blood draw component of KAIS. Blood
draw coverage was calculated as the number of blood draws completed out of all eligible
individuals based on the household schedule. Blood draw response rates indicate the
number of successful blood draws out of those completing individual interview.

Blood draw coverage increased from 2003, by 7 percentage points among males and
females, by 4 percent points in rural areas and by 12 percentage points in urban areas. The
household and individual response rates in KAIS are similar to KDHS 2003.

Table 2: KAIS response rates by residence, Kenya, 2007.

Urban Rural Total

Eligible (occupied) households 2,198 7,107 10,025
Eligible individuals 5,367 14,483 19,840
Household interview response rate 95% 97% 97%
Individual interview response rate 86% 92% 91%
Blood draw coverage (out of eligibles) 74% 83% 80%
Blood draw response rate (out of interviewees) 86% 90% 88%

Participation in the rural areas was higher than in urban areas by an average of 5 percentage
points. This was in part due to a greater proportion of urban residents being absent during
the survey. This pattern is similar to what was observed in KDHS 2003.

Table 3: KAIS response rates by sex, Kenya, 2007.

Females Males Total

Eligible individuals 10,957 8,883 19,840
Individual interview response rate 94% 87% 91%
Blood draw coverage (out of eligibles) 83% 77% 80%
Blood draw response rate (out of interviewees) 88% 88% 88%

Participation among females was higher than among males by 6-7 percentage points. This
was in part due to a greater proportion of males being absent during the survey. This
pattern is similar to what was observed in KDHS 2003.

11
3.2 Prevalence of HIV

Prevalence is a measure of the total burden of disease, including new and old infections.
Prevalence can increase and decrease based on several factors including rate of new
infections, the mortality from a disease and the length of time people are able to survive a
disease based on available treatments. Results from KAIS indicate that 7.4 percent of Kenyan
adults age 15-64 are infected with HIV, the virus that causes AIDS.

According to the survey, more than 1.4 million Kenyans are living with HIV/AIDS.

In 2003, KDHS estimated a prevalence of 6.7 percent among 15-49 year olds. For the same
age group, KAIS estimates that 7.8 percent are infected.

Sex A higher proportion of women age 15-64 (8.7 percent) than men (5.6 percent) are
infected with HIV according to KAIS 2007. This pattern is similar to what was observed in
2003. This means that 3 out of 5 HIV-infected Kenyans are female.

The HIV prevalence rates among both women and men are higher than the rates observed in
2003. There is overlap in 95 percent confidence intervals (95% CI) for both women and men
as indicated below in Figure 3; the overlap is less striking among men, suggesting the
higher rate among men in 2007 may indicate a real increase since 2003. Additionally, in
2003, there were 1.9 infections among women for every one infection among men. The
current ratio according to KAIS is 1.6. (Note: Confidence intervals and other terms can be found in
the glossary on page 27.)

2003 KDHS
2007 KAIS
HIV Prevalence %

9.2
8.7 (8.3, 10.1)
(7.4, 9.9)

5.8
4.6 (5.1, 6.5)
(3.6, 5.5)

Female Male

Figure 3. HIV prevalence among females and males age 15-49 in KAIS 2007 and KDHS
2003 with 95% CI.

12
Age and sex For both females and males, HIV is occurring in all age groups. There
are, however, some differences in prevalence across the life span. Among youth age 15-24,
women are 4 times more likely to be infected than men (6.1 percent compared to 1.5
percent). A higher proportion of Kenyans ages 30-34 are currently infected with HIV than in
any other age category. The decline in prevalence among women after age 34, and among
men after age 44 could represent a decline in new infections in older age groups or an
increase in HIV-related deaths in these age groups. The burden of infections is statistically
higher among females than males until age 35 after which the ratio of male to female
infections starts to approach 1 to 1.

KAIS interviewed and tested women age 50-64 and men age 55-64 who have not been
included in past HIV serosurveys. This addition gives us new insight into the epidemic
among older Kenyan adults who have previously been considered low risk. Prevalence
among Kenyans age 50 and older is greater than among the youngest Kenyans; this may
reflect cumulative lifetime exposure to HIV.

20
Females
Males
16 Total
HIV Prevalence (%)

12

0
-19

-24

-29

-34

-39

-44

-49

-54

-59

-64
15

20

25

30

35

40

45

50

55

60

Age (years)
Figure 4. HIV prevalence and 95% CI among participants 15-64 years old by sex and 5-
year age categories, KAIS 2007.

13
Geography The distribution of HIV infections varies greatly across Kenya. Prevalence
remains the highest in Nyanza at 15.3 percent, more than double the national prevalence
estimate. Other provinces with rates similar to or higher than the national level are Nairobi
(9.0 percent), Coast (7.9 percent), and Rift Valley (7.0 percent). Prevalence in Eastern is 4.7
percent and in Central, 3.8 percent of the adult population is infected. North Eastern
province has the lowest adult HIV prevalence at 1 percent.

Kenya: 7.4%

Figure 5. HIV prevalence in

Kenya by province, KAIS 2007.

Because of different population sizes across provinces, prevalence estimates may not
provide the complete picture of HIV burden in a province. Though the proportion of infected
adults in the Coast and Nairobi is higher than the proportion in Rift Valley, the number of
infected adults in Rift Valley (estimated 322,000) was greater than in Coast (estimated
135,000) or Nairobi (estimated 176,000). Together, Nyanza and Rift Valley are home to half
of all HIV-infected adults.

The provincial estimates for HIV prevalence among 15-49 year olds in 2007 were similar
(within 1 percent) to estimates from KDHS 2003 for Nairobi, Central, Eastern and Western
Provinces. In 2003, no cases of HIV were detected in Northeastern province; in 2007 1.3
percent of participants (n=7) tested positive for HIV, though the figures are too small to
draw conclusions. The Coast experienced a striking increase in the proportion of adults
living with HIV; the proportion of HIV infected adults was 2.3 percentage points higher in

14
2007 than in 2003, representing a 40 percent increase in HIV prevalence. Similarly in Rift
Valley, the increase in HIV prevalence of 2.1 percentage points represents a 40 percent
increase since 2003.

20.0

16.0 15.1 15.4

2003 KDHS
HIV Prevalence (%)

2007 KAIS
12.0
9.9
9.3
8.0 8.1 7.4 7.8
6.7
5.8 5.3 5.7
4.9 4.9 4.9
4.2 4.0
4.0
1.3
0.0 0.0
Nairobi Central Coast Eastern NE Nyanza RV Western TOTAL

Figure 6. HIV prevalence among participants 15-49 years old in KAIS 2007 and KDHS
2003 by province.

Below in Figure 7, HIV prevalence estimates for Coast and Rift Valley Provinces are stratified
by sex to better understand the increases since 2003. Point estimates for HIV prevalence
increased from 2003 to 2007 in both provinces among women and men though the
increases were not statistically significant at the p<0.05 level.

12.0
2003 KDHS
Coast Rift Valley
2007 KAIS
HIV Prevalence (%)

8.9 8.5
8.1
8.0 7.4
6.6 6.7 6.9
5.8 6.0
5.3
4.8
4.0
3.6

0.0

Female Male Total Female Male Total

Figure 7. HIV prevalence in Coast and Rift Valley Provinces among females and males
age 15-49 in KAIS 2007 and KDHS 2003, with 95% CI.
Note: Standard errors for overall provincial estimates from KDHS 2003 are not routinely available.

15
Residence About three quarters of Kenyans live in rural areas of the country. Among
those ages 15-64, 7 percent are infected with HIV. In urban areas, the prevalence is 9
percent.

Infected
7%

Infected
9%

About 1 million rural About 400,000 urban

adults infected with HIV – adults infected with HIV -
70% of all HIV infections 30% of all HIV infections

M ORE THAN 1.4 MILLION ADULTS ARE LIVING WITH HIV/AIDS.

7 out of 10 HIV infected adults are rural residents.

Though the prevalence in rural areas is lower in urban areas, the greatest
burden of disease is in rural areas since most Kenyans live in rural areas.

Women age 15-64 are more likely to be infected than men in both urban and rural areas,
with 10.8 percent of urban females compared to 6.2 percent of urban males, and 8.2
percent of rural women infected compared to 5.5 percent of rural men.

Below in Figure 8, HIV prevalence rates among women and men age 15-49 are presented
based on data from KDHS 2003 and KAIS 2007. There appears to be a trend of declining HIV
prevalence among urban residents, though the declines are not statistically significant.
In contract, rural HIV prevalence appears to be on the rise among women and men.
The increase in HIV prevalence among rural males from 2003 to 2007 is statistically
significant (p-value<0.05), and represents a 58 percent increase in prevalent infections.
This increase may help to explain the overall increase in prevalence from 2003 to 2007.

16
 16
Urban Rural
12.3
2003 KDHS
11.1
HIV Prevalence (%)

2007 KAIS
12
10.0 9.2
7.5
7.5 8.7
8 6.4 7.4
5.7 5.6
3.6
4

0
Female Male Total Female Male Total

Figure 8. HIV prevalence among participants 15-49 years old in KAIS 2007 and KDHS
2003 by sex and residence, with 95% CI.

Education Women age 15-64 with higher educational levels have significantly lower
HIV prevalence than those with less education. Those with primary education have a
prevalence of 10 percent compared to 7 percent with secondary education and 4 percent
with tertiary education. Prevalence among women who have never attended school is 7
percent. For men, there is also a decrease in HIV prevalence with higher levels of education
but the differences are less pronounced and not statistically significant.

Marital status Marital status can be an important risk factor when exploring patterns
of HIV transmission in a population. In Kenya, nearly 2 out of 3 Kenyans ages 15-64 are in a
union (married or cohabitating). Two findings from the KAIS 2007 stand out (Table x below).
Kenyans in polygynous unions (one man, more than one woman) are more likely to be HIV
infected (11 percent) than those in monogamous unions (7 percent). Also, women who have
ever been widowed and women who are currently divorced or separated have high HIV
prevalence at 17-21 percent. This is especially relevant since the proportion of Kenyans
(both women and men) currently widowed has more than tripled since 2003. One hypothesis
is that the deceased partners of women respondents are likely to have died from HIV-related
illness after years of infection, since HIV is the leading adult cause of death among Kenyans
age 15-49. These women were potentially exposed to HIV for several years before their
partners died. The pattern is the same among men, though the number of reporting they
were currently widowed was too small to draw conclusions (n<25).

Other findings show that women and men currently in a union (married or living with
partner; monogamous or polgynous) have similar HIV prevalence rates. Among sexually-
active men, those who have never been in a union have a prevalence of 2.8 percent
compared to 7.4 percent among men currently in a union. The disparity is probably related
to age and cumulative exposure to HIV; those never having been in a union are much
younger than those currently in a union (median age 22 years and 36 years, respectively).

17
 Table 4. HIV prevalence among Kenyans age 15-64 who were tested, by sex and
marital status, KAIS 2007.
Female Male Total
Marital Status % HIV infected % HIV infected % HIV infected
Currently in union 7.8 7.4 7.6
Monogamous 7.1 7.0 7.1
Polygynous 11.2 11.4 11.3
Currently not in union 10.3 3.2 7.1
Currently widowed 20.7 19.3** 20.5
Currently divorced/
17.1 6.4* 13.7
separated
Never in union 4.7 2.2 3.3
Ever had sex 7.3 2.8 4.6
Never had sex 1.8** 1.1** 1.5**
Ever widowed 21.2 NA*** 21.0
*Married or living with partner ** n<25 observations *** Men not asked if previously widowed

The relationship between marital status and HIV prevalence has remained unchanged since
2003 among women, apart from some small, non-statistically significant differences.
Among males, the rate of HIV among polygynous males was significantly higher by 4
percentage points in 2007 (15.9 percent) than in 2003 (11.9 percent). Though not
statistically significant, men in monogamous unions also showed an increase in HIV
prevalence from 6.5 percent to nearly 8 percent.

Couples in Kenya Historically, having sex outside of marital relationships has

been considered “high risk” sex; given the maturity of the epidemic, however, it is important
to consider all unprotected sex with persons of unknown status as potentially high risk sex.
About two-thirds of HIV infected Kenyan adults report currently being in a union. Ten
percent of monogamous married couples and 14 percent of polygynous couples are living
with HIV, with one or more partners infected with HIV.

A MONG MARRIED INDIVIDUALS WHO ARE HIV INFECTED ,

45% HAVE A PARTNER WHO IS NOT CURRENTLY INFECTED .

Pregnant women According to KAIS 2007, nearly 1 out of 10 pregnant women in

Kenya are infected with HIV (9.6 percent) with minimal differences by urban and rural
residence. Rates among women who gave birth in the last 4 years is similar at 9.0 percent.
In KDHS 2003, HIV prevalence among pregnant women was 7.3 percent and 8.8 percent
among those who were not pregnant or were unsure of their pregnancy status

18
Table 5. HIV prevalence women age 15-49, by reported pregnancy status and recent
motherhood. Kenya 2007

Total Urban Rural

% HIV infected % HIV infected % HIV infected
Pregnant 9.6 9.8 9.5
Not pregnant 9.2 11.3 8.6
Unsure 7.6 3.0** 8.5
Birth in the last 4 years* 9.0 9.1 8.3
All females (15-49) 9.2 11.1 8.7

*Not exclusive from other categories ** n<25 observations

Circumcision Among men age 15-64, 85 percent are circumcised. The highest level
of circumcision is in Northeastern (97.2 percent) and the lowest level is in Nyanza (46.7
percent). Nationally, 73 percent of 15-19 year old men are circumcised; the rate of
circumcision increases in older age groups.

In all but the youngest age group, HIV prevalence is higher by 3 to 5 times in men without
circumcision than in men with circumcision. Among uncircumcised men 35-39 years of
age, 1 out of 3 is HIV-infected.

40 Circumcised
Uncircumcised
HIV prevalence (%)

30

20

10

- 19 - 24 - 29 - 34 -3
9
-4
4
- 49 - 54 - 59 - 64
15 20 25 30 35 40 45 50 55 60
Age (5 year categories)

Figure 9. HIV prevalence among Kenyan men ages 15-64 who were tested by
circumcision status, KAIS 2007.

19
Prevalence of HSV-2 and co-infection with HIV HSV-2 is a virus that
causes genital herpes. As with HIV, not everyone with HSV-2 has symptoms. There is no
cure for HSV-2; infection is life-long but usually not life-threatening. The presence of
genital herpes in a HIV-uninfected person increases his or her chances of acquiring HIV. In a
HIV-infected person, genital herpes increases his or her chances of transmitting HIV.

Overall, one-third (35 percent) of Kenyans age 15-64 are infected with HSV-2. Women are
more likely to be infected compared to men (42 and 26 percent, respectively). By age 25, 1
in 5 women are infected with HSV-2; half of all individuals age 35-64 are infected.
Among those with HSV-2, HIV prevalence is 17 percent.
Among those who do not have HSV-2, HIV prevalence is 2 percent.

Table 6. HSV-2 prevalence among women and men age 15-64 who were tested
TOTAL FEMALES MALES
% HSV-2 infected % HSV-2 infected % HSV-2 infected
Total 35.4 42.3 26.1
15-24 15.3 21.6 7.1
15-19 9.0 13.0 4.5
20-24 21.4 29.1 10.2
25-29 33.1 41.3 19.9
30-34 42.9 51.6 30.1
35-39 48.7 56.9 36.7
40-44 54.2 59.8 46.7
45-49 51.9 56.2 46.0
50-54 48.3 53.6 41.5
55-59 48.8 57.1 39.8
60-64 43.1 49.8 38.2
Urban 40.1 47.4 29.9
Rural 34.2 41.0 25.2
Nairobi 37.8 43.4 29.2
Central 28.0 34.0 19.9
Coast 39.7 49.9 29.3
Eastern 28.6 36.6 18.4
North Eastern 6.4 6.3 6.7
Nyanza 49.7 58.2 37.9
Rift Valley 32.9 39.3 24.7
Western 38.3 44.2 30.4
HIV-infected 81.0 84.2 74.5
HIV-uninfected 31.7 38.3 23.2

32% OF ADULTS WHO DO NOT HAVE HIV HAVE GENITAL HERPES

AND ARE AT INCREASED RISK OF ACQUIRING HIV

81% OF ADULTS WITH HIV ALSO HAVE GENITAL HERPES

AND ARE AT INCREASED RISK OF TRANSMITTING HIV.

20
3.3 Coverage of HIV Testing, Care and Treatment Services

HIV testing HIV testing uptake has tripled among women age 15-49 since 2003
and nearly doubled among men.
Ever Tested and Received Resutls (%)

2003 KDHS
50 2007 KAIS
43
40
36

30
25
20
13 14 14
10

0
Females Males Total

Figure 9. HIV testing uptake among Kenyans ages 15-49, by sex. KDHS 2003 and KAIS
2007.

Overall, 36 percent of Kenyans adults ages 15-64 have tested at least once for HIV and
received results. Nearly two-thirds of Kenyans report never having been tested for HIV, and
are therefore unaware of their status and may not access appropriate services for
prevention, care and treatment of HIV. Testing is particularly low among older Kenyans age
50-64; among this cohort, only 17.5 percent have tested for HIV. The disparity between
urban and rural areas is substantial: 50 percent of urban residents have tested for HIV at
least once compared to only 30 percent of rural residents. The increase in HIV testing
among women is in part due to PMCT services and testing in antenatal clinics. Nearly one-
third of women who reported having ever tested said they were tested at an antenatal clinic.

Reasons for never testing for HIV Among those who have never been
tested for HIV, the most common reason for not testing among both sexes was low
perception of risk (61 percent). This underscores the importance of ongoing campaigns to
improve knowledge about risk factors for HIV transmission and attitudes toward testing.
Sixteen percent have never tested because they did not want to know their test results or
were afraid others would know the results. A small but notable proportion of respondents
(14 percent) said they were unaware that there was a test for HIV or did not know how to
access testing. Five percent cited distance to the nearest known testing site as the major
barrier, which may suggest that mobile testing services should be given more consideration.
The cost of the test or the lack of access to or availability of treatment were very
infrequently cited as barriers to testing (<2 percent).

21
Knowledge of status among persons with HIV Testing for HIV is an
important step toward knowing one’s status but does not guarantee it. Repeated exposure
to HIV through unprotected sex or other modes of transmission means that repeat testing
for HIV is needed for accurate knowledge of one’s current HIV status.

Among laboratory-confirmed HIV-infected individuals in KAIS, 57 percent reported that they

had never tested for HIV. Another 26 percent reported themselves as negative based on
their last HIV test, but tested positive for HIV. It is possible that some of these individuals
knew their true HIV-infected status but were not prepared to share the result with the
interviewer. Together, these two groups (never tested for HIV, and tested but misreported
as HIV-uninfected) did not have correct knowledge of their HIV status and comprised about
80 percent of all HIV-infected participants.

Figure 10. Knowledge of HIV status among HIV-infected individuals age 15-64. Kenya
2007.

2% missing
16% correctly reported
HIV status

26% reported
themselves
57% never uninfected but
tested for HIV tested positive

A S MANY AS 4 OUT OF 5
HIV- INFECTED PERSONS DO
NOT KNOW THEIR STATUS .

*2 percent missing represents those who were laboratory-confirmed HIV infected but did not report
whether they had ever tested, or what the result of the HIV test was.

22
Coverage of cotrimoxazole The Ministry of Health recommends that everyone
diagnosed with HIV take cotrimoxazole (also known as Septrin), an antibiotic that reduces
the risk of early mortality by 25-46 percent as well as rates of hospitalization, malaria,
diarrhoea, and pneumonia.

The KAIS 2007 shows a large unmet need for cotrimoxazole. The great majority of unmet
need can be attributed to low level of awareness of HIV status among those infected with
HIV, as shown in Figure x below.

12% Need CTX, know

status, on CTX (8%-16%)

4% Need CTX, know

status, not on CTX
(2-6%)

84% Need CTX but do

not know their status
(80-88%)

Figure 11. Cotrimoxazole coverage among HIV-infected Kenyans age 15-64, Kenya
2007. Due to the small proportion of HIV-infected survey participants who know their status,
the number of persons answering the care and treatment module of the questionnaire was
small (n<200). Therefore, it is important to view these figures as approximations; reporting
ranges rather than point estimates may be more useful for planning purposes.

23
Coverage of antiretroviral therapy based on CD4 distribution
The measurement of CD4 cell counts is critical for planning current and future needs for HIV
treatment. The KAIS 2007 was the first ever national, population-based survey to measure
CD4 counts among people with HIV. The following results are based on CD4 testing done as
part of KAIS.

Table 7. CD4 count distribution among adults with HIV not on ART according to KAIS 2007.
Unweighted n Weighted % Projected population
estimate
<200 123 13.1 189,000
200-249 49 4.9 71,000
250-349 104 10.7 155,000
350-499 147 15.6 225,000
≥500 513 55.7 805,000

Among adult Kenyans with HIV who are not taking ART, 18.0 percent have a CD4 cell count
below 250 cells/mL indicating a clear need for antiretroviral therapy according to current
guidelines, an additional 10.7 percent have a CD4 cell count below 350, indicating they may
need therapy now, depending on their clinical status, or will need therapy in the near future.
The remaining 71.3 percent have CD4 cell counts greater than 350.

There were no notable differences in distribution of CD4 cell counts by age, sex, urban/rural
residence, education, or wealth indicators.

Antiretroviral therapy (ART) is the most effective intervention for prolonging survival in
people with HIV, and when taken regularly is associated with a 90 percent reduction in
mortality. ART is increasingly available in Kenya. Current guidelines from the Ministries of
Health recommend ART for all HIV-infected adults with CD4 cell counts less than 250
cells/mL, and for adults with WHO Stage 3 disease with CD4 cell counts less than 350
cells/µL or WHO Stage 4 disease regardless of CD4 cell count.

Figure 12. Proportion of adults

35% Need ART, eligible for ART who were
on ART taking therapy based on KAIS
2007 and Government of
Kenya population projections
63% Need ART, do 2007.
not know status,
not on ART
2% Need ART,
know status, not
on ART

24
As with cotrimoxazole, the majority of unmet need for ART can be attributed to not knowing
one’s HIV status. The figure above indicates that two-thirds of those eligible for treatment
cannot access it since they do not know their status. Of the estimated number of adults age
15-64 eligible for ART at the time of the survey (approximately 390,000), 35 percent
(approximately 140,000 persons) ) were taking ART. Of those eligible and not taking ART,
97 percent reported they had never tested for HIV or had a tested negative for HIV. Among
HIV-infected adults who knew their status, ART services appeared to be equitably reaching
the population in need, with few differences across socio-demographic characteristics.

The information presented here reflects coverage of ARVs among HIV-infected adults 15-64
at the time of the KAIS 2007 survey. At the end of June 2008, preliminary service statistics
reports indicated that approximately 190,000 HIV-infected Kenyan adults were receiving
ARVs. In addition to the number currently receiving treatment, the number of those in need
of treatment has also increased since the time of the survey. More up to date estimates of
ARV coverage are available through NASCOP.

25
NEXT STEPS
The preliminary results of KAIS 2007 presented here are only highlights of the complex HIV
and AIDS epidemic. In-depth analysis of KAIS data is ongoing and more comprehensive
results will be presented in the final report anticipated in January 2009.

4.1 Dissemination of final results

In addition to the information in this preliminary report, the main report will offer a broader
picture of the status of HIV/AIDS and related diseases in Kenya through a comprehensive
look at the all indicators included in the KAIS questionnaires. These include:

ƒ HIV prevalence and incidence estimates and relevant comparisons to KDHS 2003
ƒ Uptake and unmet need for HIV testing
ƒ Risk of acquiring HIV among the HIV- KAIS FINDINGS PROVIDE THE
uninfected
ƒ Uptake and unmet need for care and G OVERNMENT OF KENYA AN
treatment among the HIV-infected OPPORTUNITY TO IMPROVE THE
ƒ Co-infection with STI
ƒ Impact of HIV on households WAY IT ALLOCATES RESOURCES AND

PROVIDES HIV/AIDS PREVENTION ,

The report will be released to the public and
institutional stakeholders through a series of
CARE AND TREATMENT SERVICES.
national and regional dissemination events. Soon
after the report, fact sheets and policy briefs about each province and selected target
groups, such as youths and older adults, will be available through GoK partners and online
at www.aidskenya.org; www.health.go.ke; and www.nacc.or.ke.

4.2 National programmatic response

KAIS 2007 findings provide the strategic information the GoK needs to improve the way it
allocates resources and provides HIV and AIDS prevention, care and treatment services. A
key conclusion from these preliminary findings is that prevention efforts must be intensified
simultaneously with care and treatment scale-up. The GoK intends to respond to the low
awareness of HIV status among adult Kenyans with a series of intensified, rapid HIV testing
campaigns. Additionally, NACC is coordinating a review of the Kenya National HIV/AIDS
Strategic Plan (KNASP) and organizing a second HIV Prevention Summit at which an HIV
Prevention Task Force will be launched. Acknowledging the particular vulnerability of youth
to HIV and the opportunity to instil norms of safer sex practices early, NACC and other key
stakeholders have developed a Youth Strategy for HIV Prevention.

The 2007 KAIS is the first in a series of AIDS Indicator Surveys in Kenya. The next KAIS is
planned for 2011. The KDHS survey is scheduled to begin in late 2008.

26
GLOSSARY OF TERMS
Human Immunodeficiency Virus (HIV):
the virus that causes AIDS
Immunodeficiency Syndrome. The
passed from person to person through blood,
semen, vaginal fluids, and breast milk. HIV
replicates slowly; most of the time, several
years pass between initial infection and the
onset of symptoms. HIV attacks the human
immune system and leaves infected persons
very vulnerable to illnesses that are normally
eliminated by healthy immune systems.
Acquired Immune Deficiency Syndrome (AIDS):
AIDS is the final stage of HIV infection. It
represents the late disease stage
infection which usually results in damage to
the immune and other organ systems, leaving
the body very vulnerable to life-threatening
conditions such as infections and cancer.
HIV is patients with HIV who have low counts of CD4
(Acquired cells to help them fight HIV disease.
virus is
Cotrimoxazole: Also known as septrin. An
antibiotic used in the treatment of a variety of
bacterial infections. Kenya policy recommends
that Cotrimoxazole be given as prevention to
all people HIV to help avoid some
opportunistic infections and therefore extend
the length of a person’s life.
Prevalence: The number of cases of a given
disease (or other health conditions), in a given
population, at a designated time, expressed as
of HIV a percentage of all persons who can have the
disease. Prevalence can increase or decrease
over time depending on the number of new
infections, the rate of mortality, the availability
of treatment, and surveillance methods.

CD4 cells: A CD4 lymphocyte cell is a cell of
the immune system that carries the CD4
surface protein. CD4 cells are very important
to a normal health immune system. CD4 cells
attract HIV. HIV infects and kills CD4 cells,
leading to a weakened immune system.
Incidence: The number of new cases of a
disease in a defined population, within a
specified period of time, expressed as a
percentage among all person who can acquire
the disease. Incident cases make up a portion
of all prevalent cases.

HSV-2: Herpes simplex virus-2 or genital
herpes is a common, sexually transmitted viral
infection characterized by lesions (cuts) and
ulcers in genital areas. HSV-2 can be treated
but cannot be cured.
Syphilis: Syphilis is a curable sexually
transmitted disease. 3 weeks after exposure to
syphilis, a lesion appears on the genital area.
Secondary syphilis is characterized by a rash
on the body, arms and legs. Some people can
have latent syphilis which means they are
infected with syphilis but do not show signs or
symptoms of disease.
Antiretroviral therapy (ART): Medications that
stop or slow down viruses (like HIV) from
multiplying in the body and therefore extends
the length of a person’s life. ART is given to
Statistical significance: The probability that the
results observed during the study (or more
extreme results) was not likely to be due
to chance alone. The threshold for statistical
significance is an arbitrary value called a p
value which is usually set at 0.05 or 5%. If the
probability that the observed result was due to
chance is that less than the set p value, the
result is considered statistically significant.
95% confidence interval (95% CI): A confidence
interval gives a range of possible values (using
an upper and lower bound) within which the
true population value of a variable (e.g. the
mean, proportion, or rate) will fall 95 times out
of 100. It is a measure of certainty and
precision around the sample estimate when
estimating the true population value.

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