Sentinel surveillance for HIV infection among pregnant women indicates that prevalence has declined significantly since 1998 in some but not all areas in Kenya. The decline is similar in magnitude to that experienced in Uganda in the 1990s but has occurred over a shorter period and started about seven years later than in Uganda. This trend is corroborated by changes in reported sexual behaviour, particularly in the percentage of men and women reporting more than one partner. In our estimates of trends in HIV prevalence for all adults we assume that the ratio of female to male prevalence has remained constant since the early 1990s at about 1.9 as reported in the 2003 KDHS. If it has actually increased during this period, then the decline in national prevalence would be even greater.
The decline is occurring partly because deaths due to AIDS have reached very high levels, around 130
000 per year, as a result of high incidence in the mid‐1990s. Thus about 10% of infected adults are dying each year. New infections are adding about 6%, or 80
000 people to the infected population each year. Before 2000 there were still more new infections than deaths, but since 2000 the situation has reversed.
Prevalence among pregnant women was already at high levels in some sites when the HIV surveillance system started in 1990 (19% in Kisumu, 17% in Busia, 10% in Mombasa). Prevalence continued to increase or remained stable in most surveillance sites throughout the early and mid‐1990s. There is now evidence that prevalence has declined sharply since the late 1990s in many parts of the country. The recent declines appear to have resulted from significant behaviour change in the Kenyan population. The causes of this change are unclear. Kenya has not benefited from many of the factors that are thought to have contributed to prevalence decline in Uganda: the strong advocacy of President Museveni, the work of The AIDS Support Organisation (TASO) and other organisations with families living with HIV/AIDS, the advocacy of prominent individuals living with HIV/AIDS such as Philly Lutaya, and the involvement of church officials in speaking about AIDS from the pulpit and at funerals. These factors helped to create the conditions in which people communicated with friends and family about AIDS and ultimately adopted safer behaviours.
While recognition of the problem of AIDS arose later in Kenya and the involvement of the government, community groups, and the church has lagged, significant changes have occurred in recent years. The government passed an AIDS policy in 1997,17
declared AIDS a national disaster in 1999, and established the National AIDS Control Council to coordinate the response. While condom promotion has always been strong in Kenya, new prevention services have expanded rapidly in recent years. Voluntary counselling and testing (VCT) services were used by about 200
000 people in 2003 and services to prevent transmission of HIV from mother to child were offered to 120
000 pregnant women. Antiretroviral therapy is now being provided to about 20
000 people. These and other actions may have contributed to a more open environment that supported greater discussion of AIDS as the number of deaths become too large to ignore.
There is strong evidence that adult HIV prevalence is declining rapidly in parts of Kenya. The declined started in the late 1990s in some parts of the country and has spread to more areas since then. Kenya now deserves to be mentioned along with Uganda as a country that has achieved decline in prevalence.
It is clearly encouraging to see that HIV prevalence has started to decline in another sub‐Saharan African country in addition to Uganda. More work is needed to understand the role of behaviour change in this decline and the causes of behaviour change. A better understanding of the causes of change in Kenya can be used to support and enhance these positive behaviour changes and produce continued decline in the number of new infections in the future.