How Traditional Birth Attendants are Playing Key Role in Kenya’s Quest to Create a HIV Free Society

In a stunning turnaround, Kenya’s Homa Bay County, once grappling with the highest HIV rates in the nation, is now a beacon of hope. This inspiring transformation is due to community-driven strategies, paving the way for an HIV-free future. This dramatic decline isn’t due to advanced technology or groundbreaking medical treatments but rather the tireless efforts of 2000 traditional birth attendants. Could these community heroes be the key to conquering HIV across Africa?

Homabay County, located 321 miles southwest of Kenya’s capital, was among Kenya’s regions with the highest HIV/AIDS prevalence rates. In 2015, for instance, HIV prevalence in the county was nearly 4.5 times higher than the national prevalence at 26.5 percent, contributing 15.1 percent and 14 percent of the total new HIV infections in Kenya among children and adults, respectively.

But recently, the county has slowly been changing the narrative through various interventions, among them encouraging hospital births for pregnant women. The 2023 estimates by the National Syndemic Diseases Control Council (NSDCC) show a decline in the county’s HIV prevalence rates to 15.2 percent in 2022.

Notably, the county’s new HIV infections have been steadily declining, from 15,757 in 2013 to 1,495 as of 2022, with HIV-related deaths significantly reducing to 1,260 people in 2022, from 4,867 in 2013. In the 2023 national HIV/AIDS estimates, Homabay was among eight other counties that had cut new infections by up to 49 percent.

The success story

One of the critical successful interventions in Homabay’s quest to create an HIV-free society is ensuring that all pregnant mothers give birth in health facilities under the Prevention of Mother to Child Transmission (PMTCT) of the HIV Programme. Justus Ochola, who is in charge of research and innovation in the county Department of Health, says a lot of work has gone into the success of the county’s PMTCT programme.

‘This programme is critical in our endeavour to completely achieve zero HIV infections among children and infants by 2027, and ultimately towards our goal of having an HIV-free society,’ he explains. The county’s cases of mother-to-child transmission (MTCT) of HIV were at 5.3 percent in 2023, compared to 8.7 percent in 2022, against a global target of below five percent. Ochola observes that key in this achievement have been the traditional birth attendants, whose role is to refer pregnant women, who turn to them for delivery services, to hospitals.

Homa Bay County has enlisted 2000 traditional birth attendants who are paid a stipend of 200 shillings (USD 2) for every pregnant mother they refer to a health facility during childbirth. ‘We have trained all traditional birth attendants on the need of having women give birth under the care of a trained and qualified healthcare worker. This is key in reducing new infections through childbirth,’ he notes.

Why hospital births

Ochola observes that pregnant women delivering in hospitals significantly reduced the risk of HIV transmission from mother to child during labour and birth. According to him, the PMTCT programme has seen a surge in the number of women giving birth in hospitals to 78 percent in 2023, from 48 percent in 2012.

‘Home delivery increases chances of mother-to-child transmission because the blood of the foetus mixes with that of the mother during childbirth. We not only encourage mothers to give birth in hospitals but also to start early antenatal clinic visiting labour we do HIV testing, and if the mother tests positive we take precautions to keep the baby safe,’ he says

Grace Atieno is among the many traditional birth attendants the county has employed. She says the knowledge they received through training and empowerment by the county government has made them appreciate the critical role of hospital births in the fight against HIV/AIDS. ‘Through our community work, we have seen an increase in the number of mothers coming to hospitals and giving birth to HIV-negative and healthy babies,’ she says.

She adds, ‘Part of our work is also to encourage pregnant women to start early clinics because this is key in identifying those who are HIV positive and ensuring that they are put on treatment to protect their babies from transmission.’

In 2012, while pregnant with her second child, Elizabeth Atieno, 29, made her first antenatal clinic visit to the Rachounyo East sub-county hospital after being advised by a traditional birth attendant.

To her shock, she tested positive for HIV against her expectations.

‘I had visited a traditional birth attendant for a traditional massage when she advised me to visit a nearby hospital. It was then that I was tested for HIV, and the test came out positive. I was immediately put on antiretroviral treatment, which helped me deliver an HIV-negative baby,’ she says.

During her first pregnancy, Atieno says she never attended antenatal clinics and gave birth at home with the assistance of a traditional birth attendant. Unknown to her, the child was born with the virus. She says the realisation that she had infected her child with the virus hit her hard, and at some point, she thought of committing suicide. ‘I regret because had I known the importance of antenatal clinic visits and the need of giving birth in hospital, my firstborn would be negative,’ she notes.

She was placed under the PMTCT programme, which saw her give birth to an HIV-negative baby. ‘I was placed on antiretroviral therapy (ART) and followed the doctor’s instructions during the pregnancy and after birth.’ ART helps in suppressing HIV viral load in pregnant women. A high viral load increases the risk of perinatal transmission.

Mother-to-child transmission

Mother-to-child or perinatal transmission of HIV happens when the virus is passed from mother to child during pregnancy, childbirth or breastfeeding. The success of a vibrant PMTCT programme has been cited as a vital contributor to the drop in HIV prevalence rates in Homa Bay. According to Ochola, the county is working to bring its mother-to-child transmission (MTCT) HIV rates to below 2.5 percent.

‘Currently, we are at 99 percent of testing all pregnant mothers across the county, with the remaining one percent constituting the ones who go to private hospitals where HIV testing is not done, or those who do not go to a hospital,’ he observes.

Judith Atieno, an HIV-positive mother, acknowledges that giving birth in a hospital under the programme helped her deliver an HIV-negative baby in 2019, two years after testing positive.  ‘When I got pregnant, I battled the fear of giving birth to an HIV-positive child, and because of the stigma, at some point, I stopped going to the clinic and opted to use a traditional birth attendant’s service during birth. However, when labour knocked, she insisted that I must give birth in a hospital, and as it turns out, this saved my baby,’ Atieno says.

Judith notes, ‘The good thing about the programme is that it walks with you throughout the pregnancy and post-natal.’

The Approach

Homa Bay County has a total of 218 health facilities which offer HIV testing and ART services, something Ochola observes has been vital in achieving a higher testing rate. Under the programme, pregnant HIV-positive mothers are encouraged to make eight antenatal clinic (ANC) visits as opposed to the usual four.

‘With eight ANC visits, we can do close and consistent monitoring to guarantee the baby’s safety during pregnancy and at birth,’ he explains. To further widen the scope of the programme, the county is also taking testing to the community through the integrated community approach. ‘We have vulnerable pregnant women who don’t visit hospitals, and the only way to reach them is through door-to-door visits and moonlight testing, which targets minority groups like sex workers,’ he says.

The UNAIDS has set targets for HIV epidemic control at 95-95-95, which aims at having 95 percent of all people living with HIV diagnosed, 95 percent of all HIV-positive persons put on treatment and realizing 95 percent of HIV viral suppression. In Homabay, Ochola confirms that the programme has helped realise 96 percent identification, 97 percent treatment and 94 percent suppression thanks to the increase in the number of pregnant women visiting hospitals. ‘Only five percent of women in Homabay County are yet to know their HIV status,’ he asserts.

Early testing and retention

Leonard Okumu, a clinical officer and AIDS and STIs Coordinator (CASCO) in the Kabondo sub-county, opines that early testing on pregnant mothers has been vital to the success of the programme. He says that under the test-and-treat approach, those found to be HIV positive are immediately put on treatment to prevent the risk of mother-to-child transmission.

‘Those at risk, including sex workers and those with multiple partners or those suspicious of their partner’s sexual lives, are put on Pre-exposure prophylaxis (PrEP) to protect the mother from new infections. ARVs help suppress the virus and enhance the mother’s immunity while protecting the baby from infection by reducing chances of mother-to-child transmission.’

One key thing in ensuring the success of the programme, according to Okumu, is monitoring drug adherence and retention of positive mothers. ‘Support groups and peer educators have played a big role in helping us achieve high retention levels, and with free ART services, the uptake of ARVs has also gone high.’

Kabondo sub-county reproductive health Carolyne Atieno notes that early antenatal clinic visits help identify HIV-positive mothers, with testing done from the first trimester to the day of delivery. ‘For mothers who test negative on the first test, we normally re-test continuously for up to six months while promoting the use of PrEP to avoid possible infections.’ She says they also encourage couples testing, explaining that early treatment improves the well-being of pregnant mothers and prevents infection of babies. 

Country Status

According to the World Health Organization (WHO), in the absence of intervention, the rate of transmission of HIV from a mother living with HIV to her child during pregnancy, labour, delivery or breastfeeding ranges from fifteen to 45 percent. They cite pregnancy and breastfeeding as the periods of high risk of transmission.

In Kenya, according to the National AIDS and STI Control Programme (NASCOP), five percent of mothers are newly infected with HIV during pregnancy and seventeen percent during breastfeeding, which poses increased risks of transmission to the infants. NASCOP notes that 21 percent of mothers who are pregnant or breastfeeding and living with HIV do not receive antiretroviral therapy (ART), and 47 percent drop off of ART

 In September 2023, the Ministry of Health launched an action plan dubbed Kenya Plan to End AIDS in Children by 2027. The plan seeks to, among other things, stop new HIV infections among children. In the past decade, Kenya’s HIV infections have reduced by 57 percent, while AIDS-related deaths decreased by 68 percent.

Kenya is home to 1.4 million people living with HIV, and an impressive 98 percent of them receive antiretroviral treatment. Over the past decade, Kenya has substantially reduced new HIV infections by 78 percent, thanks to the hard work and dedication of healthcare professionals and advocates. The number dropped from 101,448 in 2013 to 22,154 in 2022.

Kenya’s mother-to-child transmission rate remains high at 8.6 percent, with treatment coverage of children living with HIV being at 85 percent, with approximately 74 percent of those virally suppressed. Ochola is optimistic that with the existing interventions, Homa Bay County will lead the country in eradicating HIV among children by 2027.

‘Homa Bay is getting it right, and we will keep working to close the gap,’ he concludes.

Edited by Pius Okore.