When the human papillomavirus vaccine was introduced in Kenya in 2019, it presented an opportunity to deal a death blow to cervical cancer, the second most frequent cancer among Kenyan women (after breast cancer), and the leading cause of cancer deaths among women in Kenya.  

The human papillomavirus (HPV) accounts for 99.7% of all cervical cancer cases, and two strains of the virus – HPV 16 and 18 – are among the vaccine-preventable subtypes contributing to over 70% of all cervical cancer cases. Together, HPV subtypes (strains) also contribute to other cancers: 91% anal cancer, 70% oropharynx ( throat) cancer, 75% vagina and vulva cancer in women and 63% penile cancer in men.

Globally, the first HPV vaccine became available in 2006. In 2019 after a pilot in Kitui County, Kenya rolled out the vaccine nationwide as part of the routine immunisation schedule for girls aged 10 – 14 years, with a target uptake of 80%.

While acceptance for the vaccine during the pilot phase was 85%, the uptake of the vaccine since then has been suboptimal with only 29% of girls getting the first dose and only 44% getting the second dose.

The rollout of the vaccine faced opposition from a section of doctors allied with the Kenya Catholic Doctors Association who opposed the vaccine on grounds of safety and morality as HPV is transmitted through sexual contact and was contrary to the church teachings which promote abstinence. Early adolescence is considered the optimal age of vaccination to prevent possible HPV infections as numerous studies that shown that early sexual debut (sexual intercourse at or before the age of 15 years ) is common, as the high number of teenage pregnancies (over 13,000 girls dropping out of school annually) and the the rise in the number of new HIV diagnoses among adolescents indicates. The early sexual debut (ESD) is most likely to be involuntary, forced, coerced, or unplanned and is, therefore, more likely to occur without the use of condoms or other modes of contraception, which increases the risk of HIV/STIs, unplanned pregnancies and raises the risk of HPV infections.

The then Health Cabinet Secretary Sicily Kariuki responded to the doctors’ concerns and assured them that the government would not introduce something harmful to its citizens.

“The HPV vaccine is not new and has undergone the requisite research by the WHO and I would therefore like to appeal to sections of Kenyans to stop sensationalizing this important issue.

“No government, anywhere in the world,  would jeopardise the health of its citizenry by introducing a countrywide initiative which has not undergone the necessary research and peer review,” she observed.

During the launch of the vaccine, Dr Rose Jalang’o of the National Vaccines and Immunisation Programme said the human papillomavirus (HPV) vaccination would target adolescent girls aged 14 years and thereafter continue vaccination routinely targeting those aged 10 years.

“Since HPV vaccines are prophylactic, the largest impact of vaccination on the incidence of cervical cancer is expected to result from high coverage of young adolescent girls before first sexual contact,” Dr Jalang’o noted.

Cervical cancer is the second most common cancer in women aged 15 years to 44 years.

Cervical cancer ranks as the 1st leading cause of cancer deaths of female cancer deaths in Kenya.

Every year, 5,250 women in the country are diagnosed with the disease, and about 3,286 cervical cancer deaths occur annually. At the same time, 10.3 million women aged 15 years and above are at risk of developing the disease. The HPV vaccine was projected to reduce the incidence of cervical cancer from an expected increase of  7,057 cases per year with 4,869 (69 per cent) annual deaths by 2025.

The HPV vaccine rollout coincided with the beginning of the COVID-19 pandemic in 2020, which itself was rife with misinformation. Due to its scale across the globe, fighting misinformation about the pandemic was prioritised and little effort was put into debunking the misinformation about the HPV vaccine. There was barely any community engagement to create awareness of the vaccine, educate communities and debunk the misinformation that had taken root.

Research published in March 2023 on the challenges affecting the uptake of the HPV vaccine highlighted misinformation as a key challenge that contributed to and worsened vaccine hesitancy and refusal. The researchers noted that “vaccination in Kenya has a fake news problem.”

Community health volunteers who were mobilising parents and guardians to take their girls for vaccination came face to face with vaccine hesitancy, fueled by what people had heard from various sources. One parent told Winnie Adera, a community health volunteer based in Kakamega, that a priest had told their congregation not to take girls for vaccination, quoting a misleading article that claimed the vaccine contained contraceptives.

‘The parents believe all sorts of things about how the vaccine works and the motivation of the government. It is very challenging to convince some of them, but we keep doing outreach and creating awareness on its importance with some level of success,’’  said Adera.

One of the contentious issues was the vaccination of girls aged 10-14 years. HPV is transmitted during sex, so doctors affiliated with the Kenya Catholic Doctors Association said it was unnecessary and morally inappropriate to vaccinate girls, and added that vaccinating them would encourage sexual activity. The other claim was that the vaccine would affect the fertility of girls, keeping them from ever having children in adulthood.

Why it’s best to vaccinate girls

The truth of the matter is that vaccination against HPV should ideally occur prior to the onset of sexual activity because it offers a defence against the cancer-causing strains of the virus before a person is exposed to it.

According to Dr Angela Migowa, a paediatrician and assistant professor at Aga Khan University, since HPV has been directly linked to cancer and is spread through sexual contact, prevention is better than cure. She adds that vaccination is key in mitigating the cancer-causing effects of HPV 16 and 18.

In Kenya, where a population of 16.8 million girls and women aged 15 years and older are at risk of developing cervical cancer if exposed to cancer-causing strains, estimates published in March 2023 indicate that every year 5,236 women are diagnosed with cervical cancer, the second most frequent cancer among women after breast cancer. Further, 3,211 women die from the disease, which is the leading cause of cancer deaths among women in the country.

Nearly one in 10 women (9.1%) are estimated to harbour HPV-16 or 18 infections at any given time, and 63.1% of invasive cervical cancers are attributed to these two strains, which can be vaccinated against and treated, thus greatly reducing the incidence of cervical cancer.  Therefore, it is best to offer girls and women a defence before they are exposed to the virus.

“The opportune time is before sexual debut, that’s why early vaccination is proposed. You can start as early as nine years for both boys and girls, even though in Kenya the focus is more on girls because of the worrying incidences of cervical cancer. Boys need the vaccine too to protect them from penile cancer,” says Dr Migowa.

In addition, the vaccination of boys is important because of the role men play as asymptomatic carriers of the virus, meaning they rarely suffer from the infection but they can transfer the virus to women.

The HPV vaccine works by training your immune system to recognise and fight the human papillomavirus (HPV). The vaccine contains surface identifiers of the virus, which are unique to HPV, and through the vaccine, via an injection, your natural defence/immunity develops antibodies against the virus. These antibodies stay in your body, ready to defend you against the real HPV if you come into contact with it. As a result, the vaccine protects you from developing HPV-related diseases, including certain types of cancer.

How the HPV vaccine works

Getting vaccinated before you’re exposed to HPV is the most effective way to prevent infection and the potential health problems it can cause. It’s an essential tool in reducing the risk of cervical cancer and other HPV-related diseases.

“This then ties in with the issue of age. The opportune time to introduce this vaccine is before the person of interest has any contact with the virus because we don’t want the virus to get into any of their cells and cause uncontrolled multiplication,” says Dr Migowa, adding that while individuals between the ages of 26 and 45 can also get the vaccine, they should consult their doctors to make sure they have not been exposed to the virus before they get the vaccine.

Vaccine effectiveness

The KEN SHE study conducted in Kenya and published early this year revealed that a single-dose HPV vaccine is highly effective in preventing persistent infections of the virus over three years. Bivalent vaccines, which protect against two subtypes of HPV, have a 98% efficacy, while the nonavalent vaccine, which protects against nine strains including those that cause cervical, vulva, vaginal and anal cancer, has an efficacy of 96%.

More than 98% of recipients develop an antibody response to the HPV types covered by the vaccines within one month after completing the series, and the effectiveness of the vaccine remains above 90% with no waning of immunity through at least 10 to 12 years after immunisation.

Gardasil 9, the nonavalent vaccine, protects against nine different HPV subtypes, including those responsible for the majority of cervical cancers and genital warts. It is administered to both boys and girls in a series of two or three doses depending on the recipient’s age. For example, individuals aged 9 to 14 receive a two-dose series, with the second dose given six to 12 months after the first. For those aged 15 to 26, a three-dose series is recommended, with the second dose given two months after the first, and the third dose given six months after the first.

Cevarix is the bivalent vaccine which protects against HPV 16 and 18 responsible for a significant portion of cervical cancer. It is primarily recommended for adolescent girls and young women as a preventive measure against cervical cancer and is typically given in two or three doses depending on the age of the recipient. Like Gardasil, Cervarix is administered in a series of injections with a typical dosing schedule involving three doses — the second dose is given one month after the first and the third dose is administered six months after the first.

HPV and cervical cancer

When HPV enters the body through sexual contact, during vaginal, anal or oral sex, it infects the outermost cells on the skin and mucous membranes in these areas. In some cases, the virus can make these infected cells change and grow abnormally. Over time, these changes can lead to the development of pre-cancerous cells. If the pre-cancerous cells are not detected and treated, they can become cancerous. This means they start growing uncontrollably and invading nearby tissues. If not caught and treated early, cancer cells can spread to other parts of the body, causing more serious health problems.

Dr Edward  Sang, a gynaecologist and oncologist, explained that while not all HPV infections lead to cancer, as most HPV infections go away on their own without causing any issues, it is important for people to have regular check-ups and screenings.

“The HPV vaccination can help prevent any potential problems early, reducing the risk of cancer. Since the vaccine is readily available in Kenya, we can reduce the numbers of cervical cancer incidences by getting vaccinated,” he said.

Dr Sang recommends that women go for regular Pap smears, a screening test for precancerous and cancerous cells in the cervix, and urges those with other pre-existing conditions such as people living with HIV and other forms of depressed immunity to get the vaccine as it is beneficial to them.

Addressing misinformation

In December 2022, the Clinton Health Access Initiative launched a 100-day HPV immunisation campaign to boost the uptake of the vaccine. They published a report that showed that first dose coverage increased from 56% at the end of November 2022 to 71% at the end of February 2023, while the second dose coverage increased from 27% to 38% in the same period.

The lower uptake of the second dose is usually due to the effects of the immune response after receiving the first dose of the vaccine. Some people have a reaction such as pain, reddening, or swelling at the site of injection, or experience fever. This is not unique to the HPV vaccine; it happens with other vaccines, but these reactions play a role in the low uptake of the second dose because, without the right information, they further fuel misinformation. A study by Kemri published in April 2023 found that a single-dose HPV vaccine is effective over three years.

2023 KEMRI Study

Eric Mugendi, a fact-checker with expertise on misinformation on health issues, says that a lot of misinformation comes from well-meaning people who think they are spreading genuine and credible information, but there are also people who spread false information with a malicious agenda. For this reason, people countering misinformation should amplify the science and facts, showing the benefits of the vaccine in improving the quality of life and showing how it has worked by decreasing incidences of disease.

“The success of campaigns like the polio and COVID-19 vaccine campaigns can be attributed to information that amplified the real consequences of not vaccinating against these types of diseases,” says Mr Mugendi, adding that comparing the deaths of people who were vaccinated and those of people who hadn’t been vaccinated made it clear that the vaccine was working and reducing the number of deaths.

Mr Mugendi says that fighting vaccine misinformation requires word of mouth from people we know and trust.

“This improved vaccine uptake during the Covid pandemic as loved ones shared and encouraged their family members and friends to go for the vaccine as opposed to saying it is the government that wants you to get the vaccine,” he explains, adding that religious leaders can also champion communication about the vaccine because their audiences trust them.

Public service announcements and advertisements on television and radio also work, as do forums with knowledgeable medical practitioners where people can ask questions and learn the benefits of getting the vaccine and the consequences of not getting the vaccine.

Social media platforms like Facebook and Twitter, and messaging apps like WhatsApp have been predominantly used to spread health and vaccine misinformation, but Mr Mugendi says there’s currently no way to report health misinformation specifically because platforms haven’t identified it as deserving of its own category when people are reporting harmful content online.

“The best way would be to give people a way to report misinformation. As it is now, you report harmful or potentially harmful content like hate against specific groups of people. The platforms haven’t identified health misinformation as something deserving of its own category when people are reporting harmful content online. Consequently, it becomes really difficult to get posts or messages spreading false information to be taken down as someone could easily say this is my opinion and the way opinions are featured on these platforms, it becomes really hard to get anything that could cause harm to be taken down quickly before causing a significant amount of harm,” he says.

To deal with this, the World Health Organisation uses a social listening tool to find conversations on emerging public health crises and threats and puts out a report with factual information about the issue to counter false information.

While fact-checking has been beneficial in countering misinformation online, it’s only created a means to address individual posts rather than systemic problems when it comes to platforms like  X (formerly Twitter) where verified accounts (with a blue tick) get more visibility.

To address such, Mr Mugendi recommends responding to the motivations behind spreading false information and removing the ability to monetise false information by slowing down the flow of such information and holding those who post misinformation accountable so that they don’t get away with it.

Further, when discussing how vaccines work, Mr Mugendi says technical terms and jargon should be avoided, and experts should use analogies that communities can relate to, as well as testimonials, to breach psychological distance, especially if they have not seen or experienced consequences of the disease.

Compliance by people when it comes to vaccine uptake should be linked to the benefits and the protection it offers communities and not government-issued instructions.

“The reason why people believe misinformation on vaccines is because of the relationship we have to the institutions behind these vaccines, the companies, the agencies and the government agencies, especially, that are doing the work of trying to vaccinate people against diseases.

“The language in the publicity material should be simple, but not so simple that it loses meaning. It should include a lot of images and visual representations of exactly what you’re trying to communicate so that people who may not necessarily understand the language are still able to follow because they can look at the image,” Mr Mugendi concludes.

Campaigns to promote the uptake of vaccines in the face of misinformation or disinformation require an understanding of the community and their beliefs and perceptions, rather than dictating what they should do. Understanding their perceptions and needs can help shed light on the truth about vaccines without disrespecting their concerns. Building trust by working with the communities through their leaders can improve the uptake of vaccines by addressing concerns that could open up ways for misinformation to breed and spread.

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This story was written and produced as part of a media skills development programme

delivered by the Thomson Reuters Foundation. The content is the sole responsibility of the author and the publisher. The story has been produced with the support of the Africa Women Journalism Project (AWJP)

As of 30th June 670 million people experienced insufficient food consumption globally according to the World Food Programme’s Hunger Map.

Moreover, the findings from the 2023 Global Report on Food Crisis suggest that achieving the goal of ending hunger by 2030 is ever more challenging because the number of people facing high levels of acute food insecurity has increased for the fourth consecutive year. In 2022, nearly 258 million people in 58 countries or territories experienced a food crisis or worse acute food insecurity. Even though there has been an increase in the population analysed, this was the highest on record since the Global Report on Food Crisis (GRFC) began reporting these data in 2017.

This global food crisis is driven by three key factors – conflict, economic shocks and weather extremes – linked to the enduring socioeconomic impacts of Covid-19, the war in Ukraine and repeated droughts.

In Kenya as of 29th June a total population of 14.1 million experienced insufficient food consumption which is a 4.3 million increase from the previous month, according to the Hunger Map.

Although the country produces enough food to feed the population, economic access remains a challenge. Kenya’s rate of self-sufficiency in the production and availability of food is 90.3 per cent against an import dependency of 12.7 per cent, but on the four indicators of the Global Food Security Index in 2022, Kenya scored 41.3 per cent on affordability, the only indicator where the country scored below average.

With 8.9 million Kenyans (17 per cent of the population) living in extreme poverty – below 1.9 USD (Ksh 250) a day –and a hunger level score of 23.5 which is way above the recommended 9 or less, many Kenyans are going hungry because they can’t afford to it.

Frida Mmbone, a casual labourer at a tea farm in Kakamega, said that she earns Ksh250 per day, working six days a week. Her husband is also a tea picker at the same farm, earning a similar wage. Their combined income of Ksh500 can barely meet their needs and those of their four children, given that they spend Ksh425 on food alone. With 85 per cent of their income going to food, they barely have enough to meet other basic expenses like their children’s education, healthcare bills and clothing.

“We have a small piece of land, but it doesn’t produce enough maize to last us till the next harvest, so we have to buy 2kg of maize flour every day. We also buy half a litre of milk, a quarter kilo of sugar, a Ksh20 portion of cooking fat and paraffin worth Ksh30 every day.

“With the constant increase in the prices of basic commodities, we have been forced to do away with some things. Now we only make breakfast during weekends, and luckily three of the children are in high school so they have tea at 10 and lunch in school. My husband and I have tea at work and skip lunch to save on costs,” she said.

The current food crisis is a result of several factors, including drought following a sixth failed rain season. The increasing intensity and shorter cycles between droughts have affected crop yields for five consecutive seasons. Pastoralist communities have also lost substantial numbers of livestock due to malnutrition.

Key factors driving the global food crisis

These combined factors have led to the inflation of food prices limiting access and consumption of food staples.

According to the Kenya National Bureau of Statistics (KNBS), maize production in the country declined by 12.8 per cent from 42.1 million bags in 2020 to 36.7 million bags in 2021 and 34.3 million bags in 2022. Similarly, the volume of marketed milk decreased from 801.9 million litres in 2021 to 754.3 million litres in 2022 largely  due to drought that resulted in scarcity of fodder for livestock.

As a result of decreased production due to drought, Kenya’s maize imports in the first nine months of 2022 more than doubled to 519,611.30 tonnes (5.7 million 90-kilogramme bags), from 214,100.9 tonnes (2,378,899 90-kilogramme bags) during a similar period in 2021. This is the highest maize import since 2017. The shortage of the staple left 5.1 million people in need of relief food and pushed up retail prices of maize flour.

Similarly, Kenya imported rice worth $275 million, becoming the 32nd largest importer of the cereal in the world, and making it the 12th most imported product in Kenya.

In addition to the effects of drought on food security, the war in Ukraine has disrupted global food markets, leading to higher prices for wheat, maize, and other commodities. Kenya is a major importer of these commodities, so the war has had a significant impact on the country’s food prices.

The war has also contributed to higher costs of production by disrupting the supply chains of fertilisers which resulted in shortages, increasing demand and purchasing costs. In 2020 Russia accounted for 17 per cent of fertiliser exports to Kenya.

Given that food, followed by energy, is one of the key drivers of inflation in Kenya’s consumer price index, these factors have put pressure on food supplies, putting overall inflation at 8 per cent in May, and food inflation at 10.2 per cent, in the same month. Rising prices have reduced the purchasing power of consumers, who now have to spend twice as much as before on most food staples.

Available income to buy basic needs like food is also under pressure from policy adjustments driven by pressure from the International Monetary Fund, which has seen the government increase taxes on everything including cooking gas (with a new VAT of 16 per cent from the previous 8 per cent). These adjustments were passed in the Finance Act 2023, touted to be the way out of the country’s debt crisis and into self-reliance. The law has since been challenged in court and its implementation suspended pending the hearing of the case.

Kenya’s economy is yet to recover from the effects of the Covid-19 pandemic, which affected the tourism sector that contributed up to 10 per cent of GDP before the pandemic. As of 2022, there was a notable increase in tourism revenue by up to 83 per cent but it is yet to reach pre-pandemic levels. The pandemic also created bottlenecks in the supply chain contributing to inflation.

Further, the drastic depreciation of the Kenya shilling against the dollar has made the importation of food and raw materials necessary for food production more expensive. The shilling’s value against the dollar depreciated by an average of 0.6 per cent monthly since March 2020, plunged to an average depreciation of 4 per cent per month in January and February 2023, then 6 per cent in March. The shilling has lost more than 25 per cent of its value against the dollar, exchanging at Sh140 to the dollar, and this has pushed up the prices of imported goods.

In the midst of the crisis Kenyans have nowhere to turn for relief. Among all 113 countries assessed for the Global Food Security Index in 2022, Kenya had an average score of 26.8 on food safety net programmes, which was less than the average of 72.4 for other countries. Moreover, the country scored zero on funding for food safety net programmes, yet it scored 100 on dependency on chronic food aid, against an average of 65.5 for other countries that were assessed.

With 56 per cent of the world’s population living in cities according to the World Bank, a new study reveals how crucial urban farming is to food security, given that the urban population is projected to grow to nearly 70 per cent by 2050. In Africa, the rate of urbanisation is 47 per cent, while in Kenya it increases by 3.7 per cent annually, with the rate of rural depopulation raising concerns about food supply given that there are fewer people living and working in farms.

Dr Antonina Mutoro, Associate Research Scientist at the African Population and Health Research Center, said interventions to address the hunger crisis by promoting urban farming should be sustainable and scalable, rather than temporary. This would mean considering systemic factors and government policies in addition to individual efforts.

“There is only so much we can do because our environment is influenced by what is going on in terms of politics and government policies. I am thinking of people living in informal settlements; they need structures put in place by the government to ensure there is space or innovative methods of producing food in small spaces in urban areas, access to safe water and capacity and knowledge to produce food safely. This will ensure that regardless of whether you have an income or not you have a sustained source of food.

“That being said, there is a limited amount of food one can produce for their own consumption and it also limiting when it comes to growing maize our staple food in those small urban spaces,” she explained.

Given that affordability is a major factor driving hunger in Kenya where there is a high rate of unemployment among the youth, Dr Mutoro said that this should also be addressed to ensure that people can access food sustainably.

“There is need for systems that ensure that people have access to money to buy food through the government creating income-generating activities and promoting farming as a source of livelihood, especially among the younger population by reducing costs of farm inputs and ensuring markets are profitable to farmers rather than causing them losses.

“This can contribute to a consistent food supply and reduce reliance on imports,” she noted.

She added that youth should be supported to adopt farming as a source of livelihood, saying that the average Kenyan farmer is 61 years old and that is likely to have implications on food production in 20 or less years.

Besides promoting food security through food production, innovative solutions are needed to prevent food wastage and ensure that surplus food reaches those in need. For instance, APHRC through its Zero Hunger Initiative champions ensuring that food that is produced is transported from places where it is in excess to areas where it is needed the most. By preventing food wastage, food security can be improved without requiring increased production.

Given that adverse climate conditions, particularly in arid and semi-arid areas contribute to food insecurity through failed rains and drought, long-term planning should consider climate change and invest in innovative irrigation systems and other climate adaptation strategies to maintain sustainable food production despite environmental challenges. Learning from countries like Israel, which effectively produce food in desert conditions, can provide valuable insights.

Subsidies and trade-offs which have been contentious issues, also have the potential to alleviate the crisis while still making farming profitable and ensuring farmers receive fair compensation for their produce. However, the trade-offs and potential impacts on the industry and market dynamics should be carefully considered before implementing such policies. Comprehensive discussions involving all stakeholders are necessary to reach agreements that balance the interests of different parties, and long-term planning should be prioritised over the short-term focus of political agendas.

“It is essential to establish structures and frameworks that transcend individual governments. Long-term planning and consistent implementation of initiatives are crucial for sustainable solutions to address food insecurity in Kenya and other African countries. Shifting agendas with political changes limit the effectiveness and continuity of proposed interventions,” said Dr Mutoro.

The right to adequate food is realised when every man, woman and child, alone or in a community, has physical, social and economic access to adequate food or means for its procurement. It is the state’s obligation to not only respect but protect and facilitate the realisation of this right by ensuring during times of crisis like now there are social safety nets that aim to ensure a minimum amount of food consumption and protect households against shocks to food consumption. These safety nets should be integrated as part of a larger policy of sustainable economic development so they are not viewed as charity but as developmental and as a way of building resilience to shocks.

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This articlewas produced as part of the Aftershocks Data Fellowship (22-23)with support from the Africa Women’s Journalism Project (AWJP) in partnership with The ONE Campaign and the International Center for Journalists (ICFJ).

Comprehensive Sexual education in Kenya has been a topic of concern in recent years. The question of whether youth in Kenya are equipped with comprehensive sexual education has been raised by many stakeholders in the education sector. Responding to a recent article published by Nation Africa, the United Nations Population Fund (UNFPA) Director Technical Division Julitta Onabanjo said Kenya has withdrawn from the Eastern and Southern Africa (ESA) ministerial commitment to comprehensive sexuality education.

Ministerial Commitment to Sex Education.

This comes after the Kenya Demographic and Health Survey (KDHS) 2022 revealed in January that almost half of Kenyan adolescents aged 15-17 years do not know how to protect themselves from HIV/AIDS. Moreover, the percentage of girls and young women aged 15–19 years who have ever been pregnant is highest in Samburu (50%), West Pokot (36%), Marsabit (29%), Narok (28%), Meru (24%), Homa Bay (23%), Migori (23%), Kajiado (22%), Siaya (21%), and Baringo (20%), and lowest in Nyeri and Nyandarua (5% each).

Jane* (not her real name) is among the 41.6% of teenage girls aged between 15 -19 years who are sexually active and are not using any contraceptive according to the KDHS 2022. According to KNBS, only 11% of sexually active teenagers in Kenya are using contraceptives to prevent unintended pregnancies.

Source: KNBS

Jane falls under the other 89% who do not use birth control but are sexually active.  These teenagers lack basic information on their sexual and reproductive health. Jane, 17, who requested anonymity to speak freely, told The Elephant that she regrets her first sexual encounter, which happened in the dormitory with a boy in her school. She did it because of peer pressure.

“My friends were talking about it and how good it feels, so I wanted to fit in,” she disclosed.

Jane, however, said that she is not well-informed about safe sex and protecting herself against unintended pregnancy, HIV/AIDS and other sexually transmitted infections.

The little she knows has been gleaned from brief conversations with her mother, Sarah Nekesa, a single mother living in an informal settlement, who has on occasion mentioned that there is a right time to have sex. Jane’s mother has also advised her to use protection if she can’t wait for the “right time.”

Moreover, Jane’s mother has also told her that if she has a boyfriend, they should be tested (for HIV) before engaging in sex. However, her mother discourages her from using contraceptives at her age, which she says is too young. As  far as her mother who is staunch Christian is concerned, there is only one way that Jane can protect herself from getting infected or even pregnant—abstain from sex. What she does not know is that, apart from the incident in school, Jane has been engaging in transactional sex for several years. “I started sleeping with men who would give me money to buy pads and other essentials which my mother could not afford to give me,” Jane says.

“I could never talk to my mother about sex. I only did what I saw other friends my age do. After sex, I would take the morning-after pill (P2) to avoid pregnancy. The pills had some side effects. I experienced stomach pain and blood in the urine so I had to stop such activities. I didn’t use any protection, it is a relief I’m in good health,” Jane narrated.

A 2015 study by Guttmacher in three counties, namely Nairobi, Mombasa and Homa Bay found that most students in Forms 2 and 3 (96%) had received some sex education by the time they completed primary school, but the information received at this level is basic and does not include information on safe sex. Messages conveyed are often conservative and focused on abstinence. For instance, six in 10 teachers strongly emphasised that sex is dangerous and immoral and two-thirds strongly emphasised that abortion is immoral. Students said that the lessons focus on reproductive physiology and HIV prevention, and only 2% said they learnt all topics that constitute a comprehensive curriculum (including values and interpersonal skills, gender and sexual and reproductive health rights, contraception and unintended pregnancy).

Many curricula fail to provide adequate information about modern contraception – particularly, but not limited to, emergency contraception and female condoms – or HIV prevention through PrEP and PEP.

The inadequacy of education of children in practical matters of contraception and intercourse is often based on the belief that this information will encourage promiscuity, yet most students (93%) say sex education would be useful or very useful to their personal lives.

Yet abstinence-only programmes are still delivered in many countries despite robust evidence that this approach is ineffective. An increasing number of teen pregnancies in Kenya indicates that abstinence-only programmes are not effective. According to guidelines on sexuality education authored by six UN bodies (UNESCO, UNAIDS, UNFPA, UNICEF, UN Women and WHO), abstinence-only programmes are more likely to contain incomplete or inaccurate information regarding topics such as sexual intercourse, homosexuality, masturbation, abortion, gender roles and expectations, condoms and HIV.

The fact that Jane is sexually active but unaware of safe sex shows the risks that adolescents, especially girls who bear the brunt of teenage pregnancy, HIV infections and sexual and gender-based violence, face in the absence of comprehensive education about healthy sexuality.

A study conducted in Western Kenya in 2018 estimated that among 2.8 million girls aged 15-19 years, 24% (665,000) were sexually active and did not want a child, but were not using a modern contraceptive method. This age group accounted for 86% of all unintended pregnancies in the country.

Some of these girls are survivors of gender-based violence, including child marriage. United Nations Population Fund (UNFPA) estimates that Kenya’s child marriage prevalence rate is 23%. Child marriage is a driver of low education attainment, in turn limiting the employment and life options of girls. On the flip side, low education attainment also drives child marriage, fueling a vicious cycle.

These girls are further exposed to sexually transmitted infections. A study conducted in 2011 in the Rift Valley and Coast regions among HIV-positive adolescents aged 15-19 years found that about half had ever been tested and only a quarter of them knew their HIV status. Moreover, among sexually active HIV-positive adolescents, only a quarter reported using condoms at their first sexual intercourse. The study further found that two-thirds of HIV-positive girls had already begun childbearing or were pregnant, while 27% of boys had impregnated someone. In addition, 75% of pregnancies among HIV-positive girls were reported as unintended.

To equip young people with the information and skills needed for healthy sexuality in adulthood and to protect themselves from the risks that come with a lack of accurate and comprehensive information, UNESCO recommends that information on the cognitive, emotional, physical and social aspects of sexuality be included in the school curriculum. According to UNESCO, comprehensive sexuality education aims to equip children and young people with knowledge, skills, attitudes and values that will empower them to: realise their health, well-being and dignity; develop respectful social and sexual relationships; consider how their choices affect their own well-being and that of others; and, understand and ensure the protection of their rights throughout their lives.

Further, the Constitution of Kenya guarantees the right to the highest attainable standard of healthcare, including reproductive health, and the Health Act provides for an overarching legal framework for health. The law clearly supports Kenya’s commitments to the regional push for rights-based CSE in 2013, which includes several key goals. The ESA commitment calls for scaling up access to and quality of comprehensive sexuality education, increasing access to youth-friendly sexual and reproductive health services, eliminating all HIV infections, reducing early and unintended pregnancies, and eliminating gender-based violence and child marriage. These commitments are now on hold following Kenya’s withdrawal.

Comprehensive sex education has been opposed by various campaigners, such as the Commission for Education of the Kenya Conference of Catholic Bishops (KCCB) headed by Bishop Paul Njiru Kariuki. One of their campaigns titled Stop CSE said that the curriculum “is one of the greatest assaults on the health and innocence of children.”

The opposition to CSE, however, ignores clear evidence that CSE has a positive impact on sexual and reproductive health, notably contributing to a reduction in sexually transmitted infections, HIV and unintended pregnancy. CSE also improves knowledge and self-esteem, changes attitudes and gender social norms, and builds self-efficacy.

Purity Ngina, the evidence manager at Zizi Afrique Foundation, who recently completed a two-year survey of 17,000 teenagers aged 13-17 years in Kilifi County, said the survey revealed that only 16% have awareness of sexual and reproductive health.

“Many young boys think they can’t interact with girls because it is wrong and they will impregnate them. Lack of guidance and misinformation highly contributes to young people engaging in risky behaviours,” she said, adding that teenagers need to be trained to build decision-making and problem-solving skills, so they can make healthy decisions concerning their sexuality.

Ms Ngina added that the dissonance between what children are taught in church or at home and scientific information only leaves them confused.

“We hope that someone will use the Bible to train them on good morals and how our bodies change, but there is incongruence between science topics and what the adolescents are taught in church or by their parents at home,” she said.

Given the benefits of CSE on sexual and reproductive health, especially in reducing STIs, HIV and unintended pregnancy, it is vital for adolescents to receive proper education during this period of significant growth and development, filled with vulnerabilities. A good education presents a unique opportunity to foster better health outcomes as adolescents’ experiences likely shape their health behaviour throughout their lives. A 2020 study found that CSE programmes are highly effective, cost-effective and may even be cost-saving, especially if they are intra-curricular, nationally rolled out and jointly delivered with youth-friendly services.

This was evident in the results of a pilot study of more than 6,000 students who received sex education. The 2014 study noted a demonstrable increase in HIV knowledge, contraception and condom use among the sexually active, and a reduction in risky sexual behaviour among students. Students who received sex education also reported delayed sexual initiation compared to those who did not.

Evidence of the benefits of CSE is clear, but what will it take for it to work in a country like Kenya?

Ibrahim Okumu, a secondary school teacher says that, for one, the focus should not be on abstinence-only and that education policies that are overreliant on abstinence-only education should be reviewed.

“We are trying to tell our students to abstain but this is becoming more difficult,” he said in a YouTube video on video published by Citizen TV. 

According to human rights advocate Wangui Gitahi, Kenya should also renew its official commitment to ESA, and implement its promise to expand comprehensive rights-based sexuality education.

There is also a push for CSE to be a stand-alone subject and not integrated into other subjects as is the case currently. Research from four low and middle-income countries including Kenya, published in PLOS pointed to the drawbacks of an integrated approach. For instance, teachers trained in their primary subject areas are rarely taught how to integrate CSE and might easily skip over topics they consider controversial with the excuse that they do not have adequate knowledge to cover them. Moreover, integration can diminish the importance of CSE in the curriculum as it gets diluted and doesn’t wield the weight of a standalone subject for both teachers and students.

Implementing CSE also requires resources, and the lack of dedicated funding for CSE from governments has posed a challenge. Historically, funding for CSE has been piecemeal, mainly from external sources, and tied to specific projects. Moreover, there is a lack of coordination of the various efforts by central and local government, NGOs and development partners; and inadequate systems for monitoring and evaluating teachers and students on CSE. Curriculum implementation-related challenges included inadequate weight given to CSE when integrated into other subjects, insufficient adaptation of the curriculum to local contexts, and limited stakeholder participation in curriculum development.

Easther Mwema a youth activist from Zimbabew who runs a sexual and reproductive health data collection centre recommends that youth should be included as stakeholders in the discussions on comprehensive sex education.

“Growing up, there were lots of situations that made me feel very unsafe as a female. But I was never asked what I would like to do about them, or what I could do to protect myself. All policies related to sexual education and rights are made by adults. That’s not right. I think youth should be in the room when decisions are being made about their bodies,” she said in an interview with Hivos.

Why CSE works in some countries and not others

As Kenya faces roadblocks in CSE implementation, South Africa’s Department of Basic Education DBE expanded the Comprehensive Sexuality Education curriculum in the Life Orientation subject.

South Africa’s HIV incidence rates are highest among adolescent girls and young women (AGYW), accounting for an estimated 29% of all new infections in 2018. HIV prevalence among girls aged 15–19 years was 5.8%, and 4.7% among boys in 2017. Birth rates have decreased moderately from 78 births per 1000 in 1996 to 65 births per 1000 in 2016 among the 15–19 age group. However, these birth rates remain high with data revealing that the majority of girls who become pregnant while attending school often do not return after childbirth, and in instances where girls do return to school, they face challenges balancing school and childcare.

In response, the SA Department of Basic Education (DBE) developed the HIV, STI, and TB policy, which included the call to educate girls and boys about sexuality and sexual behaviour in an effort to reduce both unintended pregnancy and HIV rates. One of the key interventions pronounced in this policy is the provision of comprehensive sexuality education (CSE). The aim of CSE, as specified by the DBE, is to build and shape learners’ understanding of concepts, content, values, and attitudes around sexuality and sexual behaviour.

Since 2015, the DBE has developed and piloted Scripted Lesson Plans (SLPs) across five provinces (KwaZulu-Natal, Free State, Gauteng, Mpumalanga, and Western Cape) to strengthen the teaching of CSE in schools. These support materials aid educators and improve the effectiveness of CSE lessons. This formed part of the Determined, Resilient, Empowered, AIDS-free, Mentored and Safe (DREAMS) initiative, which aimed to reduce HIV infection among young women. The delivery of CSE using SLPs forms part of the DREAMS package of “layered” evidence-based HIV prevention interventions targeting biological, behavioural, and structural factors to reduce the vulnerability of girls and young women to HIV with the aim of reducing HIV incidence by 40% among adolescent girls and young women over a two-year period (2016–2018).

According to Hivos.org sex education increases the level of sexual responsibility among adolescents, as they gain essential knowledge and skills that will benefit them in adulthood. Currently, because of inadequate sex education, many adolescents and teenagers are uninformed. The myths and misconceptions about sex prevail among them.

In countries like the Netherlands where children learn about relationships from as young as four years old, the results are impeccable. The Netherlands has one of the lowest teenage pregnancies, abortion, and sexually transmitted diseases (STDs) rates in Europe.

A study by the All India Educational and Vocation Guidance Institute found that between 42% to 52% of young students in India feel that they do not have adequate knowledge about sex. In a recent survey conducted by India Today, a leading news magazine, in 11 Indian cities revealed that almost half of all young people interviewed didn’t know enough to protect themselves from HIV/AIDS.

Due to this, it is submitted that India is obliged to provide comprehensive sexuality education in all public and private schools in India and that the denial of such education to children, adolescents and young people generally and the banning of the Adolescence Education Programme (AEP) by state governments specifically is a violation of India’s commitments under international law. Arguments on culture, morality or federalism are invalid in this context. Further, the provision of age-appropriate comprehensive education on sexuality and HIV/AIDS can also have important consequences in dealing with child abuse and in reducing the spread of HIV/AIDS.

In many African countries CSE, gender sensitisation and human rights education are not supported due to lack of political will. The 2003 Maputo Protocol initiated by members of the African Union encourages member states to integrate gender sensitisation and human rights education at all levels of education; it has not been ratified by two-thirds of the African member states. Implementation of CSE is donor-driven with oversight given to both Education and Health Ministries, creating funding and accountability problems.

Without information on sexual and reproductive health and gender equality, young people face a  heightened risk of contracting HIV or experiencing unintended pregnancy, which might not only limit their future prospects but also put their lives at risk. Complications during pregnancy and delivery are one of the leading causes of death among adolescents globally. Research has established that CSE can improve sexual and reproductive health knowledge, and be effective in reducing risky sexual behaviour. Studies in sub-Saharan Africa have to an extent affirmed these results, indicating that changes in adolescents' sexual behaviour after exposure to these programmes are modest, but achievable, while positive improvements in adolescents' attitudes and knowledge were consistently produced.

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This story has been produced with the support of The Africa Women Journalism Project (AWJP)