Kenya: How a Non-Profit Fights Antifungal Drug Resistance among Sex Workers in Kisumu County

By Philder Odanga

Susan Otieno, a 35-year-old sex worker, smiles with assurance as a gynaecologist conducts a test to establish if she has any infections. It is easy to tell her confidence level from a distance as she undergoes a test many of her colleagues have failed.

She is among several sex workers who are considered high-risk groups for sexually transmitted infections (STIs) owing to the nature of their work. Such infections include syphilis, gonorrhoea, chlamydia, and HIV/AIDS, among others.

In the past, few sex workers overcame the stigma associated with their work to seek medical attention in health facilities. They faced poor treatment from the caregivers, making most of them shy away from accessing public facilities. Because sex workers get paid to perform sexual acts, they are seen as deviant and consequently labelled immoral, unclean or dangerous, she says.

But this has changed drastically after the Center for Health Solution (CHS), a non-governmental organization, came up with a program that provides services for free to sex workers in Kisumu.

The initiative collaborates with the Kisumu County Government and the Kisumu Sex Workers Alliance to help provide services tailored to the high-risk group.

The CHS was started in 2017 after many female sex workers were reported to be getting recurring infections. Its main aim was to help these women deal with the yeast infection, the commonest among them.

The program has over 50 registered sex workers. It was formed to equip the sex workers with knowledge and skills on how to take care of themselves in line of duty as well as offer education to the larger community.

The services include information on where to go for STI screening and adequate knowledge of handling recurring yeast infections.

Through the initiative, the sex workers say they now have a safe space where they can get treatment without having to struggle with stigma and lengthy explanations of how they contracted the infections.

“I used to buy over-the-counter drugs from chemists. Sometimes the symptoms would disappear, but I kept on feeling itchy and irritated in my private parts, getting a burning sensation during intercourse or while urinating,” Susan Otieno, a commercial sex worker for over a decade, explains. She says that accessing treatment in hospitals was treacherous and not for the faint-hearted.

According to Dotty Agallo, Chairperson of the Kisumu Sex Workers Alliance, through the CHS initiative, more sex workers have been able to access treatment for sexually transmitted diseases (STDs).

Agallo says the response is two-pronged. They actively find sex workers with STIs or at high risk of STIs. They are then linked with county hospitals, where they get combination therapy, which consists of different antifungal drugs. This approach prevents the emergence of resistance and improves treatment outcomes. They also conduct meetings every three months with the sex workers to discuss these infections and know the progress the workers have made in combating these infections. They also encourage them to get screened after every three months.

“We ensure they get screened after every three months to prevent infection or re-infection, and we conduct meetings after every three months to track our progress,” Agallo explains.

She adds that sex workers are also taught how to protect themselves. The Kisumu Sex Workers Alliance and the County Government of Kisumu have trained peer educators who provide health education to over 40 sex workers on the importance of protecting themselves against fungal infections.

“This move has made more sex workers aware of how they can take care of themselves in line with their duty.  This has reduced the incidence of STI reinfection among themselves,” says Agolla.

According to Dr Mitchel Okumu from the county government hospital, the community empowerment approaches among sex workers contribute significantly to reducing HIV and other sexually transmitted infections, including fungal infections among female sex workers. He states that the most typical infection among sex workers in Kisumu has been fungal, especially yeast infections. This is a fungal infection that causes irritation, discharge, and intense itchiness of the vagina and the vulva, which are the tissues at the vaginal opening.

Still in Kisumu City, we meet 38-year-old Eunice Adhiambo, a member of the Kisumu Sex Workers Association. She also developed a sexually transmitted infection that would not go away.

“I was used to buying over-the-counter drugs, but the infections kept recurring, and I developed complications. I then went for screening at the Jaramogi Oginga Teaching and Referral Hospital, where I was diagnosed with Human papillomavirus infection (HPV).”

She says the stigma sex workers experience in public hospitals makes many of them self-diagnose and self-medicate to treat sexually transmitted infections. She reveals that whenever she makes visits to healthcare facilities, conservative beliefs held by healthcare workers combined with deeply unequal power differentials between the healthcare workers and sex workers often result in the latter being particularly poorly treated.

She adds that she avoids healthcare services as much as possible rather than being subjected to prejudice and disrespect.

“We are despised in these hospitals. There was this one time I visited a hospital, and the nurse said even if I treat you now, with the nature of your work, you will still do the same thing, and tomorrow you will be here again. I felt disrespected publicly,” says Adhiambo.

The stigma is brought about by the poor treatment they face from the nurses and the kind of questions the nurses ask them with no privacy, making them feel uncomfortable most of the time.

“The initiative has helped us a lot. Nowadays, we do not have to go to health facilities to be subjected to stigma. The screening is done. Where most of us work,” she explains.

Kisumu sex workers have a high rate of antimicrobial resistance (AMR). The University of Chicago says that in Kisumu, from 2000 to 2010, resistance to ciprofloxacin, a fluoroquinolone drug commonly used to treat STIs, grew from zero percent to 50 percent of the samples tested.

Another trial, conducted from 2020 to 2022, enrolled 449 cisgender women ages 18 to 30 in Kisumu, an area with high STI rates. They were given doxycycline as post-exposure prophylaxis after sex – known as doxyPEP – to reduce the likelihood of STIs, but it did not work.

The researchers said this was because Kisumu has a high background level of antibiotic-resistant gonorrhoea. All the women who tested positive for gonorrhoea either at baseline or during follow-up showed evidence of drug resistance, and the use and abuse of antibiotics are directly contributing to the development of drug resistance, a global public health problem.

According to the Centers for Disease Control and Prevention’s Antibiotic Resistance Threats Report, antimicrobial resistance is an urgent global public health threat, killing at least 1.27 million people worldwide and associated with nearly 5 million deaths in 2019.

Antimicrobial resistance occurs when germs like bacteria and fungi develop the ability to defeat the drugs designed to kill them, and data shows that Kenya has the 177th highest age-standardized mortality rate per 100,000 population associated with AMR across 204 countries, according to the Institute for Health Metrics and Evaluation, based at the University of Washington.

In the same year, Kenya witnessed more than 8,500 deaths attributable to AMR and 37,300 illnesses associated with antimicrobial resistance.

Though yeast is treatable with oral antifungal therapy, many sex workers have developed resistance to common antifungal drugs, according to Dr. Okumu, a medical officer in Kisumu.

“The county government responded by creating a county antimicrobial stewardship inter-agency committee. The committee works with sex workers within the county to address their challenges,” Dr Okumu says.

He adds that the Kisumu Sex Workers Alliance is one of the partner organizations in that stewardship committee, helping create awareness among sex workers. Dr Okumu says the county offers sex workers combination treatment for free in public hospitals, adding that medics first take vaginal swabs from sex workers and test them in the laboratory at Jaramogi Oginga Odinga Teaching and Referral Hospital (JOOTRH) in Kisumu to determine which fungus causes a particular fungal infection before issuing medication.

“The county has dedicated two laboratories, one at JOOTRH and another in the Nyakach sub-county, where sex workers can now get screened and know if they have any infection or which type of infection they have before they are given medication.  They also get adequate information on how to protect themselves and about antimicrobial resistance to curb drug misuse,” he added.

Dr Okumu says the response is relatively new, so the county has not collected data to show its impact.

However, the Kenya National Guidelines for STI (2006) show that such outreach services and combination treatment are proven to work in reducing STIs and drug resistance among high-risk groups such as sex workers.

Dr. Denis Miskella, a gynaecologist in Nairobi, says vaginal yeast infection is not considered a sexually transmitted infection per se. However, in some instances, the medic argues that infections may be linked to mouth-to-genital contact, which is also regarded as oral sex. Dr. Miskella is the Deputy Secretary General of the Kenya Medical Practitioners Pharmacists and Dentist Union (KMPDU).

He says most yeast infections occur when women wear tight clothing, especially underwear, which traps heat and moisture. This makes them prone to yeast infections.

He also notes that using scented sanitary products and douching can also upset the healthy balance of bacteria in the vagina and make yeast infections more likely.

“There are helpful fungi and harmful fungi, and when harmful fungi invade the body, they can be difficult to kill, as they can survive in the environment and re-infect the person trying to get better,” says Dr Miskella.

According to the National Syndemic Disease Control Council (NSDCC), cases of STIs among youth aged between 15 and 34 have been on the rise.

The council notes that 75 percent of new HIV infections in the country have been recorded among the youth in the said age bracket, which it attributed to the surge in unprotected sex.

Dr Ruth Masha, the council’s Chief Executive Officer, said there has been a rapid rise in STIs among the youth in Nairobi, Mombasa, Nakuru, and Kisumu due to unprotected sex. Statistics show Kenya has the seventh highest number (1.4 million) of people living with HIV in Africa.

According to NSDCC, the country has made critical milestones within the HIV program in reducing new infections between 2010 and 2023.

In 2010, there were 71,000 new infections which dropped to 41,416 in 2019. In 2020, the number of infections dropped further to 32,027. However, the figure increased slightly to 34,540 in 2021, and in 2022, new HIV infections fell to 22,154.

According to the 2023 national HIV infection rates, Kisumu County stands at number two nationally with 14.5 percent in HIV prevalence, with Homabay leading at 15.2 percent, Siaya at 13.2 percent, and Migori at 9.7 percent.

In Kisumu, the sex workers are hailing the interventions by their leadership alongside partners to ensure that they have access to early screening and testing for infections.

Eunice Adhiambo now says her constant vaginal infections have become a thing of the past. However, she says the two laboratories set aside for sex workers are not adequate.

“In as much as the County Government of Kisumu and the sex workers alliance are working together to find solutions to recurring yeast infections among sex workers, as well ensuring the well-being of the general public in Kisumu county, there is a need for health facilities across the county to have laboratories,” she explains.

Susan Otieno says that before the program started, she used to have recurring yeast infections four times a month. However, after getting enough information on what to do, it’s now a thing of the past.

“I can take care of myself as well as pass information to other sex workers and the public in general to end yeast infection,” she says.