How Riders Are Positively Changing Health-Seeking Behavior in Central Kenya
By Joyce Ojanji
On the bumpy, dusty, and rutted roads of Ruiru Town, Kiambu County, in Central Kenya, motorcycle taxis, or Boda Bodas in local parlance, crisscross the busy town while honking at pedestrians with all manner of sounds.
I am in town this Tuesday morning to talk to the riders about why only a few of them opt for HIV testing. Low HIV-testing rates in Kenya derail efforts to eliminate HIV/AIDS as a public health threat by 2030.
A few meters away, I see and hear the boda boda riders exchange banters, occasionally interrupted by the haggling for clients. Boda Bodas are part of the fabric of everyday life in Kenya, from the busy metropolitan city of Nairobi to the rural villages of Ruiru.
I am here to find out how the riders are assisting the county on its journey towards meeting the goal of eliminating HIV/AIDS as a public health threat by 2030.
photo credit : Joyce Ojanji
I meet Mr. Lawrence Kariuki, the Kiambu County Boda Boda Association’s chairperson, who tells me, “I have been a boda boda rider for the last 27 years. I even married one of my clients. ” He laughs, admiring his wife sitting nearby but oblivious to our conversation.
Owning a motorbike those days was rare, “so I was among those people in the community who had a voice,’’ he reminisces.
Kariuki recalls that in the 1990s, owning a motorbike was profitable since fuel was cheaper. Still, very few could afford to ride a motorbike since bicycles were the primary means of transportation.
With confidence and pride, Kariuki points at his house made of bricks: “It is through this business that I managed to save some coins for this house construction before my children started schooling.’’
In his line of business, Kariuki had interacted with many customers, some of whom he had sexual relationships with for several years. However, it had never crossed his mind that he needed to check his HIV status.
He narrates how he came to learn that he is HIV positive. ‘‘I had ferried a customer to Lari town when I saw some fellow riders (my colleagues) enter a small tent one after the other. When I inquired, one told me that it was an HIV test being carried out for riders. And that’s how I became part of the initiative.’’
Kiambu Boda Boda Association started spearheading HIV-related interventions after joining the Local Innovation Scaled Through Enterprise Network (LISTEN), a community of practice (CoP) dedicated to health interventions began in 2019 by the National Syndemic Disease Control Council (NSDCC).
“We like calling it a process, not a program, because we take people through a process. It involves understanding what it means as a person before you even get to others. It’s designed as a human-centered design model where you help people appreciate what they have in terms of resources or intellectual capacity to solve their problems but also what is around them that can be localized and becomes the solution to problems that sometimes look unsurmountable,’’ said Dr. Ruth Laibon Masha, Chief Executive Officer (CEO) of NSDCC.
She said that the first thing they do under LISTEN is to train or bring people together under the CoP through interactive sessions where people tell them about their day-to-day challenges.
Dr Masha said that when LISTEN was formed in 2019, they thought about “the need to demonstrate the success of the process to different groups of people. We first chose the fisherfolk in Homabay and the Boda Boda Riders in Kiambu. This was based on the unified grouping of the fisherfolk and the riders, and there was that discussion of them being viewed as people who were contributing to HIV infection and categorized as key populations with a high prevalence of HIV.’’
She explained that the idea was to try to be innovative since, for a long time, they used to organize meetings in health facilities with groups that did not share anything.
photo credits: Joyce Ojanji
The initiative combines the Boda Boda riders’ indomitable spirit to improve their community’s health-seeking behavior, including HIV testing and prevention.
According to the WHO report, In Danger: UNAIDS Global AIDS Update 2022, a lack of adequate access to medications and testing has meant that the burden of HIV/AIDS, Tuberculosis(TB), and Malaria in Africa far surpasses the rest of the world.
In Kenya, for example, the NSDCC says more than half (53 percent) of the 1.6 million people living with HIV are unaware of their HIV status.
Kiambu County is among the counties with low HIV testing rates. Despite the importance of HIV testing as a way to increase prevention and treatment, about 73 percent of people in Kiambu County had never tested for HIV by 2022, according to the Kenya Demographic and Health Survey 2022.
The reported barriers to HIV testing over the last 15 years have remained consistent despite improved service offerings. Lack of knowledge about HIV and the location of testing sites, low perceived risk of infection, fear of testing positive, discrimination, and stigma are some of the barriers, according to NSDCC.
The association chair intimates that the riders’ first action after joining LISTEN was to ensure that their members registered to access National Health Insurance Fund services because that was what they had mapped as their immediate concern.
Once registered, the NSDCC trained them on how to use the HIV self-testing kits, HIV prevention methods such as condom use, Pre-Exposure Prophylaxis (PrEP), and Post-Exposure Prophylaxis (PEP), and the importance of treatment. The riders’ chairpersons and the Council coordinated the groups.
They have set aside two days monthly, the first and last Mondays, for HIV awareness. The group organizes HIV counseling and testing activities for its members and community members. They also sensitize the community to register with the NHIF, now the Social Health Insurance Fund (SHIF).
According to Kariuki, the group aims to reach every association member and community with health messages, spread awareness of the importance of HIV testing, treatment, and care, and encourage proactive health-seeking behaviors.
“We have seen most of our members now coming out to test for HIV and have also enrolled in the health insurance. Most of them are walking into the office and picking HIV prevention items like condoms and self-testing kits,” says Kariuki.
He says they get a monthly supply of HIV prevention kits from the NSDCC and sometimes bi-monthly refills from the National AIDS and STIs Control Programme (NASCOP).
“In March last year, I was not feeling well. I had a fever and headache and was feeling very dizzy. Since this felt like malaria-like symptoms, I went for over-the-counter drugs, which I took for three days, but the symptoms seemed to persist,’’ narrates Kariuki (not his real name).
Like many in the area, Kariuki felt no need to go for a checkup at a nearby health facility. Instead, he decided to Google which disease could match his symptoms.
“Among the diseases I got on the list was HIV/AIDS. This stressed me, but I feared taking a test due to stigma. As I was resting under an avocado tree in my compound, three gentlemen on a motorbike rode in,” he narrates.
They “talked to me about the importance of going for medical tests whenever one feels unwell. I was convinced and agreed to take the test. They sensitized me on the importance of going for checkups in a health facility, which includes HIV testing. I agreed to be tested, which was a game-changer in my health journey.”
“I found out that I was HIV positive. I went through counseling. I started my antiretroviral drugs (ARVs) journey, and so far, my viral load is undetectable,’’ he says while smiling.
According to the Kiambu County Executive Committee Member (CECM) for health, Dr Elias Maina, the County Government is working closely with the NSDCC to eliminate one of the Triple Threats in the county – ending new HIV infections. The other threats are adolescent pregnancies and sexual and gender-based violence (SGBV).
To eliminate the triple threat in the county, Dr.Elias said that last year, the county conducted a sensitization walk dubbed ‘End the triple threat’ aimed at addressing the rising cases of gender-based violence, new HIV infections, and teen pregnancy in the county.
He added that the walk enables the healthcare workers to provide valuable information on vaccination campaigns, proper hygiene practices, and the significance of regular health checkups.
He notes that the county is sixth among the 18 HIV high-burden counties in Kenya, with a prevalence rate of 5.6 percent. It has an estimated 52,812 people living with HIV, according to the 2020 NSDCC report.
Of these numbers, 49,632 are adults; adolescents (aged 10-19) number 2,536 or 4.8 percent; young adults (aged 15-24) are 3,978 (7.5 percent).
The county contributes to 1.1% and 6.0% of the total new HIV infections in Kenya among children and adults, respectively.
Through the LISTEN program, Dr. Maina notes that the county aims to end the threat of new HIV infections.
Between 2020-2023 NSDCC notes that every week, about 98 adolescents aged 10-17 years old got infected with HIV in Kiambu Country alone.
Dr Maina noted that fighting new HIV infections is a continuous process. It requires bringing together all members of society through the LISTEN program, actively speaking up and acting, and prioritizing regular screenings to detect and manage these conditions effectively.
“As the country targets to end HIV as a public health threat by 2030, there is a need to focus on our young people who are currently leading with new infections. These riders exemplify the true spirit of compassion and dedication, making Kiambu County a safer and healthier place for all.”
‘We leverage the association’s meetings to spread the gospel of HIV (prevention and treatment. Together with NSDCC, we capacity-build so that when we are not around, they continue spreading the HIV gospel in their different groups and other social networks.’’
Additionally, the Kiambu County Health CECM says the county government supplies them with commodities such as condoms and HIV self-testing kits, educates them on other HIV preventive measures apart from the use of condoms, and creates awareness on other Sexually Transmitted Infections (STIs).
Dr. Masha explains that the LISTEN Community of Practice has impacted the HIV behavioral prevention component.
‘’Most of the Boda Boda riders are now the ones rescuing our girls from any cases of SGBV and advocating for HIV testing among their peers. With this initiative, we have seen new HIV infections in Kiambu County reduce immensely, from 4.6 % to 2.3%, and we are advocating for other counties to take in the initiative so that the whole nation can fight this threat,” she said.
She adds that LISTEN is a very cheap intervention compared to what they could have spent on organizing workshops and refresher courses of training.
‘’For example, when World AIDS Day was being celebrated last year, the Boda Boda riders in Kiambu asked for commodities such as condoms to help us distribute. This was indeed a paradigm shift. They are feeling the urge to serve and be part of HIV prevention ambassadors for their community, and all in all, they have abandoned the high-risk behaviors.’’
The Boda Boda in the county operators have become more than just motorcycle taxi riders; they have become beacons of change, health advocates, and community pillars. Their tireless efforts have not only improved their business but also positively impacted the lives of their fellow riders, fostering a community of health-conscious individuals.
According to Kariuki, the rate of HIV testing has improved but varies from time to time because of inter-county migration.
He says that in a month, they test approximately 400 people. The association has reached about 10,000 people and referred 2,000 for ART treatment.
“Looking at the numbers of men visiting health facilities in Kiambu, there is a huge improvement compared to before the sensitization. Also, the HIV commodities supplied by NSDCC at the two boda boda testing stations in Ruiru town are taken in large numbers,’’ he narrates.
Kariuki notes that, despite their efforts, some people still doubt them and are hesitant to go for checkups and HIV testing.
“This is the first time boda boda riders are being used to help convey health-related messages. We were previously known to be used by politicians and are perceived as an illiterate group in society. Hence, our messages on health are still not convincing to some,’’ the chairperson says.
In addition, due to fear of being stigmatized and discriminated against by their peers, some clients prefer taking commodities such as condoms and going for HIV tests far away from their community.