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Making HIV prevention services accessible to the most at-risk – Dr Kimani Makobu

Meet our recent PhD graduate Dr Makobu Kimani who successfully defended his PhD on the 19^th of October. Dr Makobu is a Kenyan trained medical doctor with postgraduate training in global public health. His current research work is an extension of his interest in global health. His branch of research is known as implementation research exploring how to do things more efficiently to achieve a greater impact on the population. He has been investigating how HIV prevention modalities can be better rolled out in Kenya.

Thinking beyond the  basics of clinical practice

I have almost always been involved in some form of STEM. While pursuing my undergraduate studies, we had a unit involving a community visit to collect data and develop a write up on the health status and challenges on the same.

However, I have had mentors that have encouraged me to think beyond the basics of clinical practice and seek ways of doing things better. One such mentor is Dr Joshua Kimani (no relation!) who introduced me to research in 2002.

I also like to ask questions about why things are the way they are and what can be done better. This is especially important in public healthcare delivery in Kenya where innovation is often the norm.

Taking up a PhD Position and working with marginalized populations

I am a firm believer in self-improvement. I have always challenged myself to be a better version of myself. It was a logical step for me a few years after my graduation with a master’s degree, to move into a PhD position.

However, the position at KEMRI was not a walkover. It was a competitive process and I only ended up in the position after multiple processes including interviews and aptitude tests.

I have always had an interest in working with marginalized populations. I have worked in rural parts of Kenya where health services are hard to access. Even in urban areas, I have always worked with ostracized populations including female sex workers and injecting drug users.

When I joined the HIV research group at KEMRI, it worked perfectly that they were also interested in HIV prevention in a significantly marginalized population that is male sex workers and gay men.

Exploring how to better deliver HIV prevention products to vulnerable populations 

While there has been significant progress in the reduction of new HIV infections globally, there are still sections of the population that have sustained or even increased cases of infection. These pockets are known as key populations or at-risk populations. Key populations include female sex workers, injecting drug users, gay men amongst others.   Worldwide, gay men also known as men who have sex with men (MSM), are disproportionally infected with HIV. Even in developed economies with better healthcare provision, they still have the highest number of new HIV infections (also known as incidence).

My research explores how to better deliver HIV prevention products to these populations to reduce HIV incidence. While it may not seem to be a significant number of individuals, it is important to note that every new infection prevented results in overall reduced prevalence (total number of cases) for the country. This is a saving to the economy as a massive amount of national resources goes into HIV treatment activities. Probably a less acknowledged fact is because of the illegal nature of same-sex relationships in Kenya, the population may be much larger, justifying making HIV prevention among them a health priority. Additionally, some gay men may also live double lives having both female and female partners and therefore in the event they are HIV infected, they could be onward transmission, thus reversing any gains in HIV incidence in Kenya. All these facts justify making HIV prevention in MSM a priority area.

Demonstrating the existence of TGW in Kenya

When we first began the work, we encountered a previously unrecognized sub-population amongst MSM. This population are known as transgender women (TGW). TGW are individuals who were assigned male gender at birth, currently identity as female.  These individuals have been shown to have the highest incidence of HIV globally. Our study was the first to demonstrate the existence of TGW in Kenya. Additionally, from the work, we constructed what is the first HIV incidence estimate for TGW in sub-Saharan Africa. We demonstrated an extremely high incidence in TGW compared to MSM.

Unmet prevention needs

The extremely high HIV incidence amongst the TGW is indicative of an unmet prevention need. The results of our work and others since then has begun to influence HIV prevention programming in Kenya. Indeed, there are draft transgender service provision guidelines that borrow heavily from the work I have been doing in Kilifi.

I have since completed a second phase of the actual provision of prevention services specific to TGW and MSM. This work is currently under review at a journal and will soon be published. Hopefully, this will further guide HIV programming for key populations in Kenya and possibly in the entire region.

 Postdoctoral support

My work has been funded by SANTHE but I am based at the Kemri-Wellcome Trust where I am managed under the training department as an IDeAL student. Therefore, I feel qualified to speak from a point of view that addresses both sides of the conversation.

I think I have been very fortunate to be in a situation where I have a scholarship that covers pretty much every aspect of my PhD. I have funds that allowed me to run a high-quality PrEP cohort. Additionally, I have support for travel and training and most important a living wage in the form of a monthly stipend.

IDeAL and by extension Kemri-Wellcome Trust have policies in place that govern trainees, and this has helped to keep all of us to a very strict timeline. Except for disruption caused by the current COVID-19 pandemic, I would probably have submitted my thesis earlier than December. Additionally, IDeAL has a scheme called the Career Development Year (CDY). This is a form of transition support offered once one has submitted their thesis. I look forward to this period. Overall, my experience with both SANTHE and IDeAL, has for lack of a better word, been ideal!

As mentioned above, there is some transition support offered by IDeAL. This is important as often at the end of a PhD studentship, while one has the credentials, they may not necessarily have the experience on grant application and management. Postdoctoral training comes in to fill that gap where one is transitioning to independence and deciding as to the direction they would want to take i.e. remain in academia/research or move into industry. Postdoctoral training provides a chance for one to network without the limitations of being a PhD student. This probably allows for more vertical engagement. Finally, postdoctoral training helps to avoid the terrible situation of unemployed but overqualified individuals as may have been the case previously.

To a brighter future

As a trainee at the Kemri-Wellcome Trust, I have made connections that I believe will be fundamental in the next phase of my career in science. By creating a space that was only occupied by like-minded PhD fellows, we have similar future aspirations and can only benefit from each other.

I am grateful for the multiple training opportunities that have been presented to me just by being a trainee within the program. I think it would be a shame if all I could quote from IDeAL would be the PhD training. Instead, I have received both theoretical and practical leadership skills. I have also had access to a mentor for the duration of my studies. He provides some stability and reassurance on how bright the future can be.