It is astounding how much HIV clinical care has expanded in Kenya since I was here in January 2004. At that time, I was in Eldoret, a smaller and more mountainous city about 3 hours by matatu from Kisumu. We were just beginning to roll out antiretrovirals (ARVs), and most patients who were on them had to pay out of pocket for their ARVs. Cipla was producing Triomune 30 and 40, the generic fixed-dose combination pill which includes d4T (stavudine), 3TC (lamivudine), and NVP (nevirapine), and ARV treatment suddenly became more affordable. Part of my project in Eldoret back then was to help link patients diagnosed with HIV in the hospital to be properly referred to the subsidized HIV treatment available at the new AMPATH HIV clinic, which was in the process of being built. That program in Eldoret was also starting to branch out to a few rural and more remote clinical sites.
You can read an article about the AMPATH program in Eldoret here: http://alumni.indiana.edu/magazine/kenya.shtml
Imagine providing HIV management and treatment in a place without roads, electricity or clean water. It is still like that in many places. But now these places are remarkably better staffed, better resourced and are seeing 10 to 20 times the number of patients. The Kenyan government has trained young medical officers in ARV management, and now Kenyan 20-somethings are running HIV clinics with 10-20 staff and managing huge public health programs. I’ve never witnessed such rapid development and growth in healthcare. And I am fortunate enough to be a part of it.
Back in early 2004, the AMPATH program in Eldoret had only a couple thousand patients involved, and only a small fraction of those on ARVs. We were just beginning to roll out Triomune for free or heavily subsidized rates. Of all the people who needed to be on ARVs due to advanced HIV disease, less than 1% of those people were getting it. Now AMPATH is serving 33,000 patients, runs several children’s programs and innovative farm-based nutritional and micro-enterprise programs. In Kenya, roughly 20% of the people with HIV who need ARVs are now getting ARVs. That means 80% still go without, but this is way, way better than more than 99% of people going without treatment. This is a result of a massive influx of attention and resource allocation by the Kenyan government, NGOs and global public health institutions. They’ve built clinics, they’ve provided lab equipment, we’ve trained thousands of clinical staff in HIV care. We’re in the middle of a 20-fold jump in treatment, and there’s still a lot more to do to get it to 100%.
I will visit Eldoret and the AMPATH program at a more rural site called Turbo at the end of this week. It’ll be really interesting to see how much it has changed.
FACES (Family AIDS Care and Education Services) is the clinic where I am now working in Kisumu. First, I should note how great it is to work at a place where people are incredibly welcoming and happy that you’re there. It creates a much happier, positive work environment. The staff at FACES seems to naturally create a constructive work community. Similar to AMPATH, FACES started with a partnership between a Kenyan medical site in Kisumu, and a US-based institution. In this case, it was the CDC and UCSF Ob-Gyn program. They had started with PMTCT (prevention of mother to child transmission of HIV) and microbicide projects, and then expanded their clinical care to include one of the biggest glaring health needs: HIV clinical care for adults. This is where the UCSF ASPIRE and internal medicine residents (like me) step in. We can actually be helpful in training folks here to manage complicated adult HIV cases.
Their family-based model is great in involving whole families and encouraging everyone in the family to be tested and treated as needed. It is much more holistic than dividing families up into internal medicine, pediatrics, and ob-gyn. It also includes home-based, hospital-based visits by staff, nutritional supplementation and counseling, as well as programs such as “Kids Club” and “Family Empowerment” workshops. [I attended the most recent Kids Club yesterday and got some really great photos and video of the kids. It’s not hard to get great pictures of kids- they love the camera. I’ll post some up.] FACES also has an integrated lab and pharmacy, so patients can get all these services on site, rather than having to trek around town to get blood drawn and their medications. The approach is so much more comprehensive than most of our out-patient clinics in the US. And they do it with a lot of people-power but not much in material resources.
The FACES clinic in Kisumu started out in September 2004 with just a few hundred patients and now sees over 4,000 patients, most of who are on ARVs, including children. It is truly inspiring to see how far HIV care in Kenya has come since 2004. They have a lot more to work with than what I had 3 years ago: a full formulary of medications, CD4 counts, HIV qualitative PCR (measuring the presence of the HIV virus), and they used to provide viral loads too. And it’s free for patients. The clinic has a very deliberate patient flow model which allows them to see about 200-250 patients every day. For the number of clinical staff, it is incredibly productive.
I’ve seen patients for three clinical days during my first week at FACES, and already I’ve initiated (alongside a clinical officer) several people on ARVs, diagnosed ten or more smear-positive malaria cases, managed people with extrapulmonary TB on ARVs. I’ve seen with Liz and Everia (a Kenyan FACES clinical officer) a young man stumble into clinic with left-sided pain and weakness and treated him for presumptive toxoplasmosis, a parasite that can create masses in the brain causing focal neurological deficits. I see about 20 patients a day… and I’m relatively slow! It’s a very very busy clinic. And amazingly, despite my newness to this clinical site, I feel helpful: seeing patients and helping clinical officers think about the differential diagnosis and treatment options, assisting with paperwork and getting the patients the treatment or investigations (labs and studies) they need.
You can read more about FACES at their website:
I also have a number of projects that I created for myself and have been assigned to do by the rotation. Because the clinic is so busy, it feels a little crazy to add so many things on top of the clinical work. However, it is the diversity of my work that keeps me engaged. I think I would go crazier if I saw patients from 8 am to 6 pm every day without other work projects going on. This is not news, but I am once again confirming that I need a wide variety of creative, clinical and program/systems-level projects to keep me happily and actively engaged with work. Here’s my current list of projects, in rough order of what I personally think is most important. Pole, sorry, it’s like showing you my to-do list, but at least you get an idea of what I’m doing here. You’ll hear more about them as they develop:
1. video documentary on capacity building and training at FACES (my own gigantic project)
2. the faces of FACES staff photo book (my own project)
3. CME (continuing medical education) session on HIV and pulmonary (lung) diseases
4. mentoring clinical officers and nurses
5. organizing the rotation for future UCSF residents with proper orientation materials and resources so that they are useful and get the most out of being here
6. less formal educational workshops for clinical officers; i will do one on a subject they choose
7. journal club (not my favorite thing to do because it is highly entrenched in academia, but it has become part of the rotation)
8. developing sections in the clinical officer handbook; i will likely tackle sections on HIV and pulmonary disease, diarrheal disease (my personal fave!)
Somewhere lodged into this list is the clinical work of seeing patients. I can’t decide how to prioritize that because it always becomes a priority once I commit to seeing patients on certain days. I’ve decided to see patients for at least 3 days a week and spend one full day and some half-days on my other projects.
Yikes! It’s a lot to get done in the next 3 ½ weeks. Time here always goes so quickly.