Catholic Relief Services Article on Kijabe HIV Program

Steven Chege

Within minutes of arriving at the Kijabe Hospital, Steven Chege is already at work. Today, a new patient is going home, and Chege sets the pace early for what will be another busy day caring for a tiny fraction of the 1.8 million Kenyans infected with HIV.

And while nurses across Kenya every day face the influx of patients flooding rural healthcare facilities, Chege, a community care nurse, fills a unique role in the care and support of Kenya’s HIV positive population, taking his work to the homes of those who are living with HIV in the Kijabe community.

“A community health worker is the bridge between the patient and the hospital,” Chege said. “You have to harmonize and create a good environment for the patient.”

It is a critical role in Kenya, where rural healthcare centers like the 205-bed Kijabe Hospital have been overwhelmed by the scope and scale of the HIV crisis. Across Kenya, 60 percent of all hospital beds are now filled by patients requiring care for HIV-related illnesses, care which rural Kenya is poorly equipped to provide. In the Kijabe region of Kenya, about 40 miles west of Nairobi, there is only one doctor for every 30,000 people. As poverty increases, more young women turn to sex work to support themselves and then, once infected, have little access to health care, a cycle of poverty and infection one doctor at the Kijabe hospital described as “the perfect storm” of causative factors in the transmission of HIV. The result in Kenya has been the near total breakdown of the rural healthcare system.

“There is no infrastructure support to take up the kind of care that HIV demands,” said Jonathan Mwiindi, an administrator at the Kijabe Hospital.

Because hospital beds are scarce, patients who would have once been hospitalized are now treated and sent home with illnesses that require regular follow up care – care that community health workers like Chege step in to provide. Their bodies weakened by the effects of the virus, HIV patients often spend years fighting off serious opportunistic infections – infections that eventually cause death for most who are HIV positive. Though accurate figures are difficult to come by, some estimate that 600 people die of AIDS-related illnesses in Kenya each day.

And while the numbers are shocking, hospitals like Kijabe are now being provided with a powerful new means of mitigating the impact of HIV in the form of antiretroviral (ARV) medications. Provided as part of the PEPFAR grant that has pledged $15 billion to 14 countries worldwide affected by HIV, these drugs are helping to reshape the nature of healthcare in countries like Kenya, where more than 3,000 people are already on PEPFAR ARV medications.

A witness almost daily to the efficacy of these immune-boosting medications, Chege has been amazed by the impact of ARV’s, which were introduced through the Kijabe Hospital in August 2004. Where once HIV was shrouded in stigma, Chege said, people today flock to be tested through the hospital’s Voluntary Counseling and Testing (VCT) program – a change he attributes largely to the increasing availability of ARV medications and the promise they offer.

“[Before], nobody wanted to be tested because they believed that once they tested positive they would die,” Chege said. “But now the ARV’s put some weight behind what we tell them, which is that they will not die.”

The impact of that shift has been dramatic. Within months of the rollout of the ARV medications at Kijabe, the number of HIV positive patients seen by the hospital jumped from 240 to 670, with an average of ten new patients added each day. In total, 310 patients are already on PEPFAR-supplied ARV medications through Kijabe, a number set to climb still further as more HIV-positive people qualify to begin the medications.

His visits today are typical of what he deals with daily. Of the nine patients he visits today in the impoverished rural community of Ndeiya, six are on ARV’s provided through the hospital. Of the other three – a 34-year-old woman battling with meningitis, a 21-year old woman just starting tuberculosis medications, and another whose youngest child is also HIV-positive – all will be able to access the ARV medications when doctors at the hospital judge them ready to start the drug regimens. In the mean time, each is being provided with vitamins and antibiotics through the hospital, also provided by PEPFAR, to bolster their immune system for as long as possible before starting the ARV medications.

During his visits, Chege plays many roles for his patients, all of whom are impoverished and living with chronic illness. Though each patient who is on ARV medications first undergoes a one-day course detailing all aspects of the ARV medications, Chege says that poverty is perhaps the greatest obstacle he faces in working to ensure that those on ARV’s have constant access to the medications. It is access that is sometimes threatened when patients cannot afford transportation to the hospital to pick up their supply of drugs.

“We are very sensitive to transport issues, that’s why we have community health workers,” Chege explained. “I even carry drugs with me, so in case they can’t come when they are supposed to come we can give them enough for another day, because they cannot miss a day.”

It is a message reinforced constantly for those on the ARV medications, as missing even one dose of the powerful medications can lead to drug resistance in some cases - a risk many health care professionals in Kenya see as the greatest threat to the ARV program in years to come. It is a threat Chege and his colleagues at Kijabe take seriously.

“When it comes to ARV’s we tell them, ‘You must take these every day for the rest of your lives to avoid the need for assistance,’” Chege said. “‘If you stop taking these drugs, even if you take them later in life, they will not be any help to you.’”

During his day, Chege sees all manner of illness and problems associated with HIV. Skin rashes, ulcers, and headaches are nearly universal among those not on ARV medications, and more serious ailments like tuberculosis and even meningitis, a dangerous brain infection, are also common. Before patients can start on ARV medication, they must first be treated for as many of these conditions as possible, as it has been shown that patients who start ARV’s at higher levels of physical health respond more quickly to the drug cocktails, with often dramatic results.

Attentive and soft-spoken, Chege brings an effective combination of listening skills and clinical competence to his work, which often keeps him busy through weekends and long into the evening when any of the 60 patients for whom he is responsible are not doing well. With ARV medications becoming more widely available, Chege hopes such cases will become less the norm and more the exception. After six years now working at ground zero of the AIDS pandemic in Kenya, Chege said, he is astonished at the impact ARV medications are having in his community, and across Kenya.

“I have been amazed with these patients,” Chege said. “ARV’s have given them hope. They have given our country hope.”

Shadrack Were

True to the nature of its role, the lab at Kijabe Hospital is cluttered with the vials and droppers of science. As they do in labs around the world, white-jacketed technicians bend to the tabletops here, scrutinizing the latest results on the smallest elements of health and sickness. It is here, amidst the organized clutter of a busy laboratory in rural Kenya, that the reality of AIDS in Africa passes daily through the fingertips of Shadrack Were.

Were, a lab technologist at the Kijabe Hospital center, knows more than most about the effects of HIV and AIDS in Kenya. Every day, he tests the blood of some of the more than 1.8 million Kenyan’s living with HIV, divining from the samples whose body is winning the fight against HIV, and whose is losing.

With the increasing availability of antiretroviral (ARV) medications in Kenya, where a conservatively estimated six percent of the adult population is HIV positive, it is a battle whose nature is slowly changing. Working at Kijabe, which began distributing PEPFAR-supplied ARV medications in August 2004, Were says he has seen a dynamic shift in the nature of the war on AIDS here.

“Before, many people were stigmatized,” Were explained. “But now, with the availability of drugs to keep you well, many people have come to terms with HIV, and they want to know what their status is.”

But Were is not only a scientist. When he is not testing the CD4 counts of HIV patients – a measure of the lymphocyte cells which help to boost the body’s immune system – he is counseling HIV-positive patients at the hospital’s Voluntary Counseling and Testing (VCT) center. One of five counselors at the VCT center, Were is uniquely positioned to understand both sides of the HIV crisis – the clinical impact of a runaway pandemic and the human face of the crisis in Kenya, where an estimated 600 people die each day of AIDS-related illnesses.

Through programs like the VCT center, which opened at Kijabe in June 2004 to meet the unique needs of HIV positive patients flooding the hospital, Were and his fellow counselors meet the needs of those suffering from HIV openly and directly, a change Were says that is perhaps the most noticeable of the many ways that HIV and AIDS have altered the nature of health care in Kenya.

When he started work as a lab technologist, Were said, “There were no specific sections in the hospital for HIV patients. In fact, it was kept sort of secret. But now, with the VCT, people can walk in and learn their status. This is having a big impact.”

It is an impact the full brunt of which Kijabe Hospital absorbs daily. Since it began distributing ARV medications, Kijabe has seen the number of its HIV patients skyrocket as more and more people shed their fear of stigma in search of the powerful immune boosting drugs. In two months in late 2004, the hospital saw its HIV positive patient load jump from 240 to 670, with an average of ten more being added each day. Currently, 310 people are on PEPFAR ARV medications through Kijabe, and Were tests as many as 40 blood samples daily to determine CD4 levels, an important factor in helping doctors determine when to start HIV positive patients on ARV medications. Those with CD4 counts below 200 are considered to be symptomatic of full blown AIDS, and of the 592 samples Were has thus far tested since ARV’s became available at Kijabe, several had CD4 counts in the single digits – signs of a completely defenseless immune system.

Once on ARV’s, however, Were has seen remarkable results in the patients he tests, with many of their CD4 counts climbing well above the 200 level within weeks of beginning the ARV regimen, depending on factors like diet and the effects of opportunistic infections. Once on ARV’s, patients return every six months to have their CD4 retested, and are also examined by doctors when they pick up their supplies of medications to ensure the drugs are working effectively.

It is a comprehensive care package that is saving lives in the Kijabe community. But for Were, is it also work that allows him to bridge two passions in his life - that of science and that of caring for others, a role he says comes naturally to him.

“I was born someone who is empathetic,” Were explained. “Also, I come from Western Kenya, and so many people I know died of AIDS, so I was thinking, ‘What can I do?’ I am proud of the work I do here.”

Faith Warimu

Even in a country where nearly two million people are HIV positive, Faith Warimu knows she and her daughter Gladys will not fall through the cracks. Sitting in an empty training room at the Kijabe Hospital in Kenya, Warimu, 24, is as positive about her future as she is open about her past.

And she has reason to be positive. Testing positive for HIV in 1997, two months after her daughter Gladys was born, Warimu is today one of 312 people receiving antiretroviral (ARV) medications provided by PEPFAR through the Kijabe Hospital, a mission hospital on the edge of Kenya’s Rift Valley, and on the front line of the war against AIDS in Africa.

And though living positively for seven years now, Warimu remembers those early days of her many illnesses long before she started the powerful ARV medications.

“I had boils, and I was feeling very weak,” Warimu said of the days during her pregnancy. “I was admitted just after my delivery for two months.”

It was a pattern of illness and hospitalization she was to follow for seven years, until her mother heard of the Kijabe Hospital and brought her to the center to see if they could help. After being examined by one of the 12 doctors on staff at Kijabe, Warimu was placed in the home based care program – a program designed specifically to ensure that patients like Warimu, chronically ill but not intensively sick enough to qualify for hospitalization, do not fall through the cracks of a healthcare system that has been overwhelmed by the AIDS pandemic. In Kenya, 60 percent of all hospital beds are occupied by patients receiving care for HIV-related illnesses.

Through the program, Warimu was started on vitamins and antibiotics intended to help her weakened body fight off the various opportunistic infections that plague many of those living with HIV. In June 2004, the first of Kijabe’s patients were placed on ARV’s through PEPFAR, and late the same year Warimu learned she would soon quality to start the medications.

“I came for training, and two weeks later I started the ARV’s,” Warimu explained.

Like all who start on ARV medications through the PEPFAR initiative, Warimu had to first attend an intensive one-day course designed to educate patients on all aspects of HIV and the medications they are soon to start. Only once patients have demonstrated a full understanding of the intensive drug regimen, especially the need for strict adherence to the medications, are they started on the therapy.

“They told me how [the ARV’s] work, and about some side effects,” Warimu said. “They taught me a lot about personal hygiene and nutrition, and the importance of complying with my drugs.”

During the first month of their drug course, patients are provided with two-week dosages of the drugs, during which time the home based care nurses at the hospital visit often to ensure that patients are taking the medications and are not responding adversely to the medications. Once they are comfortable that the patients are complying, they are provided with drugs each month, and finally every two months. After each period elapses, the patients return to the hospital to receive a new supply and to have a check-up by the hospital staff, an important part of the overall care and support of HIV positive patients at Kijabe Hospital.

“I am happy that it’s a mandatory check up when I come for drugs,” Warimu said. “Because if I have any other problems that need to be addressed they can take care of them.”

It is that level of support and care that helps to keep patients like Warimu alive and healthy when as many as 600 people a day are dying of AIDS-related illnesses across Kenya. On ARV’s for only a month now, Warimu is already feeling the effects of the medications.

“I had blurred vision for a couple days after I started ARV’s, but I am better now,” Warimu said. “Since I started I am feeling stronger. Now I am able to do my work like before.”

But the biggest impact of ARV’s on Warimu’s life sits beside her on a wooden chair at the Kijabe Hospital. Gladys, born positive, will one day also be provided with ARV medications through the hospital – a fact that lifts an enormous burden off of her mother.

“I know that when it’s the right time for her to take the ARV’s, they will help her like they are helping me,” Warimu said, a second chance many in Kenya would have deemed impossible just a few years ago.

Anne Gitau

That Anne Gitau tested HIV-positive is in itself a story. That she did not know the results of that test until nearly a year after she took it is a bigger story still – a story that speaks to the stigma and misinformation that still surrounds HIV and AIDS in Kenya.

Sick with chest pains and a host of other ailments, Gitau, 40, first went to the hospital in 2003, where she was tested for tuberculosis, a highly infectious lung disease and also one of the leading indicators of HIV infection. Unbeknownst to Gitau, the doctors at the hospital also tested her for HIV. When the results came back positive, however, they did not tell her of the development, but rather passed the information on to her two brothers, a breach of confidentiality difficult for many of us to understand but one that happens routinely in Africa today, where misinformation about HIV and AIDS still abounds in rural societies.

“They were afraid that my condition would deteriorate if I found out,” Gitau offers as explanation for the time that elapsed after she tested positive.

It was not until nearly one year later, when her brothers brought her to the rural Kijabe Hospital about 40 miles west of Nairobi, that she learned of her status – and began the journey of acceptance and management on which she finds herself today.

It was a process that began immediately after the doctors at Kijabe, a 205-bed mission hospital on the edge of Kenya’s Rift Valley, notified her of her HIV-positive status when her two brothers turned over the results of the previous HIV test. She was immediately taken for counseling at the hospital’s Voluntary Counseling and Testing (VCT) center, which handles the bulk of the hospital’s HIV and tuberculosis patients. Nearly six months later, Gitau is still involved in the counseling and support groups offered through the VCT center, which she attends every two weeks.

“I really get a lot of help here, especially with counseling and support groups,” Gitau said. “I realize I am not the only one who is positive.”

Battling with a host of secondary infections that troubled her during the year, Gitau learned in 2004 of the powerful antiretroviral medications that were then becoming more widely available across Kenya, home to an estimated 1.8 million people living with HIV and AIDS. Through home based care workers, Gitau learned that the drugs would soon be available to patients at Kijabe, and that she would be eligible.

“They told me that there was the chance of getting ARV’s if I accepted my status,” Gitau recalled, listing one of the several requirements the hospital places on potential ARV recipients before they can begin the drug cocktail. “I told my mother I was positive.”

Armed with the support of her close family, an important condition for potential patients to meet so as to ensure long-term adherence to the drug regimen, Gitau was given the training course that all of those being started on ARV medications undergo through the hospital – a one day course that covers all aspects of the ARV medications, and which emphasizes the importance of strict adherence to the twice-a-day drug cocktails.

“I had a one-day training where I was told not to miss any drugs, and to take them at the same time, on a proper diet,” Gitau recalled. “I started ARV’s on August 26, 2004 - I cannot forget that date – and now I am gaining weight, and I am able to do everything I could before.”

Having gained more than 22 pounds in six months, all of them lost during her long illness, Gitau is today well on her way to a life free of the many illnesses that once weakened her. As with all of those on ARV medications provided to the hospital through PEPFAR, Gitau was at first given only two-week supplies of the drugs, allowing doctors and care workers at the center to closely monitor her health during the first months of the regimen. Today, she comes every two months to receive a check up and to pick up her supply of ARV medications – medications without which, Gitau says, she does not know how long she would have lasted.

“That was the end of me,” Gitau recalled. “Without these drugs it could be that I would not be alive.”