Innovative measures to ensure AIDS and TB treatment during Kenya's post-election violence

On top of the violence that has been raging in the post-election crisis in Kenya, there is an issue of great concern for MSF: HIV and tuberculosis (TB) patients who fail to show up for their appointments and collect their life-saving medicines.

By Anouk Delafortrie, MSF Health Promotion/Community Programme Advisor

"It broke my heart," said Xavier Tislair, MSF Programme Coordinator, "to see this woman, badly beaten up, sitting in the waiting bay with her four month old baby. She was making her way back home to fetch the baby's patient card when they got hold of her. She looked completely petrified."

Xavier has seen many patients since post-election violence started in Kenya. But nothing seemed to shock him more than the sight of this woman. After some calm had returned to Kibera, the slum where she lives crammed together with half a million other Kenyans, she and her husband, who belongs to another tribe, thought it would be safe to return to their house.

"The woman is one of our patients in the revention-of-mother-to-child Transmission programme. She is HIV positive and needed formula milk for the baby," explained Zuhura, an MSF social worker who lives in the same neighbourhood. "But when they arrived there, more than ten men started beating her. Her husband ran away. She and her four children have taken refuge at the Jamhuri showground. She doesn't know where her husband is. He probably ran from the area because he's likely to get into trouble for being married to her."

In the Jamhuri showground, MSF ran a weekly clinic for HIV patients who could not go to the clinics in Kibera.

This story is one of many that illustrate how communities have been pitted against one another in the post-election crisis. In slums like these, where poverty and overpopulation form an inflammable cocktail - even in more tranquil times - the announcement of the results of the presidential election result sparked violence instantly.

Unlike many other health facilities that remained closed, MSF managed to keep one of its three clinics, the Kibera South Health Centre in the Nkisumu Ndogo "village", open. A second MSF structure, the Gatwekera clinic, opened shortly after. Amidst shooting and security forces cracking down on protesters, a skeleton team tended to dozens of wounded. During the following days, MSF kept the health centre open to guarantee health care for an increasingly isolated and hungry population.

Risk of resistance

MSF has been struggling to trace those HIV and TB patients who failed to show up for their appointments and collect their medicines.

"It is best for HIV patients to be permanently on treatment," explains Dr. Ian Van Engelgem. "When you stop your medication abruptly, one of the three ARV drugs stays longer in the blood than the others, considerably increasing the risk of developing resistance."

Another risk is that patients who are left with insufficient stocks of medicines will be tempted to stretch their supply by reducing their daily dose.

"A person who has only three days worth of pills but can only return to the health centre a week from now, might think it is a good idea to take only one pill per day," said Dr. Engelgem. "But this way you expose the virus to a lower dose, with an even higher risk of creating resistance than when you stop abruptly."

Patients who suffer from other chronic conditions face similar problems of discontinuing their treatments, as do TB patients.

"In the case of TB the delay of diagnosis of patients and the interruption of treatments can possibly lead to even higher infection rates than the staggering numbers that we are already seeing today. This could also fuel possible outbreaks of multi-drug resistant TB," says Dr. Van Engelgem.

Mistrust and fear

The mistrust and fear that has been sown between communities and neighbours by the outburst of violence will not be easily forgotten. Evelyn is 26-year old, HIV positive and a patient at MSF's Gatwekera clinic. After her house in Kibera was set ablaze, she fled. She says that she wants to leave Nairobi.

"I don't have any place to go," she said. "I want to leave, but I don't have the money for transport. Ever since I left Kibera, my stomach has been hurting."

During one of the first calm days between two waves of violence in Kibera, John (name has been changed), was in the health centre for unusual business. As one of the Post Test Club (PTC) leaders, he is HIV positive and one of the patient volunteers with whom MSF collaborates closely.

"I am here on behalf of one of my members who has fled the neighbourhood," whispered John. "He wants to know what he should do since he cannot come and collect his medicines."

He managed to get in touch with all his PTC members thanks to phone credits provided by MSF. Five of his PTC members left Kibera and are not planning to return. This is an undercover mission.

"If the people in my village would know that I am helping, it could create real problems for me. But as a PTC leader, I feel I need to be above these divisions."

Through the PTCs, MSF hopes to trace some of the people defaulting from treatment. But, as special times call for special measures and 290 patients have missed their appointments in the first two weeks of the year, a free hotline has been set up and advertised in newspapers countrywide. MSF hopes to reach patients who are at risk of interrupting their treatment, either because they fled their homes with little or nothing or because they are not planning to return to Nairobi.

Asked whether bad blood will affect their patient volunteer network, John has a straightforward answer: "I am very hopeful that the relation between all our members will remain good. Our network is non-political. Any discrimination, any tribalism is unacceptable. We have to consider each and every one of our members on humanitarian grounds, regardless of their tribe."