Bulletin of the World Health Organization

Turmoil disrupts AIDS care in Kenya

Post-election turmoil in Kenya has disrupted the fragile and complex systems for delivering HIV/AIDS treatment in rural areas. Peter Mwaura reports from Nairobi.

Health services in Kenya have been scrambling to get life-saving antiretroviral (ARV) treatment to thousands of people displaced in a spiral of ethnic violence following the disputed presidential election on 27 December 2007.

An estimated one in 20 people are infected with the virus that causes AIDS in Kenya, a country of about 35 million people.

AMPATH’s Kenyan staff line up before going into Kachibora Kitale camp for internally displaced people in Kenya.
AMPATH/Regina Owino
AMPATH’s Kenyan staff line up before going into Kachibora Kitale camp for internally displaced people in Kenya.

By early last month, about 250 000 people had fled their homes and were living in temporary shelter, prompting fears that thousands of people with HIV/AIDS would be unable to reach health-care facilities for treatment because of the violence.

WHO expressed concern for the well-being of the internally displaced who were sheltering in crowded spaces with poor water supply and sanitation, and shortages of food and medicines.

The unrest has been particularly acute in western Kenya, where 62 000 HIV-positive people have been enrolled at 19 clinical sites and seven satellite clinics as part of AMPATH (Academic Model for the Prevention and Treatment of HIV), one of the largest and most comprehensive AIDS programmes in Africa.

Its clinics are located in towns and rural centres, while the main referral centre is at Moi University in Eldoret, one of the parts of Kenya that was worst affected by the violence.

“The initial disruption in HIV/AIDS care was huge and, if prolonged, could have disastrous effects on care and outcomes,” said Dr William Michael Tierney, AMPATH’s research director. He told the Bulletin that access to medication was “a huge problem because of patients not being able to travel and many staff being homeless, unable to travel, and perhaps leaving permanently because they are of the wrong tribes.”

Tierney added however that “because we have an electronic medical record system and record the tribe of every patient enrolled, we were able to identify how many of our patients – overall and by care site – were of the Kikuyu tribe and were most likely to be affected (about 4500 patients or 7.4%).” The programme’s catchment area in western Kenya has a population of five million with an estimated 300 000 HIV-positive individuals.

“Such information allows us to plan for which communities may need more assessment and interventions as we move forward,” said Tierney, who is also a professor at Indiana University School of Medicine, which established the programme with Kenya’s Moi University Teaching and Referral Hospital in the 1990s.

The violence has not only affected AMPATH clients but also its workforce, according to the programme’s team leader Dr Joseph Mamlin, who is based in Eldoret.

In the first week of violence, less than 10% of the programme’s clients and staff found their way to a clinic.

“The very next week a remarkable rebound occurred in all sites, except for Burnt Forest,” Mamlin told the Bulletin in an e-mail message. “We have multiple large IDP [internally displaced persons] camps, many housing 10 000 to 20 000 people, all around us now. We have been able to work closely with all relief agencies and have the programme’s teams engaged in every large camp. We clearly have hundreds of patients in the camps and many others, unknown numbers, moved far beyond our reach. But every day our register of displaced patients becomes more complete.”

Kachibora Kitale camp for internally displaced people in Kenya.
AMPATH/Regina Owino
Kachibora Kitale camp for internally displaced people in Kenya.

“Most of the displacement is around Eldoret and nearby clinics like Turbo, Mosoriot and Burnt Forest,” Mamlin said. “The worst affected so far is Burnt Forest. That site is devastated. But even then, the team has formed mobile units so as to reach Kalenjins [who were fighting Kikuyus] too fearful to return to the clinic [due to the high concentration of Kikuyus in nearby internally displaced persons camps] and making regular rounds in the camps housing mainly Kikuyu and some Kisii.”

The disruption, however, has shown that the programme’s plans to decentralize care and deliver more in the community were correct. “If we had been delivering more care in the communities and less in the health centres, the interruptions in transportation systems would have affected our patients less, especially getting drug refills. I anticipate that this will accelerate our efforts to ramp up community-based care,” Tierney said.

Mamlin praised the loyalty and commitment of the programme’s Kenyan staff. “They have taken every risk to stay at their posts. Many of our workers have lost homes or have been forced to send members of their families to safer locations but the core of the programme’s staff is working overtime to meet the needs of our patients.”

With its staff of about 900, the programme had made progress in confronting the HIV/AIDS pandemic in western Kenya. Before the outbreak of violence, it enrolled more than 2000 people every month and tested 169 000 people every year, including more than 30 000 pregnant women, for HIV. It also provided 23 000 patients with psychosocial support, fed 30 000 people every week and provided school fees, housing and other assistance to 1900 orphans.

Record keeping which is essential to patient care delivery and outcomes has also been affected. In some cases only a single staff member was able to reach a clinic on a given day and, at worst, the programme simply recorded the name and ID of a patient, and refilled drugs, with no encounter forms completed to record details each time the patient visited a clinic. The programme has developed two new encounter forms for collecting data on HIV/AIDS treatment in camps for the internally displaced.

“Record keeping is the cornerstone of what we do and will not be compromised any more than is absolutely necessary,” Tierney said.

Tierney and Mamlin said it was too early to know the precise impact that the violence had had on the prevention and treatment programme, but were optimistic about the prospects of restoring treatment to most people in need. Mamlin said: “I fully expect all AMPATH sites to weather this storm, find the majority of their patients and continue to grow in comprehensive care.” ■

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The initial disruption in HIV/AIDS care was huge and, if prolonged, could have disastrous effects on care and outcomes. Dr William Michael Tierney

Many of our workers have lost homes or have been forced to send members of their families to safer locations. Dr Joseph Mamlin