When the battle against superstition, stigma and scant sex education is over, the fight to treat HIV patients begins. So what is stopping more Kenyans from taking antiretroviral therapy?
Residents of Kibera listen to a talk about TB at an Amref health centre. Photography by: Anthony Karumba
By Kirsty Taylor-The Guradian
Some striped cloth and a basket full of earth formed Damaris Cagina’s first line of defence when she kept falling ill. “I was getting sick for months at a time – I couldn’t walk,” the slight 34-year-old from Kenya’s rural Makueni district recalls.
The domestic worker took her HIV-denying husband’s advice and turned to witchdoctors to shake off the string of infections she later discovered sprang from the virus.
Waiting in line to see the doctor at Makueni district hospital’s HIV/Aids clinic, Cagina now scoffs at the practices she once trusted to ward off ill health.
“I went to very many herbalists to try and find a cure, but they didn’t know what was wrong with me,” she explains. “They told me my mother-in-law had bewitched me. They told me to buy special fabric – a white cloth with red stripes – and to put soil in a basket to stop the spell. I tried it all but nothing helped. It was only after very many visits to herbalists that I decided to come to hospital.”
Cagina is one of the estimated 1.4 million people living with HIV/Aids in Kenya today. But like many of them, she first refused tests to discover her status, viewing a positive result as an immediate death sentence and spiritual curse.
The country’s government has supplied antiretroviral therapy (ART) to suppress the virus to patients for free since 2006.
According to a 2007 Kenya indicator survey, of the 390,000 adults estimated as being eligible for ART at the time of the survey, around 140,000, or 35%, were taking the medication.
“Stigma is still the biggest challenge in terms of gaining treatment for people with HIV,” Makueni district hospital’s medical superintendent Dr Charles Maina says. “People can pay a lot of money for spiritual remedies before seeking medical treatment. They only come to hospital when they are not able to recover – by that stage their conditions can be very complicated.”
Deep-rooted stigma and patchy health education has led many to cower from the disease, which has seen the country’s life expectancy rates shortened by 20 years in the last two decades.
Even those signed up to take their two daily doses of ART drugs often struggle to adhere to the lifelong treatment – an error that can lead to drug-resistant strains of the HIV virus and of opportunistic infections like TB.
Those waiting on Makueni hospital’s concrete benches for repeat prescriptions, or tests to check their viral loads, tell how the nationwide food and water shortages are especially hard for those surviving on ART.
“You have to have good nutrition to take the drugs,” says 37-year-old mother Ruth Sambua, who tested positive in 2004. “I dig ditches in a food-for-work scheme but it doesn’t give you enough food to get by.”
Fatal waiting times
At Makueni even emergency patients can queue for hours – some die before being called by the nurse. Others cannot afford to travel from homes at the edge of the hospital’s 70km catchment area. The government-run facility’s two ambulances often sit idle for lack of fuel.
While sick patients travel miles by foot, progress to control the HIV virus moves at walking pace. Medics are anxious for solutions, yet many have dismissed a radical new proposal to eradicate the HIV/Aids epidemic in the space of a decade.
A World Health Organisation (WHO) consultation this month examined whether treating all HIV/Aids patients with ART could halt transmission of the disease. Experts examined a 2008 WHO report’s claims that treating the disease immediately, rather than the standard practice of waiting until a patient’s immune system dropped, could cut new infections by 95% in just 10 years.
The study used mathematical models predicting that universal annual HIV testing followed by blanket ART for positive patients could see new cases fall to less than 1% of a treated population within 50 years – even in Sub-Saharan African countries with a high disease prevalence.
But the scheme would be a shift for many health providers following current WHO advice. Guidelines state patients should receive ART only when their CD4 count – used to determine low immune levels – drops below a certain point.
“Can you imagine starting someone who is still very healthy on ART? It would not do them any good,” argues Walter Kibet, a clinician at the African Medical and Research Foundation’s (Amref’s) Kibera health centre in Nairobi.
“Fine, transmission may go down, but it does not stop completely,” says Kibet, who treats patients in Africa’s biggest slum. “You risk transmitting a medicine-exposed virus to someone who has never taken any [ART] medicines. This is how we can shoot the virus into resistance.”
While Kibet says ART adherence using current guidelines was improving, he argues that extending prescriptions is no solution. “We need to focus on what we call prevention with positives. We say: ‘OK, you are positive, but you need to protect others and yourself from re-infection by using condoms’.”
Dennis Wanyama, Medecins sans Frontieres’ clinician for Kibera agrees, adding: “I don’t think it is something that would be doable for our set-up here, because we don’t have enough medicines, equipment or human resources. Also, if you start someone on ARV with a high CD4 count the side effects can be greater than normal.”
But Ministry of Health district Aids coordinator for Nairobi West, Margaret Mwangi, says: “It [universal testing and ART] could be a good idea – if you started with a high CD4 count that person might be able to live a longer and better life.
“The government are fighting so that
we should have enough drugs for everybody – there are many issues but now there is enough [with careful management].”
Even recent hopes that a breakthrough vaccine against the HIV virus had been found, are now being called into question in some quarters. In September, it was victoriously announced that an Aids vaccine tested in Thailand had protected 31% of inoculated participants from becoming infected with HIV.
But quibbles over data analysis in the 16,000-volunteer study are already casting doubts over the statistical power of the findings. Some members of the scientific community now argue the vaccine in fact protected only 26% of those who received it.
Back at Makueni district hospital, Maina has more immediate concerns: helping those already infected with the disease. Though drug supply is not currently an issue, even some medical staff remain unaware of ART’s essential role. Maina says: “They don’t understand how ART can prolong someone’s life. It is naturally difficult for them to counsel a patient on medication they don’t believe in.
“A chief from the area called the hospital recently asking for names of HIV positive patients from his area,” the clinician recalled. “He wanted to know their burial dates for his diary.”
Defying even her own expectations, Cagina has been living a healthy life on ART since 2005. She borrows the 90KSH (94p) Matatu fare to hospital when she lacks the funds, and tells everyone she meets about living positively with HIV.
Unfortunately some do not want to know. “My husband is one of six brothers and three of them have died,” she says. “I tried to advise their wives to get tested but they will not accept they could be dying of HIV. It is very sad. They all still believe they have been bewitched by my husbands’ mother.”
But when her husband forbade her to continue treatment, she had an easy decision to make. “He said I had to choose staying with him or visiting the hospital. “I chose my health, so I left him. He should be checked too but he is better at taking a drink of beer than going to the hospital.”
Source: http://www.guardian.co.uk/
Comments