Lumumba

I realized that we’re halfway through our time in Kisumu (!) and we’ve yet to write about our work. UCSF has a relationship with the Kenya Medical Research Institute (KEMRI) and together they run a cluster of clinics in western Kenya  under the aegis of the Family AIDS Care and Education (FACES) program. Visitors like us are often clinical, either medical students, residents, or fellows, or doing research here. You may have heard about this large HIV study which has been in the news recently. One of the study sites was our clinic in Kisumu.

The FACES clinics  serve HIV positive people and their families  in the Nyanza province of Kenya. This province has the highest rate of HIV positive people in the country, some clock it as high as 25%. The clinic we are working at is called the Lumumba Health Center and serves 9-10,000 patients, including a large number of children who were congenitally infected. The clinic is a busy, busy place.

The majority of the work at Lumumba is done by non-physicians: clinical officers and nurses. The clinical officers do 3 years of training after high school and a one year clinical rotation in the hospital. The closest approximation in the US would be a physician’s assistant. Medical doctors in Kenya do 5 years of training post high school and a year of internship to be a general practitioner. The only time we see the medical officers, as they are known here, is during multi-disciplinary rounds where the CO’s and nurses bring difficult cases that they need help with. Then there are a cadre of CCHA’s, or clinical assistants, that take vital signs, do counseling, home visits and other miscellanea.

The clinic doesn’t necessarily run smoothly or speedily. Patients don’t have an appointment time, just an appointment day, so the wait is long.  Patients start lining up at the clinic entrance at 4 or 5 in the morning. But its a pretty amazing example of HIV care in a resource limited setting.  The vast majority of patients know their drug names and follow their CD4 counts (a measure of the immune system in HIV) avidly. These are people who often have just a primary school education. Its pretty amazing. They also do a lot to reduce the stigma around HIV through counseling and HIV education classes. The issues they deal with are tough, in some ways tougher than those we see in the US. At what age do you disclose HIV status to a child who was infected at birth? How do you protect co-wives in a polygamous relationship? What do you do with HIV positive teenagers who won’t come to clinic?  There really aren’t any easy answers to those questions.

HIV mortality is still high here. There are only 2 lines of antiretroviral therapy (ART)  and after that patients have to pay out of pocket which is basically impossible (the first two lines of drugs are paid for by PEPFAR). However, we’ve seen ways in which the patients get better care through their association with FACES and thus their HIV positive status. Whenever a FACES patient goes to the hospital, which is inevitably the public hospital, they are visited every few days by a FACES staff member. This person looks over the chart, sees the patient, discusses the case with a medical officer if necessary and generally tries to make sure the patient is getting what they need. If the patient can’t afford a test that is available at the clinic, they do the test free of charge. Given the public hospitals in Kenya, and much of the developing world, are overcrowded, understaffed, and care is only given if you can pay, this is huge.
It’s obviously not all rosy and rainbows, there are some deep systems issues and problems which I’m sure will come out in later posts, but by and large it’s an example of how to give solid, quality care at low-cost.

Rachel

Learn more about FACES here