Kibera, the sprawling mass of tightly packed structures roofed with corrugated iron that makes up the largest slum in Nairobi, the Kenyan capital, is home to more than 600,000 people, most of whom relocated from their rural homes in the hope of making their fortune in the city.
Precious few achieve that dream - the majority eventually settle for a life in the slum, working as casual labourers and living a hand-to-mouth existence.
"I've lived here for 10 years," a young man said as he led the way through the slum, leaping over piles of garbage littering the ground. "Sure, it's hard to live here, but it is preferable to the village, where you can't earn a living."
Women sit on stools selling mandazi (deep-fried doughnuts) alongside an open sewer - the stench is overpowering.
Disease is rife in Kibera, and the medical centres that operate here are overwhelmed by the numbers they have to treat. Malaria is widespread, as is TB, whose spread is exacerbated by the cramped living conditions.
HIV/AIDS is endemic - transactional sex is often the only means of survival for many of the slum's young women. They trade their bodies for as little as 20 shillings (US $ 0.30) - just enough for a small meal - and are rarely in a position to negotiate the use of a condom.
TREATING MORE THAN JUST HIV/AIDS
The problems of Kibera's residents run deep: most of the shelters can barely be called houses, and because it is an informal settlement, there is no running water, electricity or proper infrastructure.
Dr Marjory Waweru, who runs a community health centre for the African Medical Research Foundation (AMREF) targeting an estimated 97,000 people, said it had been built as a model of the best way to provide services in similarly impoverished areas.
"Our facility is integrated: it provides several services, from treating non-HIV-related illnesses to providing ART [antiretroviral therapy], water and sanitation facilities, and counselling," she commented.
Waweru emphasised that the area's HIV/AIDS needs were great, with HIV levels at 50 percent among TB patients, 40 percent among those who came for diagnostic counselling and testing, and 14 percent among expectant mothers attending the antenatal clinic.
Treatment was accompanied by other services to improve quality of life among residents, such as providing fortified flour to those who needed it, and running a project that paid school fees for orphaned children.
"The centre also provides microfinance, giving loans to Kibera's residents so they can start small businesses," she said, pointing to a row of stalls a short distance from the centre, where traders were selling everything from shoes and television sets to fast food.
"Many of the businesses you see here are as a result of the microfinancing we provide," she noted. "People need to be able to generate an income to improve their standard of living and move out of the slum, or at least afford to pay for treatment when they are ill."
POVERTY HINDERING TREATMENT
The international medical charity, Medecins Sans Frontieres (MSF), runs an HIV clinic in Kibera's Gatwekera zone, with a target population of about 150,000. The clinic has treated more than 2,000 patients since it opened and provides free ART to about 560 people.
"We have been here since 1997," said Florencia Maghanga, the nurse in charge of the clinic. "We provide diagnostic counselling and testing, psychosocial counselling and antiretroviral therapy."
Although the clinic's ART provision has been relatively successful, Maghanga said people were often afraid they would be unable to afford the good nutrition that should accompany the medication because they were so poor.
"It can be difficult to provide services to people here - many refuse to start ART because they know they cannot faithfully adhere to it," she added. "They often travel to find work in order to afford the food they need, and could be gone for days, interrupting their treatment."
The MSF clinic arranges for social workers to visit patients, counselling those who need it, providing HIV/AIDS education and linking them with other organisations that can provide the nutritional, financial or medical support to enable them to remain on ART.
DETERMINED TO LIVE
Despite the severe difficulties of dealing with HIV and grinding poverty, many of Kibera's HIV-positive residents are resolutely trying to live the best lives they can.
Charles Omondi, 36, spoke openly and honestly about living with HIV. "I am not sick," he emphasised, "I am HIV positive."
He has joined MSF's team of people who encourage members of the Gatwekera community to seek counselling, testing and treatment. He believes his own life is proof that HIV is not a death knell. "If you live positively, others see that and know that they can also live the same way," he said.
Charles was not always the optimistic, life-affirming man he is today. "When I was first diagnosed with HIV, I did not accept it. I continued my training to be a schoolteacher, but my frequent illnesses interfered with my studies," he said.
The training centre management soon got wind of his HIV status and he had to leave the programme. He moved back to Kibera, where he spent most days in bed, self-medicating with across-the-counter painkillers and refusing to deal with the fact that he was slowly dying.
"Eventually a friend suggested I visit the MSF clinic and, once I did, I received much counselling to assure me that I was not dying," he said. "I also came to terms with telling my mother, and later others, about my situation."
Today Charles is gainfully employed and in robust health. He proudly showed off his medical file, noting his improvement in the three years he had been receiving ART. More than the treatment of his physical sickness, he said, it was the psychosocial counselling he received that allowed him to believe in a brighter future.
He is now engaged to an HIV-positive lady, and the two spend their evenings planning the future. They are saving to send her to hairdressing school and even thinking of having a child once they are in a better financial position.
"One of my favourite things about my fiancée is that, like me, she is determined to live," he said.