KENYA: Clinics struggle to keep patients not yet eligible for ARVs
Newer, point-of-care diagnostic technologies are likely to improve patient retention
NAIROBI, 2 August 2011 (IRIN) - Jairus Musau tested HIV-positive two years ago, but when he was told he would not immediately be given antiretrovirals, his parents insisted he visit a traditional healer in his eastern Kenya hometown of Kitui.
"The doctor told me I would not be given ARVs since I still did not qualify for them," the 25-year-old told IRIN/PlusNews. "When I shared this with my parents, they told me I would live with somebody who would pray for me."
When Musau first sought treatment, his CD4 count - a measure of immune strength - was 389. The UN World Health Organization
currently recommends that HIV-positive people initiate treatment at a CD4 count of 350 and below; while Kenya has indicated that it will switch
to these guidelines, most people still access treatment at the national guidelines-stipulated threshold
of 200 and below.
When he started feeling very ill, Musau left the traditional healer's home and went to Mbagathi District Hospital in the capital, Nairobi, where his CD4 count was found to be well below 200 and he was immediately given treatment.
"Now I can see I am improving soon after I started taking my drugs. If I had sunk my head in prayers, I would be dead today," he said. "Many people die like that, not because they want to, but because when you are told you are HIV positive but you must wait and start taking ARVs later, you believe even swallowing a rock can save you."
More than 400,000 HIV-positive Kenyans are currently on ARVs, but another 600,000 need the drugs and have no access to them; an estimated 1.5 million Kenyans are infected with HIV.
The national guidelines state that all patients diagnosed with HIV be put on cotrimoxazole, an antibiotic used as a prophylactic against opportunistic infections. A 2011 study
conducted at Nairobi's Coptic Hospital found that provision of cotrimoxazole improved the retention rates of Kenyan HIV programmes from 63 percent to 84 percent; 16 percent continued to be lost to care.
According to Georgina Masivi, a senior Comprehensive Care Centre Nurse at the country's largest referral facility, Kenyatta National Hospital, retaining HIV-positive patients not yet eligible for treatment remains a challenge.
"[Some] will come while they are still being treated for opportunistic infections and once they start to feel better, they just disappear, forgetting it is ARVs that they need for their long-term survival," she said.
According to Andrew Suleh, medical superintendent at Mbagathi District Hospital, the many processes involved in attaining ARV treatment can act as a deterrent. "There are procedures that health workers need to follow like taking CD4 counts of a patient, waiting for the results, counselling for adherence and making sure that a patient is psychologically prepared to be initiated on treatment," he said. "Some patients are lost along the way because of the frustration of having to wait and they run to seek treatment through some other means.
"Children are even more susceptible to loss to care because somebody, either a parent or a caregiver, doesn't care to take them back for treatment or fails to go back and collect their test results," he added.
A recent review
of studies on retention of patients between testing and treatment found that more than two-thirds of people who tested positive for HIV but were not yet on treatment were lost.
Health workers in Kenya say some of the major reasons include: the stigma involved in visiting a health facility where they are known, long distances from health centres and the long wait for test results.
Ibrahim Mohamed, head of the National AIDS and Sexually transmitted infections Control Programme, noted that the government was trying to improve record keeping at health centres in an effort to keep track of patients.
"It would be too ambitious to say you can eradicate cases of patients getting lost before they can be initiated on treatment, but we emphasize proper health records and patient information management by healthcare workers to ease follow up," he said. "Maybe what we need to do now is share this information with all ART sites so that if one patient is lost at a particular centre, he or she can be traced should they seek treatment at another."
According to Suleh, boosting community health worker numbers and introducing technologies
that give much faster CD4 and TB diagnoses would improve programmes' ability to retain patients on care. Most recently, the developers of an "mChip"
successfully tested in Rwanda, say it can diagnose infectious diseases such as HIV and syphilis at patients' bedsides and potentially streamline blood testing worldwide.
"Now we are talking about point-of-care CD4 count and advanced technologies that can give results of TB diagnosis in just hours," he said. "If we invest in these and have more community workers to track down patients, then such cases of loss of patients can be reduced."