For three years, Lydia* and her three small children have slept rough on the streets of the Kenyan capital, Nairobi, begging for handouts from passers-by during the day and huddling together for warmth in alleys at night. She was diagnosed with TB a year ago when she visited a public health facility, but was unable to finish her medication due to lack of food and now her health is deteriorating.
"When you take them [drugs] without food, you feel weaker," she told IRIN/PlusNews. "If I can get steady food, I can resume my treatment, but for now, I will stay without it."
People living on the street say accessing medical services is a challenge. "We can't go to the hospital because… [sometimes we are] sent away, and some ask for money, which they know we don't have," Mary Alusa, 32, and a mother of three, told IRIN/PlusNews.
"Even when I was pregnant, I went to a clinic and I was sent away because I had no money. I never went back," she said.
Health workers say many homeless people avoid health facilities because they are afraid of being victimized. "I think they believe everybody is against them. They think they will get arrested when they walk into the hospital, but those who are brave enough to come - and we do receive some - will receive care because it is their right," said Justus Mogeni, a clinical officer at the Pumwani Hospital in Nairobi.
The Ministry of Local Government estimates that there are 150,000 street families and 450,000 street children in Kenya's major cities and towns.
"The cost of living is spiralling and many people can't cope... when people are evicted from what they have always known to be home, they troop to the streets - cost of rent is so high, many can't afford even a shanty," George Miseda, an urban planning expert and lecturer at the University of Nairobi, told IRIN.
Lucy Chesire, a clinical nutritionist and coordinator of the Kenyan chapter of the NGO, Advocacy to Control TB Internationally, said, "Street persons are vulnerable to TB because they live in conditions that predispose them to infection - poor diet, inadequate access to diagnostic facilities, and treatment default."
Without proper treatment, a person infected with TB can infect as many as 10 to 15 people each year. Kenya is ranked at 15 on the UN World Health Organization (WHO) list of 22 countries with the highest TB burden in the world, and has the fifth-highest burden in Africa.
People living on the streets are also more likely to experience sexual abuse and exploitation, putting them at risk of HIV, and many use illegal drugs. "Sexual violence and exploitation in the streets, drug abuse, and engagement in commercial sex work makes street people vulnerable to HIV," said George Githuka, head of the most-at-risk populations programme at the National AIDS and Sexually Transmitted Infections Control Programme.
Government officials say it is harder to design programmes for street families than other hard-to-reach groups, such as sex workers and men who have sex with men. These marginalized and at-risk groups can be targeted through peer groups and community follow-up, but such methods are less effective with street families because of their transient way of life.
"Reaching them is a challenge because you will never find them aggregated in one place, and we have no strategies currently that we can use to take services to them," said Joseph Sitienei, head of the Division of Leprosy, TB and Lung Disease at the National AIDS Control Programme. "We haven't done any assessment to find out the level of TB infection among these people."
The WHO Stop TB Strategy includes addressing TB and drug-resistant TB among poor and vulnerable populations.
"There should be programmes targeted specifically at them [street people], and it is important to get entry points to help reach them with services,” said Chesire. “We can't make progress on the fight against TB by neglecting other groups."