Sunday, November 30, 2008

Thirty eight million divided by a few hundred...

HIV was first identified in Kenya in 1984. However, it has probably been present there since some time in the 1970s. The political response to what may then have been only a potential epidemic was generally one of denial. There is still a lot of denial, though it is now often cloaked in politico-technical jargon.

The HIV epidemic appeared to decline from the late 1990s, from a prevalence of 10.7% in 1997 to around 6.6% in 2004. However, much of this decline may have been due to a high death rate. Recent figures suggest that HIV prevalence began to increase again after 2004 and stood at 7.8% in 2007.

Much of the HIV prevention work carried out in Kenya started in the late 1990s and early 2000s. This could suggest that the prevention work has been of little benefit. Of course, that is just my analysis. But through this blog, I hope to be able to say why I think that Kenya has so far failed to control the HIV epidemic.

I’ll return to historical details at various points, but first, I’d like to concentrate on this week, National Aids Week, 2008, here in Mumias, Western Kenya. This is where my interest in HIV began, way back in 2002.

Mumias is a very typical town, surrounded by many other smaller towns and villages. (I hope my photographs bear witness to this.) Much of the HIV awareness, prevention, treatment and care work is carried out by an organisation called SAIPEH (Support Activities in Poverty Eradication and Health).

On Thursday, we went to a town called Malaha (pictures on Picasa). There was music and drama to raise awareness about HIV. SAIPEH volunteers went from place to place, asking people if they knew about HIV and getting tested. A mobile VCT clinic (Voluntary Counselling and Testing) was set up for the day.

So far, so good. Over 100 people turned up to be tested. But there were only 100 testing kits. A car was sent off for more testing kits but they were not available at such short notice. After mobilising hundreds of people who were willing to be tested, only around 120 people were tested.

So the mobile VCT could come back next week? Well, yes and no. The Kenyan Government sets up VCTs but they are only just realising that a few hundred clinics is not adequate for nearly 40 million people. Let’s not do anything hasty, VCT clinics have only been around for nearly 20 years.

The government is also just realising that about 80% of people live in rural areas. Most VCTs are in towns. Malaha is less than half an hour from Mumias, where the nearest VCT clinic is. But the return journey costs around 200 shillings, about 2.5 dollars. That would buy more than three kilos of maize flour, the staple food.

Maybe a few days without food for yourself and your family is a small price to pay for knowing your HIV status, but if you are sexually active in an area with high HIV rates, you need to be tested regularly, perhaps every year. But I don’t see anyone choosing to be tested if it means spending scarce cash that could be used for food.

SAIPEH put forward a proposal for a VCT clinic to be set up in Malaha, but it was turned down. SAIPEH is expected to pay some of the costs and supply some of the labour to carry out the government’s work, but if they mobilise people and can’t provide the testing facilities as well, people will know all there is to know about HIV except whether they are positive or negative.

And if someone is positive? Eventually they will need to go on ARVs (Anti Retroviral Drugs). These are free. Well, the drugs are free, if you can get hold of them. Sometimes, the supply doesn’t move from central areas, such as Nairobi, to more remote areas. Sometimes, supplies don’t move at all, such as during a civil disturbance. And when the supply of ARVs does move, it stops in Mumias.

Back to the isolation problem. Malaha is not that far from Mumias but people there find it hard to meet the costs of going there for a test. Even harder to meet the costs of travelling there regularly for fresh supplies of drugs. This is not even counting the cost of special dietary requirements for people on ARVs, drugs for other illnesses, time taken off work, etc.

If there was a VCT in Malaha, ARVs could also be distributed from there. I don’t think I am the only one to question the Kenyan Government’s commitment to fighting the HIV epidemic.

Ok, Malaha is just one town. On Friday we went to Shibale (photos). Shibale is not as far from Mumias and it is a very busy place with a bustling market. Mumias is known throughout Kenya for one thing, sugar. You can drive a long time in the region and see little but sugar cane. Everywhere there are bits of chewed cane because people become addicted to sugar from a very young age.

But it’s not just the people that become addicted. Once an area commits itself to a monoculture, it’s hard to get away from it. A market and infrastructure develops around the sugar industry. The Mumias Sugar Company is, pretty much that market. They can provide the transport, fertilizer and anything else you may need. Sounds ideal, till you come to get paid for your sugar and find out how much those all cost!

But why whinge, the Mumias Sugar Company is in Shibale. So the people there are rich? Well, no, there are rich people working for the company but most people in the town do casual work. They dependence is not just on sugar but on the single employer for many miles around. But given all the wealth in sugar, there is a VCT clinic in the town?

No, there is no VCT. Being close to Mumias, a mobile VCT that could test and distribute drugs would be ideal. So SAIPEH turn up and make music and merriment. People come and talk. Free condoms are distributed. Demonstrations are given on how to put on and take off condoms. People exchange views and enjoy the activities. But some ask for a test, having expected a mobile VCT and they are told to wait or to go to Mumias.

Saturday, SAIPEH are in Shianda, it’s a market day. We drive around, the musicians and performers in the back of a truck, shouting, singing, stirring up curiosity. And when the band starts playing, many people turn up to watch and enjoy. More condoms, more demonstrations using the wooden dildoes.

And more people asking for a test. Friday is market day in Mumias. I met a woman there who said she was afraid to be tested because she didn’t know how she would cope if she turned out to be positive. She was within easy walking distance of the Mumias VCT. But this is why SAIPEH volunteers go around mobilising people and persuading them to be tested. There are many reasons why people are reluctant and SAIPEH have spent nearly 14 years addressing these problems.

This same woman turned up and said she had decided to be tested. She was just one of the many people who was disappointed to find that there was no mobile testing unit. But she said she would go to be tested anyway. She is mobile, she can go to Mumias on a market day. As for those who can’t afford to travel, maybe SAIPEH will be able to organise for them to be taken to a VCT or arrange a mobile VCT visit.

Even if there were 1000 VCT clinics in Kenya and even if they were in isolated as opposed to urban and semi-urban areas, this would not be enough to achieve universal testing. Of course, universal testing depends on many things aside from an adequate number of testing facilities. Even unlimited mobile facilities would not persuade people to be tested if they don’t want to be tested. But it would be a start.

How many VCTs, mobile and otherwise, would be required for Kenya? I don’t know. But I will write to Dr X (I'll reveal the identity another time). Dr X is an advocate of universal testing and universal roll out of ARVs. The former is a prerequisite for the latter. Maybe it would be possible to indicate how far away Kenya is from reaching even those who will willingly be tested. If I get a reply, I’ll post it here.


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