HIV/AIDS in Mombasa, Kenya
Nicholas Gavin and Lara Bishay describe their visit to the Bomu Medical Centre
When HIV/AIDS emerged in the early 1980’s, its burden lay disproportionately with the poor. This generalization still stands today. While the pandemic has had its greatest impact in sub-Saharan Africa it has also scarred South East Asia, the South Bronx in New York, and Brixton London. These low income areas continue to bear the brunt of HIV/AIDS. This is an account of our visit to Mombasa, Kenya, before the recent violence.
Mombasa
In this port city of 700 000 people, countless mysterious smells fill your nostrils. New foods, equally Middle Eastern, Swahili, and Indian, drift out of small restaurants with hand-painted signs. The people, who are descendants of African tribesmen, South Asian technocrats, and Arab merchants, fill the air with exotic perfumes mixed with the scent of hard labor. And then there are the piles of garbage which are unrelenting and endless. Some are next to markets and others confined to dumps along the pothole-laced highways. Generally, the delicious smells outweigh the pungent, but in sum, they are wholly Mombasa.
At rush hour, you take in a scene of controlled chaos. Women covered from head-to-toe in black hijabs rush down the street on their way to work. News stands crowd every corner and scream the morning’s headlines, usually detailing the latest corruption scandal. Matatutus (mini-vans stuffed with 15 passengers), whiz by as their attendants shout destinations. Shop owners offer their latest wares and newest acquisitions.
Symbols of progress are seen throughout the city, interspersed with vestiges of centuries past. Shoeless men pulling rickshaws filled with mangoes and potatoes run past advertisements for the most advanced cell phone service. Across from Fort Jesus, a powerful symbol of Portuguese colonialism, stands an Internet café with an international calling center. While technological progress seems to have taken a foothold here, access to these modern (Western) conveniences is, for the most part, reserved for the rich.
This socioeconomic divide in Mombasa is tangible and all-encompassing. Many wealthier residents live in well-guarded fortresses just outside of the city with servants and sentries, while the residents of slums aim simply to survive. The rich, mostly Asians and Caucasians, dine on the cuisines of their native lands while poorer people, mostly Africans, eat the most common staple food, sima, an oatmeal-like substance made of ground corn and water.
However, unlike so many less fortunate parts of Africa, there is hope in Mombasa. The President’s Emergency Plan for AIDS Relief (PEPFAR) provides treatment for thousands of people living with HIV and AIDS in this city. While continuing to invest in treatment strategies, developing countries such as Kenya and donors such as the United States and European Union must not minimize prevention efforts. Throughout the city there are voluntary counseling and testing (VCT) centers. Also, community-based HIV/AIDS organizations run countless education campaigns to make the public aware of modes of transmission, symptoms of disease, options for testing, and methods of treatment. However, the emerging victor between the virus and those fighting its spread through prevention and treatment is not always clear.
The Bomu Medical Centre
The Bomu Medical Centre in Mombasa, a USAID Center for Excellence in HIV/AIDS treatment, is characterized by contrasts, contradictions, and half full glasses. Bomu’s staff and its inspirational leader, Hayati Anjarwalla, have been leading prevention and treatment efforts in the city since the HIV/AIDS pandemic was first recognized. In the United States and Europe, triple therapy for HIV has significantly simplified its management, rendering it comparable to that of chronic illnesses like diabetes, sickle cell disease, or hypertension. Yet in settings like Mombasa, only first and second line medications are available, necessitating complicated regimens that are challenging to maintain. In cases where a drug regimen goes without completion, the risk of wide spread viral resistance increases, which would be a disaster. As a result, clinic staff at Bomu are dedicated to spending a lot of time with patients educating them on strict adherence to the first line regimens.
At the Clinic
For us, two medical students interested in global health, visiting Bomu clinic provided an example of an African public health success. Bomu resembles a well-oiled medication-distributing machine. It is a meticulously cleaned, organized, and efficient operation through which about 150 patients receive free antiretroviral therapy every day. HIV testing and medications are provided free of charge thanks to PEPFAR funds. HIV-positive patients undergo three counseling sessions before beginning antiretroviral therapy. They designate a “buddy” for the patient so they can provide support and reminders to ensure they stick to their regimen. These regimens are complicated and must be taken correctly with 97% accuracy in order to achieve viral suppression.
Tuberculosis infections, which often occur concomitantly with HIV, are also managed at Bomu. Every patient who is found to be co-infected with TB is given a personalized TB medication kit and their progress is recorded carefully with each biweekly visit. This ensures that they finish their treatment regimen, preventing the development of multi-drug resistant TB (MDR-TB). MDR-TB, especially in resource poor settings, is difficult to treat because many times second and third line drugs are not available.
While there are many examples of Bomu’s stellar performance in the care and treatment of HIV/AIDS, significant challenges still remain. Disclosure and stigma are two such issues. Because women are more likely to get HIV tested, many times in the antenatal clinic, it is their burden to go home and tell the husband that they are infected. There have been multiple reports of domestic violence in response to hearing this news. Many women are simply thrown out of the house. With these stories circulating around the village it becomes clear why so many are reluctant to disclose their status, or even refuse HIV testing altogether. Too many men and women come to test in stealth; stranded and alone in their diagnosis should they turn out to be positive.
Current strategies for combating this stigma include education, intensive counseling, and outreach. Volunteers at Bomu clinic promote awareness of HIV/AIDS and how women are more likely to be infected. They spread a message of empowerment in getting tested and knowing one’s status in order to get treatment and become healthier. Through educational skits, voluntary counseling and testing outreaches to the community, and providing support for youths, Bomu is able to convince people to get tested and begin treatment.
And yet, it takes more than the eradication of ignorance to change behavior. The reality is, actions are driven by the need to survive. Unfortunately, women seem to bear the brunt of this reality. As victims of an inequitable economy, many women have turned to commercial sex work as a way to survive. Kenya’s reputation as a sex tourism attraction leaves women, and many times young girls to unspeakable abuse and vulnerable to HIV infection.
Advocacy groups like Nairobi-based Solwodi (Solidarity for Women in Distress) approach these women at night, encouraging them to practice safe sex, get tested, and even try to start new businesses with collective microfinance loans. As more women take control of their lives and each other in the face of the threat of HIV/AIDS, they find themselves empowered, and willing to find other ways to safely maintain their livelihood.
Back at the clinic, there is a bittersweet feeling in the conference room every week as about 30 new patients are discussed who have been deemed sick enough to start antiretroviral treatment. As we mourn the reality of the large number of people infected, we also celebrate the fact that so many are now receiving treatment.
As students visiting the clinic, our journey was defined by conditional flickers of hope. For instance, one of the most powerful moments we experienced at the clinic was witnessing two natural births in the span of one hour. Initially it was difficult to watch the mothers suffer such inordinate amounts of pain, but when a baby girl opened her eyes for the first time, filled with wonder, innocence, novelty, and hope, we were transfixed on a natural high and the hope of that baby girl seeped into our minds for the remainder of our trip. No matter the circumstance, a new birth carries with it potential and opportunity.
As the news of the efficacy of HIV/AIDS treatment moves into the community, more social challenges and large systemic obstacles abound. It is with the mindset of a new birth that these challenges should be faced: with every new challenge comes great possibility.
Nicholas Gavin and Lara Bishay
Third year medical student
University of New York
New York, USA.
Nicholas.Gavin@nyumc.org and Lara.Bishay@nyumc.org
Lara and Nick are grateful for the guidance and assistance provided by their colleagues in New York and Mombasa. Also, it is their great hope that the political divisions which have affected Kenyans recently will peacefully come to an end soon. Government and civil society are the greatest supporters of public health. Without stability in these arenas, the advances seen in Kenya can only deteriorate
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