Kenya: Disasters and triumphs at the HIV clinic

Fresh into his first MSF assignment in Kenya, Irish doctor Eamonn delves into work at our HIV clinic in Homa Bay County.

‘Pole sana’ is a Kiswahili phrase that seems to express sympathy quite tactfully. Last week, feeling overwhelmed and a bit helpless, I said it to a poor woman who had just lost her son.
She responded with grace, dignity and gratitude despite the tragedy that had just befallen her.
Her poor son was a young, strong lad of 17 who came to our facility diagnosed with HIV. He was short of breath and had catastrophically low blood oxygen levels.
Eamon at work at the Homa Bay Hospital, Kenya.

Eamonn at work at the Homa Bay Hospital, Kenya. Photo: MSF.

Without access to most tests I would have liked, and with time fast running out, I initiated every reasonable treatment that may have made a difference – treatment for bacterial pneumonia, HIV-related fungal pneumonia, blood clot, TB, and gave fluids, oxygen and nebulisers... What he desperately needed was an ICU for 24-48 hours to support his organs and to give these treatments time to work.
I stood around uselessly the next few hours as I saw him slipping in and out of consciousness and tried to explain what I could about the situation to this distressed and devastated woman.
He died shortly after.

Homa Bay County

It’s been an eventful six weeks since I had my mandatory Dublin airport long-term pre-departure pint.
I had been waiting patiently for three months for the opportunity to go away with MSF and then had been alternating swiftly between excited and apprehensive when it finally arrived. My eventual destination on this journey was Homa Bay, Homa Bay County, Nyanza Province, Kenya.
Homa Bay County, Kenya.

Homa Bay County, Kenya. Photo: Jean-Christophe Nougaret.

Homa Bay County is an area about half the size of my native County Galway, on the shores of Lake Victoria in Southwestern Kenya. It has a population of almost a million people according to a 2013 census.
Homa Bay District Hospital is a collection of buildings with 200 beds covering adult medicine, paediatrics and maternity and is the main referral facility for the aforementioned million people. To put that in context, it is a hospital a third the size of that in my native Galway serving four times the population. 

The HIV problem

The scale of the HIV problem in Homa Bay County is enormous. The most accurate figures available show a prevalence of 24.1 percent, which represents the worst epidemic anywhere in Kenya.
About two thirds of these people are aware of their HIV status and most of these are leading happy, full and healthy lives thanks to anti-retroviral treatment.
The MSF team here consists of primarily of excellent and committed national staff and seven ex-pats, all of whom have made me feel extremely welcome since my arrival.
MSF’s goal here is two-pronged. 1) Most importantly, going door-to-door to increase testing and diagnosis of HIV and to get as many people on treatment as possible and 2) To improve inpatient services in the Ministry of Health-run Homa Bay District Hospital which, as I mentioned earlier is the main inpatient facility for almost one million people.
People attend a health information session at Homa Bay Hospital.

People attend a health information session at Homa Bay Hospital. Photo: Jean-Christophe Nougaret.

My mission for the next six months is to help with the second part, and contribute what I can to these desperately stretched services.
And desperately stretched they are. The ward I have been working on was built 60 years ago to house 24 beds. The 32 beds that are now crammed in there contain an average of 44 patients. This means over half the patients, often with contagious illnesses having to share a bed.
Fifty percent of the inpatients are people living with HIV, which in medical terms tends to make them much more complex and sicker than the average patient. One in five of these people will be diagnosed with tuberculosis (TB).

Disasters and triumphs

The cruel reality is that even in my four weeks of work I’ve seen young people become critically ill and die due to largely preventable complications of HIV and will see a lot more in my time here.
There have been cases where I have had no access to tests that may guide treatment, and yet more where I’ve made a diagnosis and have been unable to provide useful treatment due to expense or unavailability. The feeling of helplessness that comes with this has been by far the most difficult thing to come to terms with as I descended from my high-income healthcare ivory tower.
Unfortunately situations like the one above are the things that stick out in your mind. The disasters are generally more dramatic than the triumphs in medicine.
The well-managed patient who walks out of the hospital and proceeds to live a long and happy life never weighs on anyone’s mind. No one dwells for long on the potential death/disability averted in the patient casually diagnosed with HIV in the community and started on anti-retrovirals.
But triumphs these are and I think I might indulge myself and dwell on one such triumph now.
A patient chats with an MSF staff member at Homa Bay Hospital.

A patient chats with an MSF staff member at Homa Bay Hospital. Photo: Jean-Christophe Nougaret.

Earlier in the week a young woman turned up on our ward with severe malaria. Thanks to bedside tests provided by MSF, within an hour of landing she had not only a diagnosis of malaria, but of HIV, a precise idea of how advanced it was and a basic screen of TB and the most serious HIV-associated infections.
Within 24 hours she had been educated and counselled by specialised MSF-trained staff on her illness and its treatment - they even explained the need for her partner to get tested.
Earlier today she was discharged well on oral antimalarials and HIV treatment with an outpatient appointment in the near future to ensure all is going OK.
Her life expectancy just increased from a sickly three to five years to a healthy 45+ more years.
She can expect with good adherence to lead a nearly completely normal life, have HIV negative children and who knows? Perhaps even a cure some years down the line.
With 15,000+ tests performed in the district by MSF monthly that’s a lot of averted disasters, avoided transmission and most importantly healthy, happy patient years.
I’m extremely grateful for the opportunity MSF have given me to be here.
It’s wonderful seeing a tangible and sustainable difference being made. And despite the obvious challenges and difficulties, as well as running dangerously low on factor 50 sun cream, I do very much look forward to the next five months.