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MSF in Kenya, 2003
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Dorothy, infected with HIV/AIDS, receives antiretroviral (ARV) treatment through MSF's program in Homa Bay. She is a widow struggling to raise three children. She now has the courage to speak openly about being HIVpositive, and has regained the strength and energy to care for her children and go to work.
This is the case for increasing numbers of people in Kenya, where irrefutable proof is being built up that people can be treated in resource-poor settings. The proof is undeniable and can be seen in strength regained, lives taken up again, hope in the future given new life. MSF is helping to foster this through ARV treatment at four project sites in Kenya, where 460 people were receiving life-saving treatment as of July 2003. Unfortunately, in Kenya and in most developing countries, there is still a big gap between the number of people who are receiving treatment and the number of people who need it – today – to stay alive.
In Kenya, around 3 million people are infected with HIV, for which there is currently no cure. Around 500 people with AIDS die each day. ARV treatment, however, can enhance and prolong the lives of people living with the disease. Because AIDS often strikes the young and economically active, key economic sectors – including agriculture and education – suffer directly from the consequences of the epidemic. ARVs can do much to reverse this loss of productivity: not only do patients feel better, but they can often resume employment and provide for themselves and their families. In Kenya, 220,000 people whose immunity levels have already dropped enough to make them very sick need ARVs right now.
The treatment that has given Dorothy new life is, at as little as US $200 a year, still too expensive for people in developing countries who need it. Affordability is just one barrier. Structural problems in public health care in many poorer countries, lack of funding and lack of political will to identify and implement solutions, all constitute the major barriers that keep millions of people from getting the treatment they need.
Since MSF became involved in the fight against AIDS in Africa in the early 1990s, the organization has been working hard with other groups to tear down what were once considered insurmountable obstacles to ARV treatment. MSF's projects are showing that it can be done. The focus is now on scaling up the programs and encouraging the government and other actors to do the same.
Showing that treatment works, one patient at a time
In Homa Bay's District Hospital, in Kenya's Western province, MSF started ARV treatment in cooperation with the Ministry of Health in November 2001. Similar MSF projects started in April 2003 at two sites in Nairobi and July 2003 in the town of Busia on the border with Uganda – all areas with particularly high HIV/ AIDS prevalence.
For MSF's doctors, the results of their efforts are tangible. "Each time I get discouraged, I think of Paula, one of our first patients," says Agnes, former head of MSF's program in Homa Bay. "When I prescribed her ARVs, she weighed 36 kilograms. Today, she weighs 57."
For people with AIDS, the possibility of getting treated can change everything. Victor, 46, had not been feeling well for years. When he heard there was treatment available at the hospital in Busia, he decided to go in and get tested. On treatment since July 2003 through MSF's program there, he is now very active in encouraging others to go in and get tested: "Look at me," he says. "I've been tested and now I'm benefiting!"
These successful programs have taught MSF valuable lessons on the practicalities of AIDS treatment in settings where the medical and financial resources are limited. MSF has now simplified admission criteria patients to treatment programs (it is now based on clinical diagnosis and not lab tests) and adapted protocols. New patients are now given the same standard treatment, in a fixed-dose combination, so it is easier to take. This has made treatment provision easier, but there are still many challenges to the practical implementation and scaling up of these projects.
Nonetheless, and in opposition to many skeptics, MSF is demonstrating that ARV treatment can be used effectively in developing countries and that it is essential in the battle against HIV/AIDS.
Working to promote change
Although MSF's program is a start, the great battle lies in making these drugs more affordable and more available to put them within reach of the greatest number of people possible.
In Kenya, MSF's Campaign for Access to Essential Medicines has been working with local organizations to lobby pharmaceutical manufacturers, distributors and the Kenyan government for more affordable medicines for AIDS and to increase accessibility of treatment. In August 2002, years of intensive advocacy by MSF and other Kenya-based and international organizations paid off, when the Kenyan government signed a patent law permitting importation and local manufacturing of more affordable generic ARVs. To push for passage of the law, MSF and the group of organizations, all together called the Kenya Coalition for Access to Essential Medicines, actively contacted the media, briefed policymakers and organized public events. The result of all these efforts is a patent law that is progressive by international standards. However, there is still a long way to go.
Despite the number of daily casualties, there has been a lack of political will to fight the AIDS pandemic with the urgency required. "It was such a mess. It was so frustrating to know that we could treat so few people when much more could be done," said Christa Cepuch, MSF's regional pharmacist. "MSF was successfully treating a limited number of patients, knowing that the government wasn't playing its role or making efforts to start its own programs."
Elections in December 2002 and the ensuing change in government brought fresh motivation. The Kenya Coalition is working to inform the new policymakers about what the policy priorities – in terms of access to medicines – should be. As part of these efforts, MSF organized a symposium in April 2003 to share experiences and solutions on how to scale up ARV treatment. The symposium brought together people from the public and private sectors: officials from various ministries, health institutions, mission hospitals and AIDS organizations, as well as business people and journalists. A key aim of the gathering was to entice others to begin providing ARV treatment. During the conference, the government announced that it would strive to provide ARV treatment to 20% of AIDS patients by 2005, hoping to reach 50-60% of those in need by 2008.
Continued lobbying focuses on concrete goals, such as the design and implementation of a national treatment policy and jumpstarting production of generic ARVs by local pharmaceutical manufacturers. For the general public, ongoing campaigns to . ght the stigma that still surrounds HIV/AIDS in Kenya are instrumental in keeping prolonged public pressure on the authorities. MSF and the other Kenya Coalition groups also plan to become involved in a treatment-literacy campaign to inform and educate Kenyans about ARV treatment and what it means. "Internationally, many obstacles to increased treatment are being brought down," says MSF's Christa Cepuch. "Drug prices are going down due to increased competition from a growing field of generic producers. There is more money from international donors. Now national governments are the ones being focused on: to implement policy change, to allocate budgets, and to strengthen infrastructure. This year the Kenya Coalition will be challenging the government to treat the Kenyan people in need."
Other projects: related AIDS care and assistance to refugees
In addition to providing ARV treatment, MSF programs in Kenya treat opportunistic infections related to AIDS, with a special focus on tuberculosis in some areas. Supporting AIDS education and prevention, providing social and psychological assistance and sometimes nutritional supplements are all vital parts of MSF's work. MSF provides voluntary HIV counseling and testing and many of the above services at clinics in the Nairobi slums of Dandora, Kibera, Pumwani and Matharé, as well as at hospitals in Nairobi, Busia and Homa Bay. For pregnant women who are HIV-positive, MSF also has projects to prevent transmission of the virus from mothers to their unborn children. After 11 years providing medical aid to around 130,000 Somali refugees in camps near Dadaab in eastern Kenya, MSF handed over its work there to a German organization in June 2003. Nutritional aid to Kenyan, Somali and Ethiopian children in Mandera, in the northeast, was suspended inde. nitely in June 2003 after a grenade explosion outside the MSF compound severely injured an MSF volunteer.
MSF continues to respond to emergencies in Kenya, such as a nutritional emergency in June 2003 in northern Kenya.