Médecins Sans Frontières began operations in Mathare in 1996 with a primary health care dispensary. By 2000 they found need for a specific HIV and TB treatment centre and the Blue House was opened in 2001.
The urban prevalence rate for HIV in Kenya is 17-18%; for Mathare it’s closer to 25-30%. While this is an alarming statistic, it is the presence of TB in Mathare that concerns Médecins Sans Frontières. ‘TB is considered a 19th century disease and largely ignored,’ said Médecins Sans Frontières’s James Lorenz in Nairobi. ‘However, conditions within areas like Mathare make it very prevalent and it’s these secondary “opportunistic infections” like TB that are so dangerous to HIV patients.’
Christine Genevier, Médecins Sans Frontières’s Head of Mission in Nairobi, backed up this concern: ‘This (TB) is the number one opportunistic disease,’ she said. ‘If we get a TB patient we have to convince them to accept an HIV test because at least 60% of TB patients are also found to be HIV positive.’
Mathare is a perfect breeding ground for a disease like TB: there is little access to water, drainage and sewerage are virtually non-existent and there is one toilet for every 400 people. The two rivers flowing through Mathare are used as a dumping ground. Houses are constructed from whatever can be found.
The residents themselves are generally unemployed or low-income earners; more than half are single mothers living on less than a dollar a day. Access to health care, in most cases, is impossible.
Medecins Sans Frontieres treat over 6000 patients in Mathare. On average, 100 patients visit the Blue House each day for primary health care (including ‘emergency’ cases), TB and HIV diagnosis and initial and follow up treatment. The Blue House also boasts a lab where TB screening via sputum slide microscopy and HIV blood tests to determine the stage of the HIV virus, are conducted.
TB is a hard disease to detect at the best of times and is especially hard in HIV patients where the sputum tests often show to be negative and chest x-rays appear clear. ‘TB presents in many different ways,’ said Laboratory Technician Andrew Mwangi-Chege. ‘We take three sputum samples from suspected patients over a period of time to increase our chance of finding the TB bacillus,’ he said.
‘In Mathare, if the patient has the clinical symptoms, even if the sputum is negative and even if the chest x-ray is normal, we still put them on treatment,’ said Dr Liesbet Ohler, one of the two doctors working in the Blue House. ‘TB is a very big problem in Mathare and we now have five MDR patients (multi drug resistant) that we cannot cure with our drugs. Normally you have to isolate those patients but here in Nairobi there is no hospital with a good isolation room.’
A major component of Médecins Sans Frontières’s work in the Blue House is education. A survey conducted in October 2005 showed that 30 out of 61 patients didn’t recognise or understand the importance of keeping follow-up appointments or adhering to their medication.
‘The risk of developing resistance is exponential with the number of times you forget to take your medicine,’ said Christine Genevier. ‘That is why, in this program, we have a big number of counsellors and such an input into the counselling of the patients to see that they are adhering to the treatment.’
The concern is trying to keep as many patients on the generic, and subsequently cheaper, ‘first line’ treatment for both HIV and TB. When first line treatment fails, pateients are put on the more expensive, and non-generic, second line treatment. ‘We started the ARV (antiretroviral) program in 2001. At that time the cost of one year’s treatment with generics was around $300-400 US dollars, two years before that it was $15,000. The generics have brought a huge difference. Now it is below $200. A move to second line treatment is a minimum of $700-800 but closer to $2000,’ Christine said.
It’s unfortunate to have to speak in dollar terms. However, with a government unwilling to help – officially the Kenyan government doesn’t recognise the existence of Mathare – health care for the slum dwellers of Mathare comes down to NGO’s like Medecins Sans Frontieres and the donations they receive.