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HIV treatment in times of civil strife: serious threats to antiretroviral drug access in the Kibera slum following the Kenyan elections

Unge, Christiana; Södergård, Björna; Thorson, Annaa; Ragnarsson, Andersa; Carter, Janeb; Ilako, Festusb; Waweru, Marjoryb; Ekström, Anna Miaa

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doi: 10.1097/QAD.0b013e32830a751a
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The turbulence in Kenya following the elections in December 2007 was broadcast across the world, but few voices were raised regarding its potential impact on access to essential healthcare including antiretroviral (ARV) drugs for HIV positive patients [1,2]. Successful ARV treatment relies on high adherence to avoid the development of drug resistance [1]. The informal settlement of Kibera with an estimated 1 million people of mixed ethnic origin, of which more than one fifth are HIV positive, was one of the areas worst hit by the postelection violence.

We studied access to ARV treatment and staff experiences during the postelection period between 1 January and 1 February 2008 at an HIV clinic run by the African Medical Research Foundation (AMREF) in the Kibera slum, where 722 patients were receiving ARV. The number of missed appointments was compared with corresponding figures for the previous year (January 2007) using patient records. A self-administered questionnaire was used to explore experiences of AMREF staff at the Kibera clinic regarding access to the clinic, safety, and alternative sources of ARV drug supply during the postelection period.

Our review of patient records from January 2008 showed that 42% of 447 scheduled appointments were missed compared with only 14% in January 2007. This corresponds to more than 25% of all currently active ARV patients at the clinic (Table 1).

Table 1
Table 1:
Activity at the Kibera clinic for the months of January 2007 and 2008, by patient category, number of patients and percentage of currently active patients.

Twenty-five out of 63 (40%) staff responded to our questionnaire. The most common reason for absence from the clinic was fear of ethnic violence and a feeling of insecurity, hindering both patients and staff from traveling back to Kibera after the Christmas holidays in rural homes. Several respondents stated that they had been attacked by street gangs or ethnic mobs and had feared for their lives coming to the clinic, which is centrally located in Kibera. All staff members said that they had provided ARV to patients who normally go to other clinics, so it is not unlikely that some AMREF patients also obtained drugs at other clinics during the turbulence.

In conclusion, more than four in 10 HIV patients are likely to have experienced treatment interruption lasting for several weeks. As many patients in this context seek care late with low CD4 cell counts, treatment interruptions may rapidly lead to AIDS symptoms and deteriorating health. Also, since 99% (data not shown) of the patients are on Lamivudine, Stavudine 30 mg, Stavudine 40 mg, Zidovudine, Didanosine 125 mg, Didanosine 200 mg (nucleoside reverse transcriptase inhibitor) and Nevirapine 200 mg, Efavirenz 600 mg (non-nucleoside reverse transcriptase inhibitor) only, even short periods of irregular drug intake may lead to the development of drug resistance [3,4], which is especially problematic when second or third line ARV are not affordable. Studies from sub-Saharan Africa have shown that adherence levels of 68–85% can be achieved [5] but weak health systems, staff shortages and stigma contribute to jeopardizing regular drug intake and patient retention in ARV programmes [6,7]. The AMREF ARV programme in Kibera is faced with fairly low adherence even under normal conditions: our unpublished data (ongoing prospective cohort study, n = 407) show that 27% of the HIV-positive patients on ARV treatment have a mean overall adherence to ARV below 95%, with consequent risks of developing drug resistance [5,6].

Kenya is considered to be one of Africa's most stable democracies. Our results demonstrate that a political event superimposed on an already fragile context puts HIV patients on ARV at high risk of treatment interruption and irregular drug supply that could rapidly lead to drug resistance deteriorating health. As most patients are supplied with ARV drugs for only 1 month in most ARV programmes in Africa, ARV providers and donors could be better prepared in future to prevent ARV treatment interruptions by providing patients with medication for extended periods, when civil disorder is expected. Evident drawbacks to extended supplies include the risk of medicines being destroyed, lost, sold or given away. A systematic back-up plan to handle these situations is necessary given the shortage of human resources [8]. Tracing of patients who are lost to follow-up could be facilitated through extended peer networks and digitized record keeping indicating when drug refills are needed. Further, healthcare providers could be better prepared for times of civil unrest by developing formal collaborations with other nearby nongovernmental organizations and international nongovernmental organizations, as our findings show that HIV patients do try to access ARV drugs even during unstable situations.


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© 2008 Lippincott Williams & Wilkins, Inc.