HIV/TB clinic in Africa

Description of proposed project

For many years, care for HIV and TB in Africa has been siloed into very specific, high-quality programs designed to find people who are infected and get them treated. PEPFAR did incredible work using this model over the past few decades, but this was quite expensive and very vulnerable to outside shocks (like someone coming in with a metaphorical chainsaw to stop payments to U.S. foreign aid.) After the foreign aid freeze back in January and the significant cuts to various aid programs caused a lot of chaos in the delivery of HIV/TB services, our hospital in rural Kenya decided that the way forward was to integrate our HIV/TB clinic with our other medical clinics to remove these silos to preserve as much of our quality of care as possible despite these outside shocks. This was always part of the long-term plan, but it became a much more immediate concern with all of our HIV/TB funding threatened and forced us to work much faster on making it happen.

While PEPFAR funding looks relatively safe for now, the question of long-term sustainability for HIV/TB care is still a big one. Donor funds (including U.S. foreign aid) is probably going to be available for antiretroviral drugs for HIV for quite a while, but all of the other things that help people get those drugs (like training doctors and other providers in how to prescribe and manage these patients, community health workers to follow up on patients who have disappeared, etc.) need funding. There’s very little money for other primary care and chronic disease management in Africa, which means that hospitals and clinics are going to have to be really strategic in how they integrate their outpatient medical services. Because of the way that money flows, HIV patients have been getting really good services for many years and other medical outpatients have been getting practically nothing. Integrating the two means meeting somewhere in the middle.

There are lots of different factors to consider as this integration proceeds, but the biggest area we’ve identified where people could improve is in training our medical clinicians. They’ve always been managing conditions like hypertension, diabetes, heart failure, etc., but now they need to know how to manage HIV (which is usually at least a 3-week course) and funding community health workers to help manage both HIV and medical conditions in the community. With lots of hospitals and clinics across the continent asking how they can integrate these services, we want to demonstrate just how valuable community health services are in managing these conditions and set up a model for how integration should proceed. We also want to help set the tone for debates about the future of foreign aid and what kinds of integrated processes should be supported going forward. A lot of this is about proving to hospital administrators that they should invest in community health work because it brings dividends to their patients that ultimately benefit the community and proving to donors that integrated primary care is a sustainable future for HIV and TB care. This includes, we hope, skeptical politicians who are currently suspicious about the value of foreign aid and want to see an “exit ramp,” so that they’re not committed to just shoveling money at a problem indefinitely.

Why are you qualified to work on this?

I’m a family doctor who’s been working in East Africa for 10 years. Our hospital has been serving patients in this rural community for over 100 years and our HIV/TB clinic has been taking care of patients since PEPFAR started in the early 2000s. You can email Rebecca Juma at bdo@pceachogoriahospital.org and our CEO Dr. Elijah Mwaura at drmwaura@gmail.com if you want to ask more specific questions about the clinic, the hospital, or how we manage other grants.

What would you do if not funded?

If we don’t get the money, we’ll try to find other grant money to do fewer renovations. The hospital will scrounge up the money to send our medical clinicians to a shorter, less comprehensive HIV education program. Our patients will keep paying for OI medications out of pocket if they can. We probably won’t launch a community health program and I’ll keep writing about foreign aid and health care in between seeing patients but we won’t try to fly anyone out to write about it.

How much money do you need?

We’re asking for $45,000, which we’ll spend on: $2,000 to train our medical clinicians in HIV care $10,000 to renovate our clinic, specifically renovating more clinical rooms so that more of our clinicians can see patients in the same space and work together. $25,000 to pay salaries for four community health workers for a year and funds for things like motorbike fuel and glucometers so that they can follow up on our patients in their homes and communities (HIV and other medical conditions) $3,000 for drugs for opportunistic infections for immunosuppressed patients. This was previously covered by the American government but those funds have been cut and now patients have to pay out of pocket for things like antifungals for cryptococcal meningitis or Bactrim for pneumocystic jiroveci pneumonia. $5,000 to fly a journalist out to our hospital twice over the next year so that they can write about what we’re doing and describe to the world what integrated care for HIV, TB, and other medical conditions might look like.