Just after dawn, patients already fill the benches in the waiting area of the FACES clinic at Lumumba, Kisumu. They quietly await their turn to navigate the assembly line of services provided at the clinic, which the FACES staff have distilled down to an exact science: reception, the vitals bench, the clinical exam room, the nutrition department, laboratory, pharmacy. Those who arrived earliest will be on their way in just a few minutes; others will be there all day.
FACES has also refined and nearly perfected the clinical management of HIV. Numerous flowcharts and algorithms decorate the clinic walls, specifying which regimens to prescribe, and when it’s time to re-check a CD4 or viral load. If a client is just one day late to an appointment, the social science department launches phone calls, home visits, and special counseling appointments to address any problems. In the six weeks I spent at Lumumba, I saw countless healthy patients at their routine check-ups and dozens of babies born to HIV+ mothers testing negative for HIV. The occasional patient with an acute medical complaint was dealt with swiftly and expertly, for example an active pulmonary TB case, or a newly diagnosed woman with a shingles rash perfectly illustrating the T1 sensory distribution.
Only one problem stood out for which the FACES staff didn’t have a ready solution: the social stigma of HIV. In the privacy of the exam room, clients opened up about the agonizing decision to test, their anxiety disclosing their status to their family members and partners, and the life-changing moments they discovered their partners’ ARVs taken behind their backs. Women in particular were at risk of HIV-related violence if they asked a sexual partner to use protection, or notified their husbands of a positive test.
This problem will require more than a simple algorithm, but there is hope. In my last week I re-filled prescriptions for a lovely family that illustrates the potential of the HIV epidemic in Kenya. The mother, father and now-teenage daughter had been on ARVs since they were first available in Kenya a decade ago. Not only had they disclosed to each other, but they supported one another and until now had attended their quarterly clinic visits as a family. On this visit, the parents beamed with pride as the daughter proudly announced that she was moving away to begin college.