Katherine 26
Wednesday Feb 17, 2010. Katherine is a young woman from Mtwapa, a suburb to Mombasa on the North side, where people generally are very poor. Katherine is brought to the Zion Clinic by her pastor William Meni. Pastor Meni is a vigilant man in his early fourties. He keeps saying how important he thinks the work of the Zion Clinic is. Before, when people got sick, we thought they had malaria or pneumonia, he said, but now when we know about HIV, we have learnt to see this in our congregations also.

He comes to the Zion Clinic with members from the congregation when he sees they are deteriorating, because he knows that there they can get a diagnosis and treatment, not only for HIV itself, since Zion has a holistic program including education, food support, home visitations much more.

Katherine is a very beautiful young woman, 26 years old. She does not speak English, so Pastor Mani tells her story. She is an orphan, both parents died over 10 years ago. She has since then stayed with an uncle on her mother’s side. Katherine is not married and has no children. For several years she has worked sewing clothes in a nearby factory and has been a very dedicated member of the congregation. Now, since three months she has been deteriorating and that’s why her pastor decided to take her to the clinic.

She has lost a lot of weight and is now only 37 kg. She has no fever, but rales over the left lung and is “R”, meaning “reactive”, that is, HIV positive. How did she contract this much feared disease? We do not ask, and right now it does not matter. The lung affection is beyond doubt tuberculosis, or “TB” as everyone here says.

Initial blood tests reveal a Hb of only 77 g/L and an elevated ESR of 60 mm/hr. She has a low MCV indicating iron deficiency as well. Here every woman we have seen has a Hb less than 100. Anemia is very common and multifactoral, dr Julius My… tells us. Hookworm is very common. So is malnutrition. Sickle cell anemia is another cause of anemia. Malaria is common. Other infections and infections due to HIV are other causes of anemia, even HIV itself. The HIV prevalence rate here is 5,9 %, according to large scale testing of whole villages of up to 2000persons that has been carried out by the field workers from Zion.

Gladys, the other Medical Officer on the staff who takes the evening shift. She delivers the test results to Katherine and starts planning ahead. It is a situation she has faced many times before and she knows exactly how to handle it. This patient immediately receives iron, vitamins and T/S prophylaxis and is invited back the following day for group education about HIV, treatment adherence, and more. Tomorrow she will also start treatment for TB and go to Mtwapa to take a chest x-ray.

The pastor pertinently asks about nutrition. What should she eat? A balanced diet, Gladys replies. Can she get it? Under what circumstances does she live? We know very little yet, but she will be visited by the community group from Zion which will find out more about her living conditions and also find and educate someone in the family that can become a supporter. Another good question from the pastor is what to tell the others in church.

So we talk about secrecy and decide to at first call it pneumonia. Later, Gladys says, the patients through the patient education program will learn how to tell friends and relatives. HIV, though common, still is a very stigmatizing disease. It may not be easy to tell your closest relatives, but in the longer perspective yet necessary.

Many thoughts come to my mind afterwards. Will she make it? Her CD4-count must be very low. Yes, most probably she will make it. There are many success stories with a beginning worse than hers. Will she get good treatment? Yes, the mediciation that is offered here, tenofovir, lamivudin and efavirenz, is probably one of the best initial combinations there are. Even second line choices are very good. Thereafter, if third line is needed, it is not today possible, but most surely will be in the near future. Why did her parents die? From HIV? Quite likely. How did she get HIV? Abuse??? We cannot know. How will she be able to support for herself? She will have to depend on her relatives for at least the next six months to come. Will they continue to support her? Probably. Even if they get to know she has HIV???

Katherine is just one of so many. Can they benefit from all new knowledge and medication for HIV? I’m quite sure. I even think that applying the program for holistic HIV dare designed by the US aid which is used by the Zion Clinic will can be one way of teaching structure and awareness to a population that is so poor in everything and need so much.

When the Zion Clinic started they had many providers, like feeding the nations, etc. These now have backed out, which means that at present the Clinic cannot provide free medical services too the neediest. The clinic has a great program, great facilities, a very dedicated personnel, good knowhow, local connections, laboratory equipment and drugs, but lack food for the food program and funds to be able to offer free basic HIV care to the most needing, those who don’t have food for the day and to whom costs for laboratory testing is not the main priority.

My impression and strong conviction though, is that these people at the Zion Clinic have come so far in raising a structure for HIV care among the poorest and that it can work even within a society with very little infrastructure. The urgent need today, as mentioned, is means to be able to continue the food program and to be able to deliver free medical care for the very poorest. 5 kgs of maise flour costs 7 USD and will give food to a family for a month. Another 8 USD per month will cover for laboratory costs and medicine for the most basic diseases for one HIV infected person, often a single parent with children.

With treatment, what can they expect? Well, to live a good life for many years to come, so that they can see their children grow up and care for them. As for the more complex issues concerning HIV treatment, advances in all areas today are so rapid, that soon they can have access even to much more sophisticated technology and treatment than today. Also, if the Zion Clinic can show that high quality HIV care can be work in a setting like this, then they have shown that it is a concept that can be spread to others.