Richard Smith: Adding treatment of hypertension to HIV programmes in rural Kenya

Richard SmithThe biggest problem with treating hypertension in rural Kenya is lack of drugs. Health workers are plentiful, and there is an impressive health system—but drugs are scarce.

I learnt this when I visited the hospital in Eldoret, a small city in the West of Kenya, and a close by community clinic. My colleagues and I were the guests of AMPATH (Academic Model Providing Access to Healthcare), an organisation that has done an extraordinary job in treating the many patients in that region infected with HIV. Now AMPATH wants to “layer in” the treatment of patients with hypertension, diabetes, chronic obstructive pulmonary disease, and other chronic conditions. Dr Sylvester Kimaiyo points out that HIV infection is a chronic disease now that it can be treated with antiretroviral drugs and that it should be entirely possible to use the established system treat patients with other chronic diseases.

AMPATH began more than a decade ago. People from Indiana University had come to Eldoret to help found a medical school, but they soon found themselves in the midst of a pandemic of HIV infection and recognised the need to act. AMPATH is now supported by a consortium of around 10 North American universities, including not only Indiana University but also Duke, Brown, the University of Toronto and others. Each university takes the lead in providing support for particular programmes.

When AMPATH began community leaders said that there was no HIV infection in the community—“despite the fact that they went to the funerals of young people every week,” as one doctor put it. So, ironically, AMPATH began by testing for hypertension and diabetes, conditions that carry no stigma, but quickly it became apparent that something like 15% of the community were infected with HIV. Slowly but surely stigma lessened (but is still present), and AMPATH now treats 125 000 patients among a population of about 2.5 million.

As part of its work, AMPATH has developed a new verb, one without any vowels—to FLTR, which stands for find, link, treat, and retain. The leaders quickly recognised that they could make no impact on HIV infection by working in the hospital, mostly treating dying people. They needed to go and find the patients in the villages, link them into a system of care, and bring treatment as close to them as possible. Eventually they established a system of visiting every house and testing everybody; now almost everybody consents to treatment and for pregnant women Kenya has an “opt out” system. Treatment with antiretrovirals means that a woman’s chance of passing HIV to her baby is reduced from 50% to 1%.

The Kenyan health system has six levels, the highest, level six, being the two referral hospitals, one in Nairobi and one in Eldoret. Level one are the community health workers, who live in the villages, speak the local language, know everybody, and visit every home. Level two is the dispensary, where people can collect drugs. Funded by PEPFAR (President’s Emergency Plan for AIDS Relief), AMPATH has established some 50 clinics and worked with the government system. The programme has been very effective with reducing the prevalence of HIV infection from about 15% to around 6%. A sophisticated electronic information system keeps track of all the patients.

Now unfortunately patients in Eldoret are much better off if they have AIDS than if they have diabetes or hypertension—because they can receive free treatment for HIV that may extend their life by 35 years; health workers in the clinics see patients with diabetes and hypertension but until now have had little to offer them. Nobody knows the exact prevalence of diabetes and hypertension, but it’s probably something like 3% for diabetes and 15% for hypertension. Disabling strokes are common among young Africans, and hypertension and rheumatic heart disease are the probable causes.

AMPATH is a research as well as a care organisation, and has funding from many sources. It is now funded by the National Heart, Lung, and Blood Institute (NHLBI) to study the prevalence of hypertension. A programme has already begun of training local health workers to measure blood pressure and blood sugar, and the vision is eventually to FLTR patients with hypertension and diabetes using the existing workforce and health system.

It is possible to offer treatment to at least some diabetics because Eli Lilly, the pharmaceutical company, provides insulin for free. The doctors are quickly realizing that diabetes is a different disease in Subsaharan Africa in that many patients develop diabetes while thin and taking lots of exercise, while other patients need insulin and then don’t need it.

The Kenyan government does provide antihypertensive drugs, but not nearly enough for the numbers of patients that AMPATH know they will find. Yet everybody agrees that to find people with hypertension and then not be able to treat them will do more harm than good and be unethical.

The probable answer is a “revolving pharmacy.” These have been tried before in other parts of Africa. The concept is that a donor funds an initial supply of drugs. Patients do then pay for their drugs, dependent on their means to pay, and so the stock of drugs can be replaced. Success will obviously depend on procuring drugs as cheaply as possible and setting prices that patients can afford but will be sufficient to replace stock. This will be a delicate exercise, but AMPATH as well as inventing a new verb has a tradition of finding a way through what can look like impossible problems. “First we fail, and then we succeed,” they say.

Competing interest: RS is the director of the UnitedHealth Chronic Disease Initiative, which together with the National Heart, Lung, and Blood Institute funds 11 centres in low and middle income countries of which the AMPATH centre is one. UnitedHealth does not at this stage fund the AMPATH centre, but he visited Eldoret together with colleagues from NHLBI. UnitedHealth paid his expenses.