A simple idea with a big future?
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There is not much light inside Lucy's corrugated ironed-roof house, but we can make out a picture of God blessing the world on last year's calendar hanging on the clay wall, and we can feel the mud floor under our shoes. Undiminished by the gloom, Lucy's bright smile glows warmly as she invites us to sit down. Today is check-up day with Naomi Njeri, her Community Health Worker (CHW). Naomi is here to make sure that Lucy's HIV treatment is going well and that she's taking her anti-retroviral medicine (ARV). Naomi is particularly careful to look for any early signs of opportunistic infections - if she finds any, Lucy will be referred immediately to Kijabe Hospital. Lucy is happy to show us that she has gained more weight. No longer bedridden, she can look after her household again without outside help. If only the cough would go (a sign of active TB)...

Naomi counts the number of pills that Lucy is supposed to take each day. Should there be so many left? Lucy explains that she vomited after taking one drug and that she stopped taking it. Naomi writes it on the report sheet that she keeps to follow-up her "clients" and gets up to leave. "Ni ngatho mùrata witu" says Lucy to me in Kikuyu, the local language, when we walk away. "Thank you for being our friend". Naomi and Lucy have become close friends during their many check-ups together.

Naomi and the 330 recently trained CHWs like her are not doctors. Like their patients, most CHWs are also HIV positive and often on treatment themselves. But they have been counseled and trained by Kijabe Hospital in the intricacies of HIV, and fully understand the implications of not sticking to the course of medicine.

A striking idea

It was a local HIV-positive man who came up with the idea of patients looking out for the health of other HIV-positive people in their community. Three years ago, in a village near Limuru, 50 kms northwest of Nairobi, Dr Jon Fielder, Consultant Physician at AIC Kijabe Hospital, was approached by one of the attendees of a support group: "Can't you train us (the patients) to be community health workers? We live with the disease on a daily basis. We are the ones taking the drugs, and we can ensure the sustainability of your HIV/AIDS program within our community. And on top of that the volunteers we had so far were never good at keeping our HIV status confidential".

Dr Fielder was struck by this simple yet powerful idea. Several patients were already active participants of HIV/AIDS support groups. They had gone through the intensive treatment preparation process provided by the clinical team before starting their ARVs, and were receiving continuous training from the community nurses and clinical officers.

Although the idea seemed brilliant, one of the main challenges would be to ensure that the patients would not only look after themselves, but would help the hospital team recognize the symptoms, diagnose the disease as early as possible and treat others before the opportunistic infections take hold. Continuous coaching and counseling from the hospital team empowered the patients to participate in a health mission that progressively gave new meaning to their own survival and to the life of their community.

Another challenge was to gather HIV-infected people in a community under the same roof, when many had never suspected that their neighbors might be HIV-positive too. Secrecy and stigma soon faded away.
As David Phairu, PLWHA Coordinator of one of the 56 support groups in the region, puts it: "When you are offered free treatment and continuous support after being told that you are HIV positive, it is easier to come out to the light".

Once the hospital management became convinced that the idea was worth a try, 30 volunteers were invited to Kijabe hospital for the first three-day patient-CHW training session (see Box for details).

The Training Program Africa Inland Church Kijabe Hospital's (AIC Kijabe Hospital) was once famous for its first class surgery. But now it is its CHW training model that is attracting the attention of Kenyan and international medical facilities alike. "Combining clinical and community-based training is really what adds value to our initiative", says Frederik Kimemia, currently HIV/AIDS Assistant Program Manager, and one of the five key teachers at Kijabe Hospital since day one of the program. The sessions are conducted using evidence-based articles and materials mostly developed in house. This material is then adapted to local people's needs. Feedback from the Community Health Workers during their training sessions is included as case studies. Patient-CHWs and Support Groups training provides basic information on the disease: different means of infection, virus replication and viral load, role of CD4 cells to keep the immune system combative, counseling, antiretroviral combination, detection of side effects, vital importance of adherence and monitoring, and management of HIV in the home setting. Other aspects like hygiene and nutrition are also included. All CHWs looking after three or more patients are given refresher courses to keep them abreast of the latest findings in HIV/AIDS. Nurses training: Each month, six nurses follow a 2 week initial session on the basics of HIV care and the management of opportunistic infections. Emphasis is on how to prepare patients for their ARV treatment and how to help them stick to it Clinical Officers training: Each month, two clinical officers follow a four week initial session on HIV/AIDS which emphasizes how to recognize ARV side effects and when to recommend a change in therapy, how to diagnose the different opportunistic infections, and the different ARV options in order to provide proper guidance to CHWs. Pediatrics for HIV/AIDS practicum has recently been introduced in the training curriculum because of the increasing number of HIV-infected children requiring care and treatment. In addition to the clinical-based training and one-to-one mentorship, the Kijabe team provides a community-based educational experience. Team members accompany learners during their home visits and they inform and counsel the support groups on the latest developments in HIV/AIDS. Most of the questions raised focus on opportunistic infections: how to identify them, how to diagnose them and how to treat them? Building capacity in the community for as long as necessary is the training team's main preoccupation, although the current trainees' empowerment shows evidence of potential sustainability in the long term. Another aspect of the approach is to harness the power of religious leaders in African society. By showing compassion and willingness to help the infected and affected people of their congregation, and by visiting patients, they can greatly reduce stigma within the community. This then allows the HIV program to get off to a constructive start. So far, the Kijabe team has instructed 400 local religious leaders, who now possess the skills and knowledge to help the communities.

The strengths of community-based care

By March 2007 Kijabe Hospital had trained 330 CHWs (30 more than initially planned), using a grant of USD $15,570 (KShs. 1.3 M) from the Merck Company Foundation.

Why is patient-provided care in the community such an attractive idea?

Continuous medical education improves the CHWs' knowledge of the disease and its treatment. Their thirst for knowledge is endless: after so many years of limited access to medical information they finally feel that they are totally responsible for their lives and that by sharing what they have learnt with the hospital team, they can also save other lives and support affected members of the community. They have become increasingly convincing when advocating for full adherence to ARV treatment and care.

The results speak for themselves: a 92% adherence rate of people on ARVs to their treatment and a 91% adherence rate to HIV/AIDS care . "These results are as good as for clinical trials, even though the number of patients is constantly rising!" says Jonathan Mwiindi, HIV Services Manager, who has played an instrumental role in the funding process of this project.

A program assessment showed a significant increase in the number of:

patients compliant with their ARV treatment after being trained at Kijabe hospital, versus those who had never been sensitized to compliance issues nor trained on HIV/AIDS in any way.

Next steps

The team is now considering increasing the number of CHWs trained to 600.
Kevin Shannon, Medical Director at Kijabe Hospital, has witnessed the incredible breakthrough accomplished with the training of patient CHWs over the last two years. "We have managed to reach out to the community better than at any time before, thanks to the path paved by the AIDSRelief CHW network. I would like to use this network for other diseases and issues that can be prevented before they actually occur and have negative consequences for the patient. I'd like to focus on women and children".

But challenges remain. For Frederik Kimemia, the most pressing needs now are to: