I remember vividly the first time I came face to face with the magnitude of the ravaging HIV epidemic in Kenya. It was in 2001, and I was a first-year medical student making my first foray into the medical wards at Moi Teaching and Referral Hospital. The last cubicle was not for the faint-hearted. The majority of the patients there had what was then known as full-blown Aids. It was heart-wrenching to see first-hand the pain and suffering caused by HIV. In those days, lifesaving anti-retroviral medications were not readily available. They were too expensive. People Living with HIV (PLHIV) would be diagnosed and placed on septrin and wait to die. Millions lost their lives.
2003 marked a watershed moment in the fight against HIV. President George W. Bush established the US President’s Emergency Plan for Aids Relief (Pepfar). Over the next 20 years, the US government invested 8 billion dollars in Kenya. Pepfar, working in partnership with the Government of Kenya, has saved thousands of lives through supporting life-saving antiretroviral treatment (ART) for nearly 1.3 million men, women and children.
As of 2023, Kenya is at the cusp of achieving the UNAIDS 95-95-95 targets (95 per cent of people living with HIV diagnosed, 95 per cent on ART, and 95 per cent virally suppressed). Pepfar has moved from an emergency programme to one focused on ending HIV as a public health threat by 2030. These gains are, however, fragile and easily reversible if not safeguarded.
The global Aids response is at a precarious point. Funding has stagnated or is dwindling. Some 44 countries rely on international assistance for at least 75 per cent of their national Aids response. As a country, we must keep an eye on the critical issue of sustainability. Some of the proposed solutions to the changing HIV funding landscape include increasing domestic sources of funding, public-private partnerships, and budgetary Health System Strengthening initiatives.
In Primary Health Care (PHC), we may have found an answer to the HIV sustainability question hiding in plain sight. In 1978, the Alma-Ata Declaration identified PHC as key to the achievement of the goal of health for all. It defined PHC as “essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals and families in the community”.
As a foundation for, and way to move towards universal Health Care (UHC), the World Health Organisation (WHO) recommends reorienting health systems using a PHC approach. PHC enables universal, integrated access to health services as close to people’s everyday environments. It also helps deliver the full range of quality services and products people need for health and well-being, improving coverage and financial protection. PHC, therefore, provides a unique opportunity to integrate HIV services as part of the package of services under the PHC/UHC umbrella.
Forty-five years later, PHC still lies at the core of the health agenda in Kenya. The Ministry of Health aims to scale up and improve the delivery of primary health care services through the establishment of Primary Health Care Networks (PCNs) in line with the Kenya Primary Health Care Strategic Framework 2019 – 2024. These PCNs form a key building block for scaling up UHC. The PCNs comprise a Level 4 health facility as a hub, which will support the spokes (Level 3, 2 and 1 facilities and the community health units).
In Turkana, Amref Health Africa, working closely with the County Government of Turkana, is piloting an innovative model to deliver PHC; the Kimormor One Health PHC Strategy. This One Health Approach involves combining human and animal health interventions in outreaches launched from Sub-Hubs, which are linked to the Hub and Spoke PHC PCN model.
The proposed model augments the PCNs with outreaches launched from Sub-Hub container clinics spread along pastoralist migratory routes and health facility hubs. This will enable the model to be responsive to the needs of the 60 per cent of the pastoralist population in Turkana and address the conundrum of a static health system serving a mobile population.
The outreaches and services offered through the PCNs are integrated and include Ante Natal, Child Immunisation, Outpatient Consultations and HIV Prevention/Treatment Services. Social services such as birth certificates, national ID and NHIF registration are also offered concurrently.
Such PHC models offer opportunities for integrating PCNs with HIV prevention/treatment services as a solution to the challenges posed by the current silo design of the HIV programme in the country. They provide opportunities for designing UHC packages of care that cover the costs of HIV services to minimise out-of-pocket expenditure and the risk of financial hardship.
A well-resourced PHC approach presents an ideal model to provide comprehensive, coordinated, continuous and people-centred care to people with chronic illnesses such as HIV and non-communicable diseases. The integration of HIV services into PHC is a crucial cog in the long-term sustainability of the HIV programme in Kenya.