February 24, 2022

Dear Readers,
 
Kicking off 2022, we are doing a tribute and update on an amazing UCSF HIV international Program in Kenya – FACES. We wanted to share with you how FACES started, its high impact and accomplishments to date and its exciting new direction. ARI is proud to support domestic and global programs—and in particular, US and global young investigators working internationally. I would personally like to acknowledge Dr. Craig Cohen for his continued leadership in the FACES program. He started this visionary program with his Kenyan Collaborator Dr. Elizabeth Bukusi in 2004. As you will see this program has had tremendous impact and saved hundreds of thousands of lives.   
 
Diane Havlir, MD, Director, UCSF AIDS Research Institute  

A New Year. A new FACES.

Fostering Advances through Care, Education and Sciences

FACES kicks off 2022 with a new direction and focus on training, education, and research, hence the new name. FACES is looking forward to continued collaboration with the Kenya Medical Research Institute (KEMRI), the Kenyan Ministry of Health (MOH), and other local partners to together improve health

and well-being for underserved populations.

How and why did FACES start?

During the summer of 2004, the Centers for Disease Control/Presidents Emergency Plan for AIDS Relief (CDC/PEPFAR) released a request for proposals to engage US-based institutions to expand HIV care & treatment in Kenya rapidly. Dr. Craig Cohen, professor in obstetrics, gynecology & reproductive sciences at UCSF, had worked in Kenya since 1994, and recently with Dr. Elizabeth Bukusi at the Kenya Medical Research Institute (KEMRI) had expanded their research program from Nairobi to Kisumu—the region with the greatest burden of HIV disease in the country. 

Over 20% of adults were living with HIV, and fewer than 1% who knew their serostatus were taking antiretroviral therapy. Men, women, and children were dying of AIDS—a disease which persons in many high-income countries had expanding access to ART. 

Thus, Drs. Cohen and Bukusi submitted an application to launch Family AIDS Care & Education Services (FACES) starting with two clinics—one each in Kisumu and Nairobi. The Kisumu clinic started as an outgrowth of a clinical trial site at Lumumba Health Centre and cared for patients in tents. Eventually, the clinic moved into its own building, thanks to the generosity of Mr. and Mrs. Steinberg, long-term friends and supporters of the UCSF AIDS Research Institute. Soon after FACES started, the program was asked to expand into Suba on the shores of Lake Victoria—this region had the highest prevalence of HIV, with over a third of adults living with HIV compared to 5% nationally. 

By 2007, FACES expanded to support over 140 Ministry of Health sites in three counties surrounding Lake Victoria.  In 2016, FACES transitioned to supporting 63 Ministry of Health facilities across Kisumu County rather than portions of three counties.

Key FACES Accomplishments

Since 2004, FACES and the local Ministry of Health (MOH) have made tremendous strides in building systems for effective and sustainable HIV services using innovative and effective approaches. These approaches resulted in UNAIDS 95-95-95 target attainment, well ahead of the UNAID 2030 target date. During the last five years, across 63 health facilities, 1.7 million HIV tests were conducted, 55,255 people living with HIV received lifesaving ART with over 95% viral suppression, and virtual elimination of mother-to-child transmission was attained. A few of the winning strategies FACES and MOH employed include: the establishment of robust laboratory networks; optimizing lay health care workers; employing community, family, and partner testing approaches, along with close follow up for linkage to treatment; integrating services; rolling out patient-centered differentiated care services; launching eight dedicated adolescent health clinics; and continuous quality improvement monitoring and data use for improvement.

UCSF played a key role in building the capacity of in-country staff to lead and manage FACES and serve as technical advisors and mentors themselves. Sustained mentorship and clinical consultation for advanced HIV care have been core UCSF contributions to FACES. The uniquely effective Train-the-Trainer mentorship model resulted in FACES contributing to the Technical Working Group, which coordinates the region's mentorship and Kenyan national guideline development. 

UCSF supported 16 Kenyan staff at UCSF for leadership and clinical training. An additional four staff completed master's degrees in public health who are now leading research and surveillance activities in the region. Through the Student Education and Training (STEP) Program, FACES has also trained over 230 post-doc fellows, residents, and students in HIV-related clinical care and research in-country from UCSF and other US and international institutions.

FACES has also been deeply involved in program evaluation. An Evaluation Unit was established to lead program evaluation and coordinate affiliated, extramurally-funded research. UCSF mentored on concept development, led scientific writing workshops, and strengthened evaluation design, analytical capacity, and dissemination, leading to 19 peer-reviewed scientific publications and 81 abstracts presented at national and international conferences. In addition, FACES has served as a platform for an array of novel affiliated research projects leading to the nationally adopted family planning and maternal-child health integration in HIV care, agricultural interventions for food security and improved health in the Shamba Maisha study, adherence and retention interventions through Adaptive Strategies for Preventing and Treating Lapses of Retention in Care (AdaPT) trials, adaptive mental health interventions through SMART-DAPPER, community-based test and treat strategies in Sustainable East Africa Research in Community Health (SEARCH) trial, mHealth initiatives such as TextIT, and collaboration with the East Africa International Epidemiology Databases to Evaluate AIDS (EA IeDEA). These affiliated studies collectively contribute to evidence-based innovations for improved HIV-related service delivery in Kenya and throughout Africa.

Impact

FACES has directly touched hundreds of thousands of lives through the years. In the early days, very sick patients with AIDS poured through the doors, many of whom were very weak and unable to walk. Seeing them rebound under the care and treatment of FACES and MOH medical experts was heartening. As prevention improved, especially prevention-of-mother-to-child-transmission (PMTCT), the emergence of effective PrEP and voluntary medical male circumcision, along with increased access to widespread antiretroviral therapy (ART) and adoption of test and treatment policies, fewer patients came through doors with HIV, and when they did, they were put on ART right away, generally before having severe symptoms. It has been an uplifting journey to see lives and the community restored and HIV well-managed as a chronic condition with patients living full and healthy lives.

Here are two stories: one from a patient touched by FACES and one from a staff member who helped shape FACES and FACES help shape his thriving professional career and goals to serve vulnerable populations through research, policy, and practice.  

Dr. Thomas Odeny

My life’s goals are to advance cancer treatment for the most vulnerable populations around the world, including underserved populations in my native land of Kenya. I was fortunate to graduate as a doctor during the scale up of HIV treatment in Kenya in 2007 and over the next decade I witnessed, both personally and professionally, one of the greatest public health victories in history: the transformation of HIV from a death sentence to a manageable chronic condition. My vision is to bring about a similar transformation for cancer through research, service, and education. I am currently a clinical fellow in Medical Oncology at the National Cancer Institute (NCI), National Institutes of Health (NIH).

In 2008, I was hired by KEMRI as a FACES frontline physician in rural western Kenya when HIV medications first became widely available. Over two years, I was fortunate to contribute to the HIV response which led to the establishment of >30 new HIV clinics and treatment of >30,000 people with antiretroviral therapy. At FACES, I witnessed the power of implementation research to magnify the impact of medications on the health of populations. As a clinician, I enjoyed having the ability to reach people and help in ways that could be measured in days or weeks. As a researcher, I enjoyed the process of finding answers to questions with the potential for major public health impact, and recognized the need for taking a long view in this work.

At FACES, and through mentorship from leading researchers at KEMRI and UCSF, I learned to harness the power of the emerging field of implementation science to design the most effective public health strategies to reach, treat, and care for HIV patients in low-resource settings. As HIV treatment has become more widespread, cancer is now one of the leading causes of morbidity and mortality among people living with HIV, and my next goal is to create opportunities to equalize and advance diagnostics and therapeutics in global oncology.

It is an exciting time in oncology, but also a time when disparities are more pronounced locally and globally. My vision is to address gaps in cancer care by translating clinical advances to practical and scalable cancer programs in low-resource settings in Africa through high level direct patient care, implementation research, and education. I also look forward to a day when cancer research in Africa may help to inform policy and practice in the U.S. My time at FACES was a critical milestone towards this vision.

Thriving in Care, a story by Mary*

“I got to know about my HIV status at a PMTCT clinic five years ago. I could not believe it.  I engaged the nurse in a long argument. I knew I would die immediately after testing positive. I was told about the HIV clinic but due to stigma, I did not access care until I got tuberculosis (TB).  One day a neighbor of ours talked to me about how she got help. I went for the idea and immediately started TB treatment. During this time, I gave birth to my 5th born baby, unfortunately my infant son was also HIV positive. My son and I both enrolled in HIV care. These events made me disclose my status to my husband. He took the testing idea positively and after also testing HIV positive, he was enrolled a few weeks later. Now the three of us are living positively.

We receive antiretroviral treatment at FACES and are doing well. My husband made a living pushing a water handcart and this was our means of survival. This worried me so much as he was HIV positive and needed rest. He started volunteering with a study as a community mobilizer and joined the Patient Advisory and Patient Support Group at FACES. One thing that helped us is that we did not blame one another. Fortunately, I was called by the FACES Program to give HIV/AIDS health talks to women at the PMTCT clinic as a Peer Educator. I prayed so hard to get the confidence and the wisdom to do this, especially since I never completed secondary school. The percentage of pregnant mothers accessing HIV testing services increased tremendously. I later landed a job at FACES as a lay health care worker. I was so excited to join the happy family as staff.”

*Names have been changed to protect our clients’ privacy

Grants and Projects based in the FACES program

Since 2004, 11 UCSF junior faculty members collaborating with FACES, many of whom had been post-doctoral research fellows in Kenya, have received an NIH career development award to launch their academic careers. As one example, Dr. Susan Meffert, associate professor of psychiatry at UCSF, has worked with the FACES since 2009. First, she completed an effectiveness-implementation study of integrated mental health care delivered by non-specialists within the FACES HIV-primary care platform. Subsequently, Dr. Meffert and colleagues at KEMRI and the University of Nairobi are funded by a joint NIMH-Global Alliance for Chronic Disease (GACD) award to conduct the “Depression and Primary-care Partnership for Effectiveness-implementation Research (DAPPER).” DAPPER supports an effectiveness- implementation hybrid randomized study of psychotherapy versus pharmacological depression to evaluate non-specialist delivery of evidence-based care integrated within an existing public sector county healthcare center. Dr. Meffert and colleagues subsequently received an award that leverages the DAPPER study to add randomized, second line, non-specialist treatment for non-remitters with depression and/or post-traumatic stress disorder (PTSD), creating a sequential multiple assignment randomized trial (SMART). Furthermore, Dr. Meffert has mentored many early-stage researchers from Kenya, including Dr. Linnet Ongeri, a psychiatrist at KEMRI. Drs. Meffert and Ongeri are in the early planning stages to develop an East African Center of Excellence in mental health research and training.

FACES will now extend its long history of collaboration with the MOH in western Kenya with a focus on training, education, and research to improve health outcomes and well-being for underserved populations. FACES will transition away from direct HIV service delivery support. For more information about our ongoing initiatives and research – including how you can support our work – visit our website.

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