In late August 2024, Montefiore Einstein hosted a unique visit. Mercy Nyakowa, MA, and Nazila Ganatra, BPharm., are program officer and program manager, respectively, of Kenya’s National AIDS & STI Control Viral Hepatitis program, a division of the national Ministry of Health. They are longtime collaborators with Montefiore Einstein, having embarked on a project back in 2015 with Matthew Akiyama, MD, MSc, associate professor in the divisions of general internal medicine and infectious diseases.

Dr. Akiyama and his team, including project director Lindsey Riback, MPH, and study coordinator Hannah Manley, MA, travel to Kenya to oversee and support ongoing research projects, but there are significant hurdles to bringing colleagues from economically developing countries to the U.S. “Because of the visa requirements, often people from lower-middle income countries are unable to visit the U.S. and other high-income countries for important activities such as attending scientific conferences,” explains Dr. Akiyama. “A lot of administrative work is needed to arrange these types of visits. Unfortunately, this continues to perpetuate divides in scientific knowledge exchange and care delivery, hindering true bilateral working relationships.”

He continues, “We felt it was important to offer our partners in Kenya exposure to the collaborating center—in this case, Montefiore Einstein—and an on-the-ground look at what happens in settings where we deliver services such as opioid treatment and syringe service programs. We made sure to build an opportunity to visit the Bronx into this project and we are hoping to make this an ongoing element of future studies.”

A fortuitous start

The collaboration grew out of Dr. Akiyama’s longstanding work to provide care and treatment for both HIV and hepatitis C in people who have been incarcerated and those who inject drugs. Injection drug use puts people at significantly higher risk for viral infections including hepatitis C, which often goes undetected but can eventually cause cirrhosis and liver cancer. Highly effective antiviral drugs that arrived around 2014 have made the disease easily curable, but only with appropriate testing and treatment, which remain out of reach in many parts of the world. Kenya had virtually no hepatitis C program, Nyakowa says, before they began working with Dr. Akiyama and Montefiore.

Collaborators from Kenya, along with other members from Dr. Akiyama’s team, also visited the OnPoint NYC location in Harlem, a leading-edge harm reduction center whose medical providers are from Montefiore Einstein.

Dr. Akiyama first connected with the team in Kenya through a mutual colleague, and was drawn to working in the country because it provides an important opportunity. “Kenya has been a leader, especially among lower-middle income countries, in implementing harm reduction strategies such as opioid agonist therapy and syringe service programs. Beginning over a decade ago, this work has had a strong impact on bending the curve of new hepatitis C infections to avoid massive outbreaks like we've seen in regions of the United States, Eastern Europe, and other countries.”

Because of this, the overall rates of hepatitis C infection are relatively low in Kenya, the team found. “Kenya has managed to keep its prevalence low,” says Dr. Akiyama. “This makes it a setting where we're hoping to be able to demonstrate that hepatitis C elimination is achievable, in keeping with goals outlined by the World Health Organization.”

Grants he has received, including an NIH Director’s Avenir Award in 2021, have supported the bilateral team’s work. In 2017, the collaborators first established hepatitis C prevalence among people who inject drugs using antibody and then PCR testing. They then implemented treatment protocols, including distributing hepatitis C medications in concert with methadone and at syringe service programs. Overall, the team in Kenya has impressively recruited over 3,100 study participants. These efforts have contributed to a reduction in hepatitis C prevalence among people who inject drugs by as much as 20 percent. Currently, with Dr. Akiyama’s collaboration and support, the Kenya viral hepatitis team is reviewing national guidelines that will direct treatment for hepatitis C across all of Kenya’s 47 counties, ensuring resources are allocated, and improving access to care.

A calling to serve opens a door to the U.S.

Nyakowa, an economics major who found her vocation after getting a job offer to do community health outreach, doesn’t hold back when it comes to her feelings about visiting the U.S. “It was a dream come true for me,” she says. “Work aside, it’s a place where everyone wishes they could come.”

One of the first places they visited was the Harlem location of OnPoint NYC, a leading-edge harm reduction center where people who inject drugs can do so in a safe space under medical supervision—something Kenya does not offer, nor do most similar centers in the U.S. Montefiore Einstein providers are the clinical staff at OnPoint. In comparison with harm reduction centers in Kenya, also known as “drop-in centers,” Nyakowa described OnPoint as a “five-star hotel.” It offers showers and laundry machines, as well as acupuncture treatments. She was impressed that it’s funded in part by New York City and state. Kenya’s harm reduction centers are completely dependent on private funding and donations, she explains. “If the donor pulls out, there'll be no harm reduction centers in the country. And we know that drug use is not going away.” 

While Kenya has been a leader in using peer-led models, meaning that people with lived experience of using drugs are involved in outreach and treatment, she was also impressed that many of the non-medical staff at OnPoint are peers. She was quick to link this to another benefit of the center—it offers access to phones and computers and connects clients with job training and professional development opportunities. “Some of these roles managing and providing services at the center require experience and training, and our peers have not been able to go through all those levels of education,” she says. Sometimes peer outreach workers in Kenya “age out” of their roles with no other professional qualifications, she says. The OnPoint model of providing job training to its clients is something she someday hopes to replicate. These personal development opportunities, she believes, “will take them a long way.”

Nyakowa and Dr. Ganatra also visited Montefiore’s Wellness Center at Melrose, which serves those with opioid-use disorder, and the Comprehensive Health Care Center (CHCC). In Kenya, patients are only able to get one dose of methadone at a time, and must take it at the designated methadone clinics. Nyakowa noted that at the Melrose Center, patients were able to receive weekly and sometimes monthly doses. “For me, that is just amazing, the recognition that patients are able to take care of their own health and be trusted with their medicine,” she says. Implementing a similar model in Kenya would help people remain in treatment and also reduce patient costs, she believes.

From left, Dr. Matthew Akiyama, Mercy Nyakowa, and Hannah Manley outside a harm reduction center in Mtwapa, Kenya in October 2024.

The presence of physicians at harm reduction centers, for patients who need medical treatment or advice, was also new to Nyakowa. Kenya doesn’t have a robust ambulatory care model or health insurance. “We don't have physicians who will go outside the hospital to harm reduction centers to provide services and counseling,” she says. “By the time they have a referral, our patients will not go to the hospital because they cannot afford it.” She and Dr. Ganatra met with addiction medicine specialist Matthew Holm, MD, and CHCC medical director Joseph Deluca, MD. After visiting the CHCC, Nyakowa connected with a hepatologist in Kenya who plans to make providing care for free at harm reduction centers part of her practice.

Bringing it home

One other important, and potentially life-saving, idea: distributing full Narcan kits in clinics, something Kenya isn’t currently doing. “I don't think it's that costly, but as a country we haven't tapped into that,” says Nyakowa. “Whenever there's an overdose, they call the outreach worker who informs the clinician since the available naloxone can only be provided by a professional. Most of the time, it is too late.”

She hopes that some of what she saw on her visit can change practice on the ground in Kenya. “Sometimes it's just a matter of creating the awareness,” she says. “Once there is awareness, we can make recommendations, and our colleagues throughout the country locally can put it in their budget proposals and see whether it can be funded. We lose nothing by trying.”

Dr. Akiyama and his team have also gained new ideas from their collaborators in Kenya and some signature successes of the program there. The Kenyan model uses peer case managers who work with a group of study participants in a specific geographic area. “It’s been remarkable in terms of retention,” notes Dr. Akiyama. “We have a hard time with loss to follow-up in our research in the Bronx. Working with vulnerable populations in urban areas, people often disengage because the healthcare system is not designed to meet them where they are, especially if they don’t have reliable access to a phone or computer.”

He continues, “In Kenya, peer case managers have a better sense of people’s whereabouts and there is a trust between them. They are able to link study participants back for follow-up visits and additional services. There's a tremendous amount we can learn from the way in which peer navigation and outreach is provided, and we would benefit from building our systems similarly.”

As with many projects, the future will depend on grant funding. But both sides have found it so fruitful, they have every intention of keeping it going. Says Nyakowa, “We just hope that we're going to have the collaboration with Matt’s team to eternity.”