People of AMPATH: Evelyn (Eve) Too, Clinician and Program Officer
Evelyn (Eve) Too is a clinician and administrator of the AMPATH HIV Clinic at Moi Teaching and Referral Hospital (MTRH). She recently spent two weeks at Indiana University focused on learning more about the care of people living with HIV as they age and shared thoughts on the experience and her career with AMPATH.
How did you become involved with AMPATH?
I have been a clinician for about 19 years and have worked in AMPATH HIV clinics for the past 16 years and in clinic leadership for the past 14 years. I started in the Webuye clinic in February 2007 and worked in four satellite clinics while supporting four other clinics when they had staff shortages.
In 2012, I moved to Uasin Gishu County Huruma Sub County Hospital where I served as the clinic “In charge” while supporting four other clinics. I helped two of these clinics move from weekly satellite clinics to fully independent daily clinics and left them fully equipped with staff. I moved to the pediatric AMPATH clinic at MTRH in 2014 which is led by Professor Nyandiko. During this time I mentored five newly employed clinicians and subsequently moved to the adult clinic Module 2 where I was the “In charge.” I sat with AMPATH co-founder Professor Joe Mamlin for about five years before he retired in 2019.
The MTRH clinic currently provides care for more than 14,000 people living with HIV and is one of the largest single clinics in Africa, if not the world. It is also one of the best performing in Kenya with an overall viral load suppression of 98% and interruptions in treatment at 0.6% at the end of 4th quarter of FY 22/23. I have been the program officer at MTRH for the past 4 years.
How did you get interested in learning more about caring for older adults with HIV?
Dr. Joe Wheat, Eve Too and Dr. Joe Mamlin met in Indianapolis last month.
Dr. Jepchirchir (Chiri) Kiplagat has really been doing a good job with her research with older adults. I was one of the people that participated in the interviews. It’s something that had never crossed my mind that older adults could be missing something. If you don’t have it in your mind, then you won’t ask the questions and won’t be able to respond adequately. I see a lot of older patients in my practice. Through Dr. Kiplagat’s research, Dr. Kamal Wagle from Indiana University came to MTRH and shadowed in our clinic to see our workflow and invited one of us to do the same here. I’m excited to have had the opportunity to rotate in the clinics here. Thanks to Dr. Chiri, Dr. Kamal, Professor Kimaiyo and Prof. Adrian for supporting the training.
What are some of the needs that older adults have?
Age can bring an increase in comorbidities, increased pill burden, memory issues, transportation challenges, mobility, mental health and hygiene issues, nutritional challenges, caregiving inadequacies and more. Everyone’s socioeconomic status gets worse as they age because most of our population live hand to mouth and as they age they cannot fend for themselves when their functionality is reduced. Doing casual or manual jobs that they were able to do when they were younger is no longer possible. That has a ripple effect on so many things including getting the fare to come to the clinic or paying for Investigations for other ailments and non-HIV medication out-of-pocket. With the budget cuts that our program suffers every year, we can no longer give food rations and social support like we would before.
What are some things you will take from your trip to Indiana?
I really learned a lot. I've just been listening, mostly just trying to take it all in. I have been exposed to the (cognitive) assessment tools that are used to see the older adults. We don't have those. The providers here really have difficult conversations with the patients which we don't have, such as asking patients “What will you do or what plans do you have for when you're not able to make decisions on your own? Do you have someone else who can make those decisions for you?”
Another good question I heard is "what matters to you?” and that was getting some really good answers that helped determine what the patient’s needs were. Seeing a highly educated patient in their early 50s with impaired memory by the end of the assessment was overwhelming!
The objective of all this is to create a protocol for older adults customized to the Kenyan population using the right language and context for the population we serve. I’m already thinking about how we will streamline care to fit this specialized care into the existing workflow.
What are some of the differences between healthcare in Kenya and Indiana?
The health seeking behavior for the patients here is quite different. One thing I really liked was the patient telling the provider about upcoming screenings they needed. We diagnose our cancers very late. People don't go for wellness checks and access is also limited. We have integrated screening for cervical cancer within HIV care, but because the funding usually comes from different places, treatment can be scattered or delayed. Health insurance coverage and scope is wider in Indiana than among our population.
What are some of the other highlights of your visit?
I spent time with Joe and Sarah Ellen Mamlin and met Dr. Joe Wheat who provided the funds for the first antiretroviral therapy for patients at MTRH who had HIV in 2000. All the people I met and who hosted me at Indiana were really hospitable.
It was an amazing experience visiting a state-of-the-art geriatric facility at Hoosier Village and Eli Lilly Company which supports our clients with Insulin and Olanzapine. The Eli Lilly History and Insulin Museum was phenomenal. The Damien Center, Indiana’s oldest and largest AIDS service organization, was inspiring.
I was also happy to visit the Regenstrief Institute where the founders of our Electronic Medical Records System sit. When we first started using the AMPATH electronic medical records system (AMRS), our patients and providers complained about system downtimes. It was also difficult adjusting to learning the system and maintaining eye contact at the same time. This was a paradigm shift. We kept switching from AMRS to paper records. I remember Joe Mamlin telling me “If you continue like this, you’re going to be left behind.”
Then we started to appreciate having notes being organized in chronological order and getting a patient history with the touch of a button, reduced waiting time at the clinic, ordering lab investigations electronically and receiving paperless lab results without having to walk to the lab or flipping patients’ files. We visualized reports for the specific clinics which enabled decision making. Before, we would depend on the monitoring and evaluation department to give us our monthly reports. With a click of a button, you're able to see how your clinic is performing.
Now we joke about how AMRS runs in my blood, and I defend it with my blood. You don't want to miss seeing how the AMRS works when you visit the AMPATH Centre!
What is the favorite part of your job as a clinician?
The most satisfying part of it is when you see a very sick client down with a certain condition and you're in there making an intervention, seeing them with short revisits they come up slowly by slowly, gradually and they improve. The clients themselves are happy. I witnessed some of those clients dance for me and be turning round and round and showing me how strong they are and it would make me so happy to see them healthy again!
What is the favorite part of your job as an administrator?
When you are looking at data and you're at a certain level, but after implementing one or two of the strategies that you had discussed, there's an improvement in performance. Then everyone is like “we made it” or “it worked after all.” It makes me feel so happy to be able to tell someone this is where we were at this point, but we've been able to do this and follow through and these are the results. I owe the good performance to my team. A leader is nothing without the team players!
What makes AMPATH special?
From my perspective, it's the mentorship-the fact that people are able to sit together, work together, share ideas, share knowledge and capacity building. You sit side-by-side with a clinician for three months before they let you sit on your own while asking questions when you're not sure of anything. That is one thing that I really like about the AMPATH practice because people are aware that there are things you may never have seen in your school or even in life.
The mission, vision and the impact of AMPATH is very special and to use Professor Mamlin’s timeless words “Changing lives one at a time. Start with Care then go beyond!”