Is treatment of tuberculosis in Malawi prolonging the lives of people with HIV/AIDS?
Over the last 15 years, tuberculosis (TB) case numbers have increased 300-400% in Malawi, in conjunction with a rise in HIV infection. This is primarily because HIV increases the risk of disease reactivation in people with latent tuberculosis infection, and also because it increases susceptibility to new TB infections.
There are currently over 24,000 cases of TB registered across Malawi, 77% of whom are estimated to be HIV/AIDS positive. Although Malawi is regarded internationally as a star performer in effective TB treatment using “direct observed therapy, short-course”, or DOTS – which boasts 100% nationwide coverage – a large percentage of HIV positive people continue to die of TB-related illnesses.
Numerous studies carried out in the last 15 years show that preventive treatment of TB in people who are HIV positive helps them live longer. If these studies are to be believed, then one would expect HIV/AIDS mortality in a country with 100% TB treatment coverage to have been reduced greatly.
Unfortunately, the situation is exactly the opposite, and a lot of HIV positive people continue to die of TB infection. Can there be another factor that is contributing to TB treatment failure in HIV positive patients?
The answer is definitely yes. A low socioeconomic status among the population, coupled with a poor healthcare system in general, is the likely explanation for high HIV mortality rates due to TB.
Malawi is currently among the ten poorest countries in the world. It has a population of 11 million people, of which 65% live on less than one US dollar per day. Agriculture forms the economic backbone of the country, and almost all indigenous Malawian farmers are involved in subsistence farming using manual labour.
However, the trend over the past ten years has been for households practicing subsistence farming to produce only sufficient food for two to three months after harvesting. After that, families usually depend on piecework, handouts and wild foodstuffs for survival. This situation makes the maintenance of good health among Malawians difficult.
Generally, it is the adult members of the family who are involved in cultivation. Unfortunately, those most vulnerable to TB and HIV/AIDS infection are the labour providers and more senior members of the family.
This division of labour impacts negatively on the ability of people infected with HIV or TB to access treatment. Put simply, most patients would rather spend time looking for ways to support their families than be in a hospital bed. In most cases, therefore, patients are only referred to hospital after they become severely ill and are too weak to work.
A study by Bertha Simwaka, a senior researcher at the Equi-TB Knowledge Programme in Malawi found that over 67% of deaths among HIV/TB-infected patients are due to treatment failure caused by lack of proper nutrition to support the immune system.
Another study on the impact of AIDS on rural livelihoods in southern Malawi found that 62% of sampled rural households only ate meals five or less days per week. In most cases they only had one meal per day.
However, the development of tuberculosis following exposure to TB micro-organisms is usually prevented by the immune system. When immune system effectiveness is reduced by HIV, the TB micro-organisms, which are dormant within the body of an individual who has been infected, begin to multiply, causing the disease.
When a person is found to have TB, they should be admitted to hospital or healthcentre for at least two to eight weeks. During this time patients receive curative drugs, which are usually very strong and tend to weaken the body. This has resulted in patients dying faster because their bodies cannot sustain the energy requirements of the treatment. For example, clinical studies from Lilongwe central hospital showed that 31% of patients dropped out of treatment due lack of food. Hence the need for energy-giving food as an integral part of treatment.
A clinical officer at Mchinji district hospital in central Malawi explained that a number of patients there have either refused or defaulted treatment because they cannot afford to spend eight weeks in hospital away from their farms. Farming activities clearly override the need for treatment. But poor adherence leads to unnecessary infection and death.
The situation is worse for people with HIV as their immune systems are already greatly weakened.
Another complication is the general belief among Malawians that all people with TB also have HIV. This has led in many cases to delayed TB diagnosis, because those with TB are afraid they will be labelled as HIV-infected, which would deny them the chance to share in communal money making activities. In most cases delayed diagnosis leads to poorer treatment outcomes.
Although TB treatment coverage in Malawi is 100%, deficiencies in the health system itself also impede the effective treatment of all TB cases. The health sector in Malawi is greatly understaffed, with 70% of the established posts in the ministry of health unfilled. This is undermining the effective administration of diagnosis and treatment. As a result, some people wanting treatment have been denied it.
The country also has very few microscopy centres, and health facilities in areas far from the ones that exist are supposed to use their own means to get to them. In order to reduce travel costs, health workers store up sputum samples over a period of time. The danger is that there may be a mix-up of samples, or samples may get damaged in storage. Such errors cause further delays in getting test results. There is therefore a real chance for patients to develop full-blown TB while they are waiting for their test results.
In conclusion, Malawi shows how a lack of sound developmental interventions to improve the livelihoods of poor people are greatly undermining initiatives to prolong the lives of those affected by HIV/AIDS and TB. There is an urgent need for local and international leaders to reconsider their development priorities, and begin improving the economic status of poor people and the health systems they depend upon. Only in this way can universal access to quality health care be assured.
HDN Key Correspondent
Email: Correspondents@hdnet.org
(July 2004)
There are currently over 24,000 cases of TB registered across Malawi, 77% of whom are estimated to be HIV/AIDS positive. Although Malawi is regarded internationally as a star performer in effective TB treatment using “direct observed therapy, short-course”, or DOTS – which boasts 100% nationwide coverage – a large percentage of HIV positive people continue to die of TB-related illnesses.
Numerous studies carried out in the last 15 years show that preventive treatment of TB in people who are HIV positive helps them live longer. If these studies are to be believed, then one would expect HIV/AIDS mortality in a country with 100% TB treatment coverage to have been reduced greatly.
Unfortunately, the situation is exactly the opposite, and a lot of HIV positive people continue to die of TB infection. Can there be another factor that is contributing to TB treatment failure in HIV positive patients?
The answer is definitely yes. A low socioeconomic status among the population, coupled with a poor healthcare system in general, is the likely explanation for high HIV mortality rates due to TB.
Malawi is currently among the ten poorest countries in the world. It has a population of 11 million people, of which 65% live on less than one US dollar per day. Agriculture forms the economic backbone of the country, and almost all indigenous Malawian farmers are involved in subsistence farming using manual labour.
However, the trend over the past ten years has been for households practicing subsistence farming to produce only sufficient food for two to three months after harvesting. After that, families usually depend on piecework, handouts and wild foodstuffs for survival. This situation makes the maintenance of good health among Malawians difficult.
Generally, it is the adult members of the family who are involved in cultivation. Unfortunately, those most vulnerable to TB and HIV/AIDS infection are the labour providers and more senior members of the family.
This division of labour impacts negatively on the ability of people infected with HIV or TB to access treatment. Put simply, most patients would rather spend time looking for ways to support their families than be in a hospital bed. In most cases, therefore, patients are only referred to hospital after they become severely ill and are too weak to work.
A study by Bertha Simwaka, a senior researcher at the Equi-TB Knowledge Programme in Malawi found that over 67% of deaths among HIV/TB-infected patients are due to treatment failure caused by lack of proper nutrition to support the immune system.
Another study on the impact of AIDS on rural livelihoods in southern Malawi found that 62% of sampled rural households only ate meals five or less days per week. In most cases they only had one meal per day.
However, the development of tuberculosis following exposure to TB micro-organisms is usually prevented by the immune system. When immune system effectiveness is reduced by HIV, the TB micro-organisms, which are dormant within the body of an individual who has been infected, begin to multiply, causing the disease.
When a person is found to have TB, they should be admitted to hospital or healthcentre for at least two to eight weeks. During this time patients receive curative drugs, which are usually very strong and tend to weaken the body. This has resulted in patients dying faster because their bodies cannot sustain the energy requirements of the treatment. For example, clinical studies from Lilongwe central hospital showed that 31% of patients dropped out of treatment due lack of food. Hence the need for energy-giving food as an integral part of treatment.
A clinical officer at Mchinji district hospital in central Malawi explained that a number of patients there have either refused or defaulted treatment because they cannot afford to spend eight weeks in hospital away from their farms. Farming activities clearly override the need for treatment. But poor adherence leads to unnecessary infection and death.
The situation is worse for people with HIV as their immune systems are already greatly weakened.
Another complication is the general belief among Malawians that all people with TB also have HIV. This has led in many cases to delayed TB diagnosis, because those with TB are afraid they will be labelled as HIV-infected, which would deny them the chance to share in communal money making activities. In most cases delayed diagnosis leads to poorer treatment outcomes.
Although TB treatment coverage in Malawi is 100%, deficiencies in the health system itself also impede the effective treatment of all TB cases. The health sector in Malawi is greatly understaffed, with 70% of the established posts in the ministry of health unfilled. This is undermining the effective administration of diagnosis and treatment. As a result, some people wanting treatment have been denied it.
The country also has very few microscopy centres, and health facilities in areas far from the ones that exist are supposed to use their own means to get to them. In order to reduce travel costs, health workers store up sputum samples over a period of time. The danger is that there may be a mix-up of samples, or samples may get damaged in storage. Such errors cause further delays in getting test results. There is therefore a real chance for patients to develop full-blown TB while they are waiting for their test results.
In conclusion, Malawi shows how a lack of sound developmental interventions to improve the livelihoods of poor people are greatly undermining initiatives to prolong the lives of those affected by HIV/AIDS and TB. There is an urgent need for local and international leaders to reconsider their development priorities, and begin improving the economic status of poor people and the health systems they depend upon. Only in this way can universal access to quality health care be assured.
HDN Key Correspondent
Email: Correspondents@hdnet.org
(July 2004)
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