Kenya: HIV/TB co-infection and challenges

by HDN Key Correspondent Team

In the past decade, there have been increasing campaigns geared towards TB treatment and many Kenyans have been treated under the free medical scheme (for TB patients). But the rise in number of TB patients has also coincided with the rise in HIV infection rates.

This has stretched the Ministry of Health’s ability to cope with the twin epidemics and at the same time resulted in many deaths. Stigma has also been extended to TB patients and in some areas TB is equated with HIV infection. This means that some people do not seek medical attention for fear of knowing their HIV status and others prefer TB treatment and do not test for HIV.

Dr. Chakaya Muhwa, Kenya’s head of National Leprosy and TB Control Programme (NLTP) confirms that the increase in TB cases has coincided with emergence of HIV/AIDS. “In 2003 there were over 96,000 cases of TB and 80% were successfully treated. Five per cent died while receiving treatment while 15 per cent were not followed up or were transferred from their treatment centres,” Dr Chakaya says.

Co-infection still a challenge
Whilst co-infection remains a major challenge, the government and other independent medical agencies have embarked on HIV/AIDS education campaign and a TB treatment campaign as two separate exercises, according to Dr Ernest Nyamato.

Dr Nyamato, who works in Nairobi’s Mathare slums, says that TB affects many people living with HIV and it is likely that 50 per cent of HIV patients will get TB at some point in their lives.

In this respect, Nyamato says there is dire need to address the two epidemics together as they are affecting the society in large numbers. The Kenyan government’s official policy is Directly-Observed Therapy, short course (or DOTS) but, according to Dr Nyamato, superior regimens are available, especially for HIV patients, that can guard against re-infection with TB. In his opinion, the insistence on DOTS is based on funding dictates. He argues that “many donors to the health ministry insist on DOTS even though the ministry has its misgivings”.

“It is possible to limit re-infection through the use of superior treatment regimes that are only available in private hospitals and at a higher cost,” Nyamato says. Asked about his misgivings about DOTS, Dr Nyamato says DOTS can limit access; it may overload the TB network if treatment is spread countrywide. This will happen especially if the TB clinics and other facilities such as modern laboratories are not put in place to ensure that people are well attended to.

“There is scarcity of facilities to test TB that may result from [HIV] co-infection such as TB of the intestines, bones, and liver. Right now, under the DOTS programme testing is limited to sputum,” Dr Nyamato adds.Dr Nyamato says some hospitals in Kenya, which are reeling from the ever-increasing brain drain from the country, may not have enough personnel to supervise patients taking drugs since these hospitals insist on personal observation. Moreover, some of the hospital laboratories are in a dilapidated state, often with obsolete equipment, and need state-of-the-art laboratories to guarantee proper testing.

In his experience, there has been inadequate screening of patients to differentiate between TB and other ailments such as bronchitis. This, the doctor maintains, will not only need modern laboratories but also well trained/retrained medical personnel. Given that DOTS is labour intensive, strict DOTS implementation will overstretch resources. In this respect, Dr Nyamato says concerted budgeting efforts will be needed from the government to ensure it can reach all those who need treatment.

“The government has to decentralize to the village level. Right now, administration of TB drugs is centralized so you can only access in hospitals like Kenyatta National Hospital or Mbagathi Hospital. If you are lucky, you can get treatment from international agencies like Medicines sans Frontieres (MSF),” Dr Nyamato argues.

On administration of drugs, Dr Nyamato recognizes the need for harmony. He wonders why TB patients have to be supervised while taking drugs while we trust HIV patients to go home with a month’s dosage. “ARVs do not need to be administered in DOTS. Right now, 90% of our HIV patients take their ARVs so we can trust they will take their TB medication. It is a double standard to tell the patients to go home with ARVs then come to hospital every day for TB tablets” he adds.

Pursuant to this line of thought, Dr Nyamato is engaged in a pilot study on modifying DOTS at the Mathare slums. The project will also explore change of regimen to give rifampicin for the entire eight-month period to establish how it can assist the patients.Mathare is also engaged in a project testing how the sputum can be tested better to give more accurate results. Under this pilot project, patients will also be educated on how to take charge of their lives and their medication.

The project will start by administering weekly dosages then move to monthly dosages. This will help to establish the rate of compliance.

HDN Key Correspondent TeamEmail: correspondents@hdnet.org

Africa's TB Crisis May Spur AIDS Treatment- Cape Town Plan Promotes Test, 'Twins' Approach

By Craig Timberg - Washington Post Foreign Service - September 26, 2005

KHAYELITSHA, South Africa -- Soon after Andile Madondile, 27, got the double diagnosis of tuberculosis and AIDS last year, his boss fired him and his girlfriend moved out, leaving him with both their leaky shack and their young daughter.

As coughs shook his body during sweaty, miserable nights, Madondile said he fantasized about walking down to the tracks that run through this gritty township, waiting for the morning express train to approach and then leaping into oblivion.

A year later, though, he has come to see those terrible coughing fits as his first step toward recovery. Long before Madondile could accept that he had AIDS, with its heavy stigma of sin and death, he began seeking relief from tuberculosis. Treating one disease became the gateway to confronting -- and ultimately controlling -- the other.

The World Health Organization last month declared a tuberculosis emergency for Africa, where the rate of infections has quadrupled in many countries since 1990. The epidemic, which is especially severe in Khayelitsha, kills more than 500,000 Africans each year, although with proper treatment TB can be cured within six months.

The crisis has been caused by the growing levels of AIDS, which weakens resistance to such infections. The two diseases occur together so frequently that doctors call them "the terrible twins."

But, as with Madondile, tuberculosis can also speed treatment of AIDS by prompting patients to seek medical help early enough for life-saving antiretroviral drugs to work. At a time when the vast majority of those dying from AIDS do not even know they have the disease, TB can serve as a vital early warning sign. In Cape Town, a glitzy seaside city whose boundaries include Khayelitsha 20 miles inland, TB patients now are the largest source of referrals for antiretroviral programs, officials say.

Though such programs still reach only a small minority of those with AIDS in South Africa, they are expanding rapidly in its biggest cities. Cape Town's health plan envisions treating tuberculosis and AIDS increasingly in tandem and having every TB patient take an HIV test.

"It works," said Ivan Toms, city health director, "but it's because the rest of the system isn't working."

A combination of political pressure and increased production of generic drugs has led to a dramatic decrease in the price of antiretrovirals. But treating AIDS on a mass scale in South Africa, where estimates of HIV infections exceed 5 million, has proven far more complicated than just providing medicine.

There are not nearly enough doctors, nurses or pharmacists to prescribe and distribute the drugs. Most public health facilities are poorly equipped and managed. And the disease's stigma remains so powerful that many choose to die at home rather than seek treatment. But here in Khayelitsha, where most of the 400,000 residents live in tiny shacks, one survey showed that 41 percent of adults said they had been tested for HIV at least once many times higher than the national average.

Part of the reason is Khayelitsha's stratospheric rates of tuberculosis, and the determination of health officials to offer those with that disease an HIV test as well. In Europe and the Americas, an average of 46.5 out of every 100,000 people contract TB each year, according to WHO statistics. The rate in Khayelitsha is many times higher.

Doctors have found that patients infected with TB are more likely, because of its less-severe stigma, to seek medical help than those with AIDS alone, providing a ready pool of patients to be tested for HIV.

Tuberculosis is a disease mainly of the lungs, and each cough spreads thousands of infectious droplets. Most people who are exposed will never show symptoms, but for those who do develop tuberculosis, it is frequently fatal if not treated.

Drugs that combat TB are cheap and effective and, taken as prescribed for the six months, they can cure most cases. But 62 percent of tuberculosis patients in Khayelitsha also have HIV, so treating one but not the other gives most patients only a brief respite.

The solution, say doctors here, is to treat them together, with two sets of pills. For those few facilities with the resources to handle both diseases, the most difficult part of recovery is getting patients to take their medicine day after day. At the Ubuntu clinic in Khayelitsha, founded in 2000 by the French medical aid group Doctors Without Borders and regional health authorities, officials demolished the wall separating the AIDS and tuberculosis sections several years ago, easing flow of information, patients and staff.

As a precaution against new infections, TB patients are seated several feet away from HIV patients in the waiting room, and initial studies have shown no evidence that one group is infecting the other. For those coming to the clinic for tuberculosis, initial consultation is followed by a visit to a counselor who urges an HIV test. A large majority agree, getting a finger-prick test in a room a few steps away.

This approach is rare, and even here it has hardly brought either tuberculosis or AIDS under control. But doctors say it offers the possibility of restoring health to patients with both the good luck to live near clinics and the determination to seek help. "It's one epidemic," said Eric Goemaere, the top Doctors Without Borders official in South Africa.

"One patient, one epidemic and two systems. That's the problem."

Madondile heard of the Ubuntu clinic in radio ads and came for a tuberculosis test in June 2004, after enduring a hacking cough for about three months. At the suggestion of a counselor, he got an HIV test the same day.

When he returned later, he learned that he was infected with both diseases, he said. Worse still, his CD-4 count, a commonly used measure of immune strength, was dangerously low. A healthy person generally scores at least 800. A person with advanced AIDS scores about 200. Madondile's score was 37.

His boss fired him the same day, he said. His brother and one sister shunned him, refusing to use the same spoons, blankets or toilet.

There were slivers of good news. His daughter, Elihle, tested negative for HIV. But the shame and rejection overwhelmed Madondile, he said. In that early phase of denial, the only treatment he attempted was a sour-tasting traditional African medicine. With his appetite gone and diarrhea growing severe, Madondile's legs became so thin that he stopped wearing shorts out of embarrassment. And after his girlfriend moved out, he began fantasizing about the express train delivering him from the pain, he said.

It took the supportive words of a neighbor, who visited his bedside with food and encouragement, to make Madondile rediscover his will to live.

He returned to the clinic to get treatment for the tuberculosis in October and asked for antiretrovirals three months later, when his CD-4 count had dropped again, to nine. He started taking the medicine on March 8.

A few weeks later, Madondile started to recover. His appetite returned. A rash on his face cleared up, as did the painful shingles on his chest. His weight gradually doubled, back to a healthy 150 pounds.

"If I had waited too long," Madondile said, "I might be dead now."

He still is jobless, and his girlfriend has not returned to their shack, which has neither a sink, stove or toilet. But on a bed that nearly fills one of its two rooms, Madondile now sleeps in peace. His daughter, healthy and generous with her smiles, sleeps beside him.

Source: Procaare eForum

Burma Must Tackle TB and HIV

By Marwaan Macan-Markar, Inter Press Service News Agency (IPS), 5 September 2005

BANGKOK (IPS) - For over 15 years a clinic in Mae Sot, a town along Thailand's north-western border, has offered a glimpse into how widespread tuberculosis (TB) is in neighbouring Burma.

It is to that clinic, run by Dr.Cynthia Maung, that a stream of poor men, women and children, escaping military-ruled Burma for Thailand, come to for a health check. "In 2004 we detected 700 cases of TB, of which 250 needed treatment," said Maung, herself a refugee who fled Burma in 1988 following Rangoon's harsh crackdown on a pro-democracy movement.

TB remains one of the major diseases that the hundreds crossing over from Burma suffer from, she explained during a telephone interview from her clinic in Mae Sot. "We are concerned because every year the cases are high".

Similar conclusions have been reached by officials at Thailand's ministry of public health, given the number of TB cases that have been detected during mandatory health tests done to the thousands of migrants from Burma who seek legal employment in this country.

In 2003, for instance, there were 1,766 Burmese with TB who required follow-up treatment, states a health ministry study. The infection that followed TB was syphilis, with 952 cases.

In 2002, in the Tak province alone, where Mae Sot is located, Thai health officials had required 885 Burmese to commence medical treatment for TB. That was out of an estimated 30,000 migrant workers who were seeking jobs in the large agriculture farms and the many garment factories there.

The number of migrant workers with TB has added to the incidence rate of this killer disease in Thailand, compelling Bangkok to step up TB detection and treatment efforts. "This year we put TB among one of the priority problems we have to tackle," Dr. Kamnuan Ungchasuk, director of the bureau of epidemiology at the health ministry, told IPS.

These numbers, however, are dwarfed by reports that Burma has 97,000 new cases of TB ever year and this South-east Asian nation is classified by the World Health Organisation (WHO) as being among the world's 22 'high burden'countries with the disease.

More troubling for public health experts is the high prevalence of multi-drug resistant TB (MDRTB) in Burma. It has four percent new cases of MDRTB, states the Geneva-based health body.

The frequency of MDRTB, which is incurable since it does not respond to available cheap anti-TB drugs, has placed Burma on the top of the list of afflicted countries in the region.

According to the WHO, Thailand has 0.9 percent of the new cases of MDRTB, Bangladesh has 1.4 percent new cases and even India, the country with the greatest TB burden, there are only 3.4 percent new MDRTB cases annually.

The only country in East Asia worse off than Burma for new MDRTB cases is China, with a reported 5.3 percent prevalence rate.

"The situation in Myanmar is a concern because four percent new cases in a high burden country is no trivial number of patients - several thousands, likely between 4,000-6,000 cases," a WHO official told IPS.

Such revelations about Burma, whose military rulers changed the country's name to Myanmar, come at a time when there is a global effort to rid the world of this pandemic, which kills nearly two million men, women and children every year.

As part of the Millennium Development Goals (MDGs), world leaders pledged at a U.N. summit in New York in 2000 to stop the spread of the world's leading killer diseases - AIDS, TB and malaria - by 2015.

Other MDGs to be achieved by that year include halving the number of those living on less than one US dollar a day, ensuring universal primary education for all boys and girls, reducing by two-thirds the number of children who die before reaching five years of age and reducing by three-fourths the number of women who die while giving birth.

And the WHO makes the alarming prediction of what the world will be faced with if TB, a curable infectious disease, is not overcome. In the next 20 years, almost one billion people will become newly infected, 200 million people will develop the disease and 35 million will die from it, it states.

It is a scenario made worse by the ease with which TB feeds off the other global pandemic, AIDS, which killed 3.1 million people last year. "TB is the leading killer of people infected with HIV," states the WHO, due to the weak immune systems of those with the virus that causes AIDS.

Currently, some 14 million people are co-infected with TB and HIV, of which 70 percent are in Africa.

The likelihood of Burma adding to those numbers has grown in the light of the fact that the country has the second highest prevalence rate of HIV in South-east Asia with an estimated

170,000 to 620,000 people living with the killer disease, according to a U.N. agency.

And a decision by an international funding agency to pull out of Burma in August due to roadblocks imposed by the military regime -- consequently hampering its 98.4 million-dollar contributions for programmes to combat AIDS, TB and malaria - has set off more alarm bells.

Yet, the WHO feels that such concern, at least over TB, may be misplaced, since the junta has implemented a range of public health initiatives despite its limited resources and a weak health system.

"For a resource-constrained country, Myanmar has a well functioning TB programme and a very good laboratory, which should enable the country to address the problem of MDRTB," says the WHO official.

"Political commitment to DOTS is high in Myanmar," added the official, referring to the Directly Observed Treatment Short Course strategy of diagnosing and ensuring administration of cheap anti-TB drugs to patients.

"DOTS coverage is 100 percent, meaning that all of the 324 townships have a DOTS clinic, although access to services varies widely."

Online at: http://www.ipsnews.net/news.asp?idnews=30136
Source: SEA-AIDS eForum

Burma Must Tackle TB and HIV

By Marwaan Macan-Markar, Inter Press Service News Agency (IPS), 5 September 2005

BANGKOK (IPS) - For over 15 years a clinic in Mae Sot, a town along Thailand's north-western border, has offered a glimpse into how widespread tuberculosis (TB) is in neighbouring Burma.

It is to that clinic, run by Dr.Cynthia Maung, that a stream of poor men, women and children, escaping military-ruled Burma for Thailand, come to for a health check. "In 2004 we detected 700 cases of TB, of which 250 needed treatment," said Maung, herself a refugee who fled Burma in 1988 following Rangoon's harsh crackdown on a pro-democracy movement.

TB remains one of the major diseases that the hundreds crossing over from Burma suffer from, she explained during a telephone interview from her clinic in Mae Sot. "We are concerned because every year the cases are high".

Similar conclusions have been reached by officials at Thailand's ministry of public health, given the number of TB cases that have been detected during mandatory health tests done to the thousands of migrants from Burma who seek legal employment in this country.

In 2003, for instance, there were 1,766 Burmese with TB who required follow-up treatment, states a health ministry study. The infection that followed TB was syphilis, with 952 cases.

In 2002, in the Tak province alone, where Mae Sot is located, Thai health officials had required 885 Burmese to commence medical treatment for TB. That was out of an estimated 30,000 migrant workers who were seeking jobs in the large agriculture farms and the many garment factories there.

The number of migrant workers with TB has added to the incidence rate of this killer disease in Thailand, compelling Bangkok to step up TB detection and treatment efforts. "This year we put TB among one of the priority problems we have to tackle," Dr. Kamnuan Ungchasuk, director of the bureau of epidemiology at the health ministry, told IPS.

These numbers, however, are dwarfed by reports that Burma has 97,000 new cases of TB ever year and this South-east Asian nation is classified by the World Health Organisation (WHO) as being among the world's 22 'high burden'countries with the disease.

More troubling for public health experts is the high prevalence of multi-drug resistant TB (MDRTB) in Burma. It has four percent new cases of MDRTB, states the Geneva-based health body.

The frequency of MDRTB, which is incurable since it does not respond to available cheap anti-TB drugs, has placed Burma on the top of the list of afflicted countries in the region.

According to the WHO, Thailand has 0.9 percent of the new cases of MDRTB, Bangladesh has 1.4 percent new cases and even India, the country with the greatest TB burden, there are only 3.4 percent new MDRTB cases annually.

The only country in East Asia worse off than Burma for new MDRTB cases is China, with a reported 5.3 percent prevalence rate.

"The situation in Myanmar is a concern because four percent new cases in a high burden country is no trivial number of patients - several thousands, likely between 4,000-6,000 cases," a WHO official told IPS.

Such revelations about Burma, whose military rulers changed the country's name to Myanmar, come at a time when there is a global effort to rid the world of this pandemic, which kills nearly two million men, women and children every year.

As part of the Millennium Development Goals (MDGs), world leaders pledged at a U.N. summit in New York in 2000 to stop the spread of the world's leading killer diseases - AIDS, TB and malaria - by 2015.

Other MDGs to be achieved by that year include halving the number of those living on less than one US dollar a day, ensuring universal primary education for all boys and girls, reducing by two-thirds the number of children who die before reaching five years of age and reducing by three-fourths the number of women who die while giving birth.

And the WHO makes the alarming prediction of what the world will be faced with if TB, a curable infectious disease, is not overcome. In the next 20 years, almost one billion people will become newly infected, 200 million people will develop the disease and 35 million will die from it, it states.

It is a scenario made worse by the ease with which TB feeds off the other global pandemic, AIDS, which killed 3.1 million people last year. "TB is the leading killer of people infected with HIV," states the WHO, due to the weak immune systems of those with the virus that causes AIDS.

Currently, some 14 million people are co-infected with TB and HIV, of which 70 percent are in Africa.

The likelihood of Burma adding to those numbers has grown in the light of the fact that the country has the second highest prevalence rate of HIV in South-east Asia with an estimated

170,000 to 620,000 people living with the killer disease, according to a U.N. agency.

And a decision by an international funding agency to pull out of Burma in August due to roadblocks imposed by the military regime -- consequently hampering its 98.4 million-dollar contributions for programmes to combat AIDS, TB and malaria - has set off more alarm bells.

Yet, the WHO feels that such concern, at least over TB, may be misplaced, since the junta has implemented a range of public health initiatives despite its limited resources and a weak health system.

"For a resource-constrained country, Myanmar has a well functioning TB programme and a very good laboratory, which should enable the country to address the problem of MDRTB," says the WHO official.

"Political commitment to DOTS is high in Myanmar," added the official, referring to the Directly Observed Treatment Short Course strategy of diagnosing and ensuring administration of cheap anti-TB drugs to patients.

"DOTS coverage is 100 percent, meaning that all of the 324 townships have a DOTS clinic, although access to services varies widely."

Online at: http://www.ipsnews.net/news.asp?idnews=30136
Source: SEA-AIDS eForum

Nigeria Ranks 4th in TB Spread

by Chuka Odittah in Abuja, THIS DAY Online, 1 September 2005

Nigeria has been rated as fourth among the world's top countries that were leading in the spread of Tuberculosis (TB).

Research showed that the bacterial infection had been a major killer alongside HIV/AIDS in Nigeria. Dr. Emeka Asandu of National Aids and STI Control, Federal Ministry of Health, disclosed this in Abuja while briefing reporters on the; "Imperatives for Handling Tuberculosis and HIV in Nigeria."

According to Asandu, a study conducted by the World Health Organisation (WHO) in recent times showed that an estimated one third of the 42m people that lived with HIV/AIDS worldwide were co-infected with TB, a bacterial infection that affected the lungs.

In the case of Nigeria, the survey showed that in 2002 alone, nearly 368,000 new cases of TB was recorded. Out of this figure, 159,000 were pulmonary sputum smear-positive (SS+) cases, one of the highly critical variants of the epidemy.

Asandu explained that the reason for the sudden upsurge in reported cases of TB was because of the spread of the HIV disease. (TB is a killer of HIV/AIDS patients). He said that HIV virus attacked the immune system, which allowed the bacteria that caused TB to multiply and spread rapidly.HIV/AIDS he said, had caused a 6 percent annual increase in the number of TB cases.TB the doctor explained, was an air borne disease, which could easily be transferred from a sufferer of active TB, to an uninfected person

As a way out, Dr. Asadu advised all persons living with HIV/AIDS to take advantage of the current operation of Direct Observable Treatment Short Course (DOTS) the treatment of their TB infection. He said at the moment, about 900 TB diagnostic centers have been set up to offer otherwise free sputum test for patients across the country. He urged people living with HIV/AIDS not conceal the ailment due to stigmatization. He said the disease could be effectively treated over a space of nine months if detected early.

Source: THIS DAY Online