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
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
posted by AIDS-Care-Watch at 6:13 am
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