NAMIBIA: Poor access to treatment hampers fight against TB

25 Jan 2006, IRIN

WINDHOEK-- Despite its status as a middle-income country, Namibia has a high incidence of tuberculosis (TB), a poverty-related disease.

Poor geographical access to health services has hampered the treatment rate of TB, the country's second biggest killer, said Alfons Babie, an official at the recently created directorate for special diseases in the health ministry. Instead of the international target of 85 percent stipulated by the World Health Organisation (WHO), the TB treatment rate in Namibia is only 64 percent.

Moreover, 40 percent of those infected do not continue with their TB medication for the stipulated six-month course, and health authorities have picked up an emerging multidrug-resistant TB epidemic.

The lack of an electronic database also made it impossible for the health system to trace patients who did not report for collection of their TB drugs, explained Babie.

In 1996 the government introduced WHO's Directly Observed Treatment Short-Course (DOTS) strategy, which includes free medication and treatment at all government hospitals for the six-month course of medication.

"If patients stop taking their medication before that they have to start from scratch again, but the TB bacillus has built up a resistance against the medication - it has mutated - so a different drug cocktail must be found for the patient," explained Kerstin van Wyk of Johanniter Hilfswerk, a German NGO working with people infected with TB.

"We had cases where patients interrupted [treatment] two or three times and had to be put on different medication each time, as the TB bacillus built up a resistance to the former medication cocktails," she noted.

The health ministry noted in its latest annual report for the Khomas region, where the capital, Windhoek, is situated, that many patients defaulted "because they become too sick and too weak to walk to the health facility, and cannot afford taxi money". The San, who live in remote corners of the country are one of the worst affected by the disease.

According to WHO, an average of 676 TB cases were recorded for every 100,000 Namibians, putting the country at the top of the world ranking for the disease.

Last year Namibia launched its first national strategy to combat TB, which is also the principle cause of death among people infected with HIV or living with AIDS.

A recent successful health ministry proposal to the Global Fund to fight AIDS, TB and Malaria stated that about 50 percent of TB patients were also HIV positive. "AIDS is worsening the TB infections," Babie told IRIN.

This month the Fund announced the disbursement of US $143,000 to the Namibian authorities to help fight TB, and approved a further $7.2 million over five years for the TB programme.

The funds will used to improve access to treatment by setting up community-based DOTS in each of the country's 13 regions, hike its treatment rate to reach the 85 percent target by the end of 2007, and monitor TB drug resistance.

Source: Reuters Alert Net

Uganda: Tackling TB, AIDS to save lives

By Moses Mulondo Daily Monitor 30 December 2005

It is reported that Uganda ranks 14th among the world's 22 countries with a high tuberculosis burden. More disturbing are findings that if one is diagnosed with TB, chances are that they also have HIV/AIDS and that TB is the single largest killer of people with AIDS.

Few people know how dangerous Tuberculosis (TB) is, especially to HIV/AIDS patients. TB and HIV are two deadly diseases fuelling each other. Statistics indicate that 50 percent of TB patients have HIV.

Every year, close to two million people die of (TB) worldwide and over 30 percent of them are in Africa. Africa is suffering more deaths from TB than in past years, more than doubling from about 200,000 in 1990 to 539,000 in 2003/2004. The factor behind this tragic anomaly is HIV/AIDS and the devastating effects of the co-infection of the two diseases.

Dr. Solomon Kibudde of Makerere University's Faculty of Medicine, said the government, NGOs, donors and other partners need to recognise the socio-economic aspects involved in the prevention of TB-HIV co-infection in Uganda.

"The impact of TB-HIV co-infection is so glaring. The cost of diagnosis and treatment due to indirect costs such as loss of employment, sale of assets to buy treatment, loss of productivity from illness and premature death have continued to retard the socio-economic status of Uganda,"Kibudde said.

This was during the International Students Conference on the TB/HIV dual epidemic organised at Makerere University, which had participants from different parts of the world discussing the challenges related to carrying out collaborative TB/HIV activities in resource-poor rural settings typical of Sub-Saharan Africa.

DANGERS
HIV/AIDS and TB are so closely connected that the term dual epidemic or co-infection is often used to describe their relationship. The intersecting epidemic is often denoted as TB/HIV.

HIV affects the immune system and increases the likelihood of people acquiring new TB infections. It also promotes both the progression of latent TB infection to active disease and relapse of the disease in previously treated patients.

Research indicates that approximately 90 percent of those living with HIV die within months of contracting TB if TB is not seriously dealt upon.

It was upon that background that Dr. Eric Wobudeya, a paediatrician at Mulago hospital advised that patients with the TB/AIDS infection should put first priority to treating TB if they are to live longer.

It was agreed that many HIV patients with TB often die before their actual death dates. "An estimated 30 percent of all deaths among patients of TB/HIV dual epidemic are attributed to TB," said Dr. Nakanwagi Anna Mukwaya of World Health Organisation-Uganda during the conference.

This was during a three-days International Students Conference on the TB/HIV Dual epidemic organised at Makerere University in which several ideas on the co-infection between AIDS and TB were discussed.

TB is the single largest killer of people with AIDS. "TB and HIV are double trouble," said Dr. Peter Saranchuk from South Africa. "The chances are that if you're being treated for TB, then you have HIV.

A person with HIV has a 10 percent chance every year of getting TB because of the living conditions. People live on top of each other in shacks. If one person is coughing, everyone is affected."

Uganda ranks 14th among the world's 22 countries with a high tuberculosis burden. The country has an estimated annual risk of infection (ARI) of 3 percent, which is equivalent to 150-165 new smear positive TB cases per 100,000 people.

A retrospective cross section hospital based study was carried out from August to September 2005 at Mbeya referral hospital in Tanzania, looking for treatment outcome, drugs reaction and resistance pattern of anti tuberculosis drugs in patients with the HIV infection.

In this study, 216 patients were examined of which 94 were males and 122 females. The number of patients co-infected with tuberculosis and HIV/AIDS was found to be 63 percent of all patients whose HIV status was known.

The treatment outcome of these patients was not good irrespective of their HIV status as the number of patients who were declared to be cured at the end of the two phases of treatment were very close to the number of patients who died during the course of treatment.

The interaction between TB and HIV highly increases the burden of both diseases to the patient. HIV is the biggest risk factor for development of active TB in persons infected with tuberculosis.

Since 1995 when the National Tuberculosis and Leprosy programme gained national coverage with TB control efforts, there has been a steady 8-10 percent increase in the annual case notifications. This has been largely attributed to HIV infection.

At present, an estimated 50 percent of TB patients are also co-infected with HIV. At the same time, TB remains the leading cause of morbidity and mortality for people living with HIV/AIDS. The interaction between TB and HIV demonstrates a need for the TB/AIDS control programmes to closely collaborate at all levels of health service delivery.

Even though the two have largely pursued separate courses in the past, they have realised that collaboration is essential as a means to offer comprehensive and quality health services to both TB and HIV patients/clients.

AWARENESS NEEDED
Although some collaborative activities have been implemented in a few public facilities and NGOs like AIDS Information Centre, AIM, Mbuya reach out, Nsambya and TASO, these have not been standardised and depend largely on the knowledge and motivation of the health workers. Most workers lack knowledge on TB/HIV collaborative activities, which has resulted into poor handling of the cases.

Research findings from South Africa where TB/HIV dual epidemic is most prevalent indicate that Tuberculosis among AIDS victims is a different disease these days. "TB is a different disease now," said Peter Saranchuk, a doctor at the Medicines sans Frontières (MSF) clinic in Khayelitsha.

"Twenty years ago, it was mainly of the lungs and you could diagnose it from a cough. AIDS has changed that. If someone is HIV-positive, they're more likely to get TB in other parts of the body. There's abdominal TB, TB meningitis, TB of the breast, TB of the kidneys... It can hit you anywhere between your feet and your brain. This is a new phenomenon," he added.

Khayelitsha town sits at the heart of a worldwide TB epidemic that has hit South Africa hard. The level of infection in the township is now four times that at which the World Health Organisation declares a medical crisis, and is continuing to rise. But ask about tuberculosis on
the streets of Khayelitsha, and almost everyone jumps to the same conclusion: what you are really talking about is AIDS.

Dr. Mezzabotta Giampaolo, a medical officer of TB, World Health Organisation Uganda said during the conference that the rate of progression to clinical TB or TB disease is 10 to 30 times higher among individuals infected by both TB and HIV than among those infected only with TB.

He said that because people with the HIV infection have suppressed immunity, chances of reactivation of dormant TB bacilli are many fold higher in them than among those without HIV. Mezzabotta stressed that HIV-infected persons are increasingly likely to get numerous opportunistic infections including the deadly TB.

"The TB situation is most common in countries with advanced HIV epidemic. Moreover a combination of TB and HIV contributes to an increase in drug resistance."

According to the study made by Dr. Haruna Muwonge of Makerere University Faculty of medicine, the TB-HIV co-infection is worse in northern Uganda.

He said due to permanent over crowding, poor hygiene, poor general health, poverty, irregular treatment schedules etc, groups of people living in IDP camps are greatly at risk of acquiring co-infection of HIV and TB. The prevalence of the TB-HIV co-infection was found to be higher than that of the national average.

"The government should ensure resettling the displaced persons, adequate follow up, and scaling up measures to improve case detection so as to reduce the TB-HIV co-infection rates in IDP camps and prisons," Muwonge said.

Source: PartnerUganda eForum

Online at: http://www.monitor.co.ug/socpol/socpol12301.php