International Activity Report 2005
The TB/HIV time bomb: A dual epidemic explodes in South Africa
By Lisa Hayes, MSF International Editor

Khayelitsha, South Africa. © Pep Bonet

The shape of the TB epidemic has been dramatically affected by HIV. TB is one of the world's leading causes of death, especially in developing countries. The World Health Organization (WHO) estimates it kills two million people each year and another eight million become ill. While onethird of the world's population is infected with the mycobacterium, most people do not become sick unless their immune system is compromised. And that is exactly what the HIV virus does.

Today, TB is the leading cause of death among people living with HIV. Despite this fact, few countries have programs that provide TB treatment alongside HIV care. MSF has been spearheading efforts to integrate care for people living with TB and HIV/AIDS in Khayelitsha, South Africa, a poor urban township near Cape Town.

In 2003, in cooperation with the Provincial Administration of the Western Cape and the city of Cape Town, MSF started a pilot project at Khayelitsha's Site B Ubuntu clinic. Khayelitsha has the highest TB incidence (1,655 new cases for every 100,000 people per year) and one of the highest HIV prevalence rates (29 percent) in the metropolitan area. The clinic's "one-stop" services, quick referrals and careful monitoring of both TB and HIV patients have made it the busiest clinic in the Western Cape for both TB and ARV treatment.

Approximately 65 percent of the clinic's TB patients tested have been found to be co-infected with HIV.

Word has traveled quickly that patients can now get care for both illnesses at the same place and the waiting room is full every morning at 8: 00. "The patients are coming," says Gilles van Cutsem, an MSF physician working at the Ubuntu clinic. "This clinic is seeing more patients than others. Integration is working for patients. They know it makes it easier to get care."

Integrating TB and HIV/AIDS care has not been easy as treatment for both illnesses have historically been provided through separate programs in the Western Cape region run by different health authorities. While medical teams on the ground see the obvious need, at a higher level, protecting existing programs and areas of control often seem to have priority over improved, more efficient patient care.

Plus, the WHO's commitment to daily directly observed TB treatment hampers efforts to introduce more f lexible and adapted treatments. "MSF is one of the few organizations working to make integration a reality in South Africa," says Marta Darder, coordinator of MSF's Access to Essential Medicines Campaign in South Africa. Places like the Ubuntu clinic show that on a small scale, integration is working, but a lot still needs to happen. Ubuntu is one of only a handful of South African health centers that are offering integrated care for TB and HIV patients and all of these efforts pale in comparison to the immense need for them.

About 200 people come to the Ubuntu clinic every day for testing, treatment, counseling, blood tests or medical examinations. Health records for TB and HIV patients are filed together for easy cross reference and recall, and all patient information is stored in a central database.

TB is more difficult to detect in HIV-positive patients as they tend to contract less common, more difficult-to-diagnose types of the disease. The fact that in many countries different health staffs and departments handle diagnosis and treatment for these two illnesses means that many patients found to have one disease may not be treated or even tested for the other. Even when they are referred for testing or care, many patients must visit multiple health centers to get the care they need. Health care providers also face frustrating obstacles in getting sick patients tested and started on treatment because of the separate systems.

One-stop services

From patient to employee "I was a patient and now I'm working at the clinic. It started long ago in 2000. I was very, very sick. I had headache. I went to the clinic and the doctor tested me for HIV and it was yes. I had to cry and cry. I talked to the counselors and they said, "No, it's no good. Don't cry, you must live!" So they talked to me. They said I must stop with crying. And that I must come to the clinic so they could check me. Then they checked for TB and they found it. So I had TB and HIV. I had to take tablets for TB and I was very, very weak. And I had to go to the hospital and was not feeling well at home. I thought with this HIV, I must go there to die. I had to take the tablets for eight months for TB. After eight months I was feeling all right, feeling better. Then I had to come to see the doctor and start taking these ARVs. Then I started to feel better, My CD4 count was 26 when I started, very low. I was feeling very bad. So I've been taken them since 2001. I must still go to the clinic. I started working for MSF in 2003. Inside I'm feeling so good. The TB is gone. Now while I'm working I see people who are very sick, who have the same problems. I talk to these people. I tell them that I was sick too. And now I'm working every day." – Nonkululo Kili, a TB/HIV patient in Khayelitsha who now works as a cleaner at the Ubuntu clinic

Good ventilation for the new clinic is essential to discourage transmission of TB as more than 200 patients come through the clinic each day. All needed TB and HIV services are available around the perimeter of the new clinic. The close proximity reduces waiting and traveling time for patients and makes referrals much easier. "Before it was always frustrating when you'd know a patient has TB clinically, but you had to send the patient to another place to be tested," says Shaheed Matee, the principal medical officer of the Ubuntu clinic working for the Provincial Administration of the Western Cape. "Invariably, patients get lost in the system. So now that we've moved over to the HIV site with the TB clinic here, it is much easier for me to say, 'You've got TB. Let's get you started on TB treatment.' It makes it easier for the patients. You know your patient doesn't have to go in your queue and tomorrow stand in another one."

Because the same patients often face both illnesses, medical staff need to be alert to signs of co-infection and possible drug interactions and side effects. Regular consultations with a doctor or nurse are a crucial part of follow-up care for all HIV-positive patients. They take place every few months — more often if there are complications. The medical staff check the patient's immune system, weight, adverse reactions and adherence to treatment.

HIV/AIDS patients displaying signs of TB are quickly referred for testing. In the same way, TB patients are encouraged to be tested for HIV once they have been on TB treatment for two months, if they haven't done so already. Approximately 65 percent of the clinic's TB patients tested have been found to be co-infected with HIV. If they are found to be positive, they are sent to see one of the HIV nurses. They have blood taken to check their immune system and receive counseling. From then on, their case will be jointly managed. While taking their TB medicine, they will be prepared to start life-extending antiretroviral (ARV) treatment (if needed). They will also be examined by the medical staff for other opportunistic infections. Those who refuse to be tested are regularly encouraged by the staff to change their mind.

Women and children

The majority of the clinic's patients are women. In South Africa, the clinic's doctors say, the average TB and HIV patient is a woman in her 20s, who often has children, some of whom are also HIVpositive. "It's easier for a woman to become infected with HIV," explains Dr. Saranchuk. "Plus women also tend to come for help early whereas men here wait until they're almost dead before they come in."

Children are difficult to diagnose for both diseases. They are unable to cough up sputum for the regular TB test. Diagnosis of HIV usually cannot be confirmed solely on clinical symptoms as they may not be present or may mimic other childhood diseases. Tests used in most developed countries to confirm the diagnosis of HIV in very young children are not available in the countries most affected by the AIDS pandemic. © Mariella Furrer

Most pregnant women (98 percent) in Khayelitsha agree to be tested for HIV. Those mothers found to be positive are offered treatment to help reduce the risk of transmission of the virus to their newborn. In 2004, MSF saw approximately 150 children in its clinic and about half of them were taking ARVs.

Once a diagnosis of TB and HIV is confirmed, other problems surface in providing treatment to children. Some HIV drugs only exist in tablet form or in foul-tasting syrups requiring refrigeration. Others call for frequent administration, an empty stomach and lots of clean water. Because of drug interactions between some common TB and HIV/AIDS drugs, children may need more expensive drugs or second-line ARV medicines that may not be available. Other drugs have not been studied in children and therefore cannot be used with very young patients. The problem of lack of treatment for co-infected infants and children will be faced more and more often by health care staff trying to treat them.

Educating through counseling

Promoting self-responsibility through counseling has been a key element to treatment compliance for those taking ARVs. Before treatment is started at the Ubuntu clinic, patients are educated about the disease and how ARV treatment works. They must also meet certain conditions before it can begin. These include disclosing their HIV-positive status to at least one person, selecting a "treatment assistant" to help them comply with daily treatment requirements and promising to keep necessary medical and counseling appointments at the clinic. Once patients on ARVs have been on treatment for a few months and show good adherence, they are given monthly or even bimonthly supplies of the medicine to simplify their own lives. New TB patients are also educated about their disease, its treatment and the importance of coming to the clinic for regular monitoring.

The difficulties of diagnosing TB

Patients thought to have TB are given a "sputum test." This test relies on finding signs of TB in the material an infected patient can cough up from their lungs. However, many HIV-positive patients develop types of TB that are difficult to diagnose with this test. Often the bacteria aren't found in the sputum of HIV-positive patients. "The maturation of the HIV epidemic has meant more sputum negative cases," says Dr. Christine Villier, a TB specialist working for the city of Cape Town at the Khayelitsha clinics. "But the message didn't get across that the patient needed further assessment if they were sputum negative. So they would just come back later, sicker."

Treatment adherence is crucial as many TB patients stop taking their pills once they start to feel better which leaves them uncured and possibly still infectious. They also run a greater risk of developing and spreading drug-resistant TB which is much more difficult to treat and expensive to cure and claims many more lives. © Mariella Furrer

As a result, many co-infected people remain undiagnosed by national TB programs that focus on "sputum positive" patients as recommended in the pre-HIV era. In the past, the typical patient was consumptive, coughing and losing weight. Although that patient profile is still the most prevalent one, many others have atypical symptoms of TB. The number of people with extrapulmonary TB (TB outside of the lungs) is going up and that is linked to HIV. Patients at the Ubuntu clinic who seem to have signs of TB but have a negative sputum test are given antibiotics and sent for an x-ray or other tests to rule out other infections. In urgent cases, TB treatment may be started the same day before a clear confirmation is made.

Simplifying treatment

To be cured of TB, a patient must take five or six pills every day for six to eight months. The WHO has adopted a strategy, one part of which calls for patients to take daily medicine in front of a health worker or trained community worker or family member to ensure that they follow the prescribed treatment schedule. When strictly followed, this Directly Observed Treatment, better known as DOT, places a heavy burden on patients who must take the time and money to travel to get their medicine and be watched taking it. It also puts demands on health staff who must observe treatment for many patients each day. WHO recognizes many of these concerns and is now in the process of adapting its global TB policy to address them.

MSF and some other organizations advocate a less rigid approach to DOT based on patients' needs and the realities of what care providers are seeing. Based on its experience, MSF promotes modified DOT, a system in which patients take their TB medication observed by a DOT provider during the first few weeks of treatment (instead of during the full treatment time) and thereafter be responsible for taking their pills at home. This gives patients much more freedom while enabling health staff to explain treatment and provide support if patients experience side efforts in the early phase of treatment. To boost adherence, tools used in AIDS treatment have been duplicated to TB programs, such as adherence counseling and designating a "buddy" for each patient.

The need for new TB treatment

At the same time, the medicines now used to treat TB were discovered more than 50 years ago and virtually no new research was done to develop new treatments and diagnostic tools until recently. Once a patient is cured, there is no guarantee that he or she will not be re-infected, especially those whose immune system is already weakened by HIV/AIDS.

The fact that MSF and its partners can treat people with TB, but cannot address the real causes for the continued high spread of the disease is frustrating. "We treat our patients for six months, and then we have to send them back to the same conditions where they got it the first time," says Dr. Matee. "They go back to the overcrowding, the lack of sanitation, no water, no electricity, that type of thing. So there are social issues that have to be looked at before we can even say we are going to get TB under control." With both diseases affecting so many people, MSF believes South Africa and other countries hit by the dual epidemic will have to push for integration based on their own national health situation and political climate. "People keep trying to block integration," concludes Darder, "but MSF keeps pushing because medically it makes sense."