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Swaziland is at the epicenter of a dual HIV and tuberculosis (TB) epidemic, and is registering a disproportionately high number of deaths.
A key strategy taken by Doctors Without Borders/Médecins Sans Frontières (MSF) and the Ministry of Health is the decentralization of HIV and TB care. Testing and treating patients at local health posts relieves them of the burden of travelling and helps ensure better adherence to treatment. It also leads to more patients being tested and treated.
Given that 80 per cent of people with TB are also co-infected with HIV, the integration of treatment for these diseases, so people need only visit one health facility, is critical.
Despite some successes in scaling up care, field results across the world still show that limited impact has been made on the drug-resistant TB (DR-TB) epidemic. MSF in Swaziland is looking to identify new approaches for multidrug-resistant TB and extensively drug-resistant TB that are shorter, more tolerable, effective and feasible to scale up.
Treatment As Prevention in Shiselweni
Research has shown that starting people with HIV on antiretroviral (ARV) medication as a matter of course not only helps protect their health, but also decreases transmission of the virus. However, most patients do not begin ARV treatment until their CD4 count (a measure of immune system functioning) drops to a certain threshold.
MSF and the Ministry of Health will implement a pilot ‘treatment as prevention’ program in Shiselweni, a region particularly hard hit by the epidemic. The pilot will start with the ‘test and treat’ of all pregnant women in the district, putting patients who test positive for HIV on ARV treatment straightaway, before working with all HIV-positive adults. Preparations for this ambitious program were completed in 2012, with care decentralized to 22 clinics and three specialist health facilities in Shiselweni.
Collaborating with Healers
Traditional healers are commonly consulted in Swaziland, but many people visit healers who cannot provide effective care for HIV or TB. MSF has collaborated with 170 traditional healers in Shiselweni, sharing medical knowledge and best practices for treatment. As a result, the healers – many of whom have now been tested for HIV and screened for TB themselves – are identifying and referring more patients to clinics.
Improving TB Treatment Access in Mankayane
Renovation of Mankayane hospital’s TB ward and outpatient department was completed and inaugurated by the Minister of Health and the Queen of Swaziland. MSF also decentralized treatment for TB and DR-TB to four health facilities in the Manzini region. The success rate for treatment improved from 62 per cent in 2010 to 75 percent in 2012 and the first multidrug-resistant TB patients successfully completed their drug regimens.
Expanding Care in Matsapha
In Swaziland’s bustling industrial center, Matsapha, in Manzini region, MSF provides comprehensive and integrated services so patients do not need to go to separate clinics for HIV, TB and general medical needs (including ante- and postnatal care and immunizations for children). The addition of rapid testing and treatment for DR-TB and treatment for victims of sexual violence has made the center a complete one-stop facility.
Albert Zondo is a traditional healer from Mnyatsi, in Shiselweni.
I can cure illnesses that I recognize. If I don’t understand the illness, I do not hesitate to refer them to Western medical facilities. For me the main objective is ensuring that the patient recovers. I am not too concerned about how.
So when a patient presents any of the vital symptoms of HIV or TB I connect them to the local MSF expert client, who then links the patients with a clinic.
I got very sick in 2004. After resisting for a long time, I eventually agreed to test for HIV and try western medication. I was diagnosed with HIV and initiated on ARVs at Mankayane hospital.
My counselor strongly advised me never to mix my medication with traditional medication. How could I turn my back against my own medicine? This felt like disloyalty to who I was. But I took the treatment as instructed and I soon saw the improvement in my health.
ARVs have worked for me. I will not keep people on treatment that will not help them. That would be wrong. My fellow traditional healers have never questioned what I do.