Fighting a Dual Epidemic: Treating TB in a High HIV Prevalence Setting in Rural Swaziland

In Swaziland a dual epidemic of tuberculosis (TB) and HIV is threatening to wipe out entire generations. The country has the highest HIV prevalence in the world among adults, coupled with one of the highest incidence rates of TB. The great majority of TB patients are co-infected with HIV, and TB is the leading cause of mortality among HIV-positive patients. To add to this, a new challenge is emerging in the form of drug-resistant tuberculosis (DR-TB). The dual epidemic is taking a deadly toll on the people of Swaziland, whose life expectancy has halved over the past 20 years – from 60 to 31 years. People are dying in large numbers, children are being made orphans and the workforce is declining. It is a health emergency of huge proportions. Tackling this crisis is being hindered by an acute shortage of medical staff, by an inadequate diagnostic capacity and by patients failing to complete their treatment, often because of the prohibitive cost of making long and frequent journeys to distant health facilities.

Médecins Sans Frontières (MSF) and the Ministry of Health (MoH) of Swaziland are working together to fight the co-epidemic. In Shiselweni, the country's poorest and most remote region, they have adopted a decentralised, integrated and patient-centred approach.

Despite numerous challenges, the joint programme has had a considerable impact in the past two-and-ahalf years. Twenty-one sites throughout Shiselweni region have been developed as fully integrated 'onestop services' for HIV and TB care, offering treatment initiation and follow-up at primary care clinics. DR-TB care has been decentralised to the region's three main health facilities, with further decentralisation to clinics and communities for all DR-TB patients on injections in the intensive phase of treatment. More generally, outreach teams are extending the provision of HIV and TB services into outlying communities.

The result is that increased numbers of patients are being diagnosed and initiated on treatment earlier, fewer patients are defaulting from their treatment, and treatment outcomes have improved significantly. The number of people tested for HIV each month has more than tripled, the number of people initiated on antiretroviral therapy (ART) has doubled, and TB outcomes have seen a marked improvement.

In a national health crisis where financial and human resources are so limited, much of the success of this model of care delivery lies in task shifting. By using trained and supervised lower cadre health workers to provide more widespread access to HIV and TB care, MSF and the MoH have succeeded in keeping care within the community and tapping into the growing resource of expert clients with direct experience and knowledge of HIV, TB and related issues.

Decentralising services has also dramatically improved patients' access to care. Instead of having to make long, repetitive and expensive journeys to the region's health facilities, many patients can now access HIV and TB services close to their homes. Giving DR-TB patients the option to receive injections and oral drugs at home during the intensive phase of treatment has been another major step forward in adapting care to meet patients' needs and support treatment adherence.

Improved infection control measures have made healthcare environments safer for both staff and patients. Intensive case finding among HIV patients at all clinics is also improving infection control in the community by identifying TB patients and starting them on treatment earlier. Psychosocial support is increasing awareness of TB and HIV among patients and the wider community, contributing to more people coming forward for testing and treatment, better retention in care and a reduced risk of infection transmission within the community.

The challenge now is to build on these successes and develop fully MOH-managed decentralised HIV and TB services that overcome the geographical and financial barriers to care that many patients still face. Task shifting must be expanded to allow nurse initiation of ART and to manage the growing number of people with HIV in need of treatment. Laboratory capacity must be further strengthened and expanded in each clinic, to cope with the projected increase in people with HIV in need of ART, and with the growing number of TB and DR-TB patients. Well-functioning, standardised systems of drug management and data management must also be introduced and maintained. Introducing these measures should be a top priority. The scale of the co-epidemic in Swaziland demands urgent political commitment translated into immediate action.

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