Malnutrition deals a double blow to people with HIV and TB in South Sudan

In Leer County, rising food insecurity poses a threat to people with HIV and/or TB, making treatment more painful and impacting adherence.

An HIV/TB patient holds medication in South Sudan.

Close-up of the medication that Nyangkury Deng Jal, 56, who has TB and HIV, has to take every day, even when there is not enough food. | South Sudan 2024 © Kristen Poels/MSF

In South Sudan, an estimated 7 million people will face acute food insecurity or worse between now and July. For people living with tuberculosis (TB) and HIV, an empty stomach can make treatment more intense and difficult to bear. Some will endure severe pain, while others may decide to reduce their medication or even stop taking it to reduce the pain, but putting their lives at risk. 

Nobody should have to choose between taking life-saving medication and living without pain, yet this is the situation that more and more patients with TB and HIV face in Leer, Unity State. A lack of food can cause severe pain and dizziness for patients undergoing treatment, which can include up to eight pills a day and can last for the rest of their lives. Doctors Without Borders/Médecins Sans Frontières (MSF) calls on aid organizations and agencies providing food assistance to scale up and prioritize vulnerable groups such as people living with HIV and TB.

TB/HIV patient

Peter Duop

I was visiting my family in Leer when I fell ill, so I had to stay there even though I live in Bentiu. I went to the MSF center and they told me I had TB and HIV. 

Now I'm dealing with it and the treatment is doing me good. However, it's not easy to follow it properly, because I don't have enough food. Taking the treatment on an empty stomach makes me vomit because I take eight pills a day. 

Man sitting against hut in South Sudan.

Managing treatment on one meal a day

Using a cane to support his emaciated body in the 104-degree sunshine, James, a 60-year-old patient with both TB and HIV, said "life is very hard here because we have nothing. I fell sick with TB and HIV three months ago, so I can't do any work and I have no savings. All we find around us are water lily roots, but that's not enough."

If I see that I'm only going to have one meal a day, then maybe I take half my medication. I know that's not good for my health, but I have no other choice. 

James, MSF patient

"That's why I usually reduce my treatment to adapt to the food I eat," he continued. "If I see that I'm only going to have one meal a day, then maybe I take half my medication. I know that's not good for my health, but I have no other choice. If I take the treatment without eating, I get dizzy, shiver, and have severe stomach pains."

Waterlily roots in a bowl that will be a family's main meal in South Sudan.
A small bowl of foraged waterlily roots will be the main meal for a household in Leer, Unity State, South Sudan.
South Sudan 2024 © Kristen Poels/MSF

Inside Doctors Without Borders facilities, Gatkuoth, a new patient, shares the same challenges. “I had TB four years ago, and at that time I completed treatment quite easily. Now that the situation is deteriorating, it's much harder because I have no food. Sometimes it's so bad that I wonder why I kill myself with the pain, maybe I’d rather die from the disease."

South Sudan’s Leer County is a fairly isolated place, and is prone to heavy flooding and recurrent insecurity. For several years, people have been reluctant to cultivate their land for fear of losing it all during rainy season floods. They depend either on the food available on the market, which inflation has made increasingly difficult to afford, or on food assistance, which has been reduced considerably due to budget cuts.

On top of that, displacement from war-torn Sudan is putting further pressure on food supplies in the area and increasing health care needs. Since April 2023, more than 60,000 people have settled in Unity State, including refugees and South Sudanese returnees.

HIV patient

John Machar

I arrived in Leer seven years ago, deployed as a soldier. I'm alone here, as my family lives in another area. Unfortunately, I fell ill with HIV in 2021 and since then I've stopped working. I told my superior that I was ill, but I didn't say what the illness was. It's better if no one knows.

Thanks to MSF, I have access to treatment and I feel better, but life is very hard for me. I sit all day and can't do anything because I feel too weak.

Yesterday I didn't get any food at all and this morning I didn't get any either. I usually get only one plate a day, sometimes less. It's very difficult to take the treatment. I feel dizzy and nauseous all the time. But I know that if I stop my treatment, my body will get worse, so I take it even if it's painful.

A man stands in front of a treatment center in South Sudan.

As a result, malnutrition has spread throughout the community, creating a vicious circle. In addition to affecting patients’ adherence to TB and HIV therapy, malnutrition is a major risk factor for the disease itself, as it considerably reduces immune defenses. Providing TB and HIV patients with food and nutritional support, transportation, and other support mechanisms helps enable treatment, and has proven to improve patient health, adherence to treatment, and overall outcomes.

Vulnerable groups must not be forgotten

"Food insecurity is becoming a problem," explained Daniel Mekonen, MSF's medical team leader in Leer. "We have a cohort of more than 600 patients co-infected with TB and HIV, and many of them tell us that they can no longer follow the treatment properly because of the lack of food. They either reduce it or stop until the situation improves.”

An MSF patient stands in front of his home in South Sudan.
James Kuong Madeng, 60, suffers from TB and HIV. Because of floods in his home town four years ago, he had to move to Leer, and lost his house, his cattle and all his belongings. He struggles to get enough food and has to reduce his medication because of the pain of taking it on an empty stomach.
South Sudan 2024 © Kristen Poels/MSF

“This is not without consequences,” Mekonen continued. “We are receiving more and more patients at an advanced stage, in serious condition, who are becoming very difficult to treat, and others are developing resistance to antibiotics. We used to see eight new patients a month, but recently that figure has doubled. If people are not supported with food, our program will not succeed. On a national level, Doctors Without Borders is deeply concerned about the ongoing prevalence of HIV and TB in South Sudan.”

About our work in Unity State

Doctors Without Borders started working in Leer, Unity State, in 1989 and remains one of the few organizations providing medical care to people in the area. While malnutrition is rising, food distribution is inefficient. Other organizations and agencies providing food support and assistance should scale up their response and consider specifically targeting and prioritizing vulnerable groups such as patients with HIV or TB.