Africa's TB Crisis May Spur AIDS Treatment
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Cross posted from our E-Drug discussion group
Washington Post - Africa's TB Crisis May Spur AIDS Treatment
Cape Town Plan Promotes Test, 'Twins' Approach
By Craig Timberg - Washington Post Foreign Service - September
26, 2005
KHAYELITSHA, South Africa -- Soon after Andile Madondile, 27,
got the double diagnosis of tuberculosis and AIDS last year, his
boss fired him and his girlfriend moved out, leaving him with
both their leaky shack and their young daughter.
As coughs shook his body during sweaty, miserable nights,
Madondile said he fantasized about walking down to the tracks
that run through this gritty township, waiting for the morning
express train to approach and then leaping into oblivion.
A year later, though, he has come to see those terrible coughing
fits as his first step toward recovery. Long before Madondile
could accept that he had AIDS, with its heavy stigma of sin and
death, he began seeking relief from tuberculosis. Treating one
disease became the gateway to confronting -- and ultimately con-
trolling -- the other.
The World Health Organization last month declared a tuberculosis
emergency for Africa, where the rate of infections has quadru-
pled in many countries since 1990. The epidemic, which is espe-
cially severe in Khayelitsha, kills more than 500,000 Africans
each year, although with proper treatment TB can be cured within
six months.
The crisis has been caused by the growing levels of AIDS, which
weakens resistance to such infections. The two diseases occur
together so frequently that doctors call them "the terrible
twins."
But, as with Madondile, tuberculosis can also speed treatment of
AIDS by prompting patients to seek medical help early enough for
life-saving antiretroviral drugs to work. At a time when the
vast majority of those dying from AIDS do not even know they
have the disease, TB can serve as a vital early warning sign. In
Cape Town, a glitzy seaside city whose boundaries include Khaye-
litsha 20 miles inland, TB patients now are the largest source
of referrals for antiretroviral programs, officials say.
Though such programs still reach only a small minority of those
with AIDS in South Africa, they are expanding rapidly in its
biggest cities. Cape Town's health plan envisions treating tu-
berculosis and AIDS increasingly in tandem and having every TB
patient take an HIV test.
"It works," said Ivan Toms, city health director, "but it's be-
cause the rest of the system isn't working."
A combination of political pressure and increased production of
generic drugs has led to a dramatic decrease in the price of an-
tiretrovirals. But treating AIDS on a mass scale in South Af-
rica, where estimates of HIV infections exceed 5 million, has
proven far more complicated than just providing medicine.
There are not nearly enough doctors, nurses or pharmacists to
prescribe and distribute the drugs. Most public health facili-
ties are poorly equipped and managed. And the disease's stigma
remains so powerful that many choose to die at home rather than
seek treatment. But here in Khayelitsha, where most of the
400,000 residents live in tiny shacks, one survey showed that 41
percent of adults said they had been tested for HIV at least
once -- many times higher than the national average.
Part of the reason is Khayelitsha's stratospheric rates of tu-
berculosis, and the determination of health officials to offer
those with that disease an HIV test as well. In Europe and the
Americas, an average of 46.5 out of every 100,000 people con-
tract TB each year, according to WHO statistics. The rate in
Khayelitsha is many times higher.
Doctors have found that patients infected with TB are more
likely, because of its less-severe stigma, to seek medical help
than those with AIDS alone, providing a ready pool of patients
to be tested for HIV.
Tuberculosis is a disease mainly of the lungs, and each cough
spreads thousands of infectious droplets. Most people who are
exposed will never show symptoms, but for those who do develop
tuberculosis, it is frequently fatal if not treated.
Drugs that combat TB are cheap and effective and, taken as pre-
scribed for the six months, they can cure most cases. But 62
percent of tuberculosis patients in Khayelitsha also have HIV,
so treating one but not the other gives most patients only a
brief respite.
The solution, say doctors here, is to treat them together, with
two sets of pills. For those few facilities with the resources
to handle both diseases, the most difficult part of recovery is
getting patients to take their medicine day after day. At the
Ubuntu clinic in Khayelitsha, founded in 2000 by the French
medical aid group Doctors Without Borders and regional health
authorities, officials demolished the wall separating the AIDS
and tuberculosis sections several years ago, easing flow of in-
formation, patients and staff. As a precaution against new in-
fections, TB patients are seated several feet away from HIV pa-
tients in the waiting room, and initial studies have shown no
evidence that one group is infecting the other. For those coming
to the clinic for tuberculosis, initial consultation is followed
by a visit to a counselor who urges an HIV test. A large major-
ity agree, getting a finger-prick test in a room a few steps
away.
This approach is rare, and even here it has hardly brought ei-
ther tuberculosis or AIDS under control. But doctors say it of-
fers the possibility of restoring health to patients with both
the good luck to live near clinics and the determination to seek
help. "It's one epidemic," said Eric Goemaere, the top Doctors
Without Borders official in South Africa. "One patient, one epi-
demic and two systems. That's the problem."
Madondile heard of the Ubuntu clinic in radio ads and came for a
tuberculosis test in June 2004, after enduring a hacking cough
for about three months. At the suggestion of a counselor, he got
an HIV test the same day.
When he returned later, he learned that he was infected with
both diseases, he said. Worse still, his CD-4 count, a commonly
used measure of immune strength, was dangerously low. A healthy
person generally scores at least 800. A person with advanced
AIDS scores about 200. Madondile's score was 37.
His boss fired him the same day, he said. His brother and one
sister shunned him, refusing to use the same spoons, blankets or
toilet.
There were slivers of good news. His daughter, Elihle, tested
negative for HIV. But the shame and rejection overwhelmed
Madondile, he said. In that early phase of denial, the only
treatment he attempted was a sour-tasting traditional African
medicine. With his appetite gone and diarrhea growing severe,
Madondile's legs became so thin that he stopped wearing shorts
out of embarrassment. And after his girlfriend moved out, he be-
gan fantasizing about the express train delivering him from the
pain, he said.
It took the supportive words of a neighbor, who visited his bed-
side with food and encouragement, to make Madondile rediscover
his will to live.
He returned to the clinic to get treatment for the tuberculosis
in October and asked for antiretrovirals three months later,
when his CD-4 count had dropped again, to nine. He started tak-
ing the medicine on March 8.
A few weeks later, Madondile started to recover. His appetite
returned. A rash on his face cleared up, as did the painful
shingles on his chest. His weight gradually doubled, back to a
healthy 150 pounds.
"If I had waited too long," Madondile said, "I might be dead
now."
He still is jobless, and his girlfriend has not returned to
their shack, which has neither a sink, stove or toilet. But on a
bed that nearly fills one of its two rooms, Madondile now sleeps
in peace. His daughter, healthy and generous with her smiles,
sleeps beside him.
--
Leela McCullough, Ed.D.
Director of Information Services
SATELLIFE
30 California Street, Watertown, MA 02472, USA
Tel: +1-617-926-9400 Fax: +1-617-926-1212
mailto:leela@healthnet.org
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