The tiny mountain kingdom of Lesotho, already burdened by the third highest HIV infection rate in the world, is struggling to contain a parallel epidemic of tuberculosis (TB).
Photo: Kristy Siegfried/PlusNews
|The Botsabelo Hospital TB clinic is the largest in the country but cannot diagnose multi-drug resistant cases
In 2006 alone, 12,000 of Lesotho's 1.8 million inhabitants were diagnosed with TB, but experts like Peter Saranchuk, of the international medical relief organisation, Medecins San Frontieres, believe the actual number of people suffering from the disease is probably much higher.
Challenges for diagnosis
It is estimated that as many as half of all adults in southern Africa carry a latent form of TB, but people with HIV-compromised immune systems are 50 times more likely to develop active TB.
The sputum tests most commonly used to detect TB often fail to recognise it in HIV-infected patients. Because the proportion of TB patients co-infected with HIV in Lesotho is one of the highest in the region - 85 percent to 92 percent - Saranchuk estimates that the amount of undiagnosed TB is "vast".
In most of the HIV-positive patients with negative sputum test results, the most reliable way to diagnose TB is by culture testing, in which samples are cultivated in a special liquid. But Lesotho has very limited capacity to do culture testing; samples must be sent to neighbouring South Africa and it takes about six weeks to get results.
A machine used to prepare the samples at the country's largest hospital, Queen Elizabeth II in Maseru, has been broken for over a year. Staff at the TB outpatient clinic at nearby Botsabelo Hospital told PlusNews they were still waiting for the results of cultures sent to Queen Elizabeth in May 2006.
Where culture testing is unavailable or simply too slow, TB in HIV-infected patients can be diagnosed by means of x-rays and clinical assessments. But this approach is relatively new and Lesotho's department of health and social development is still in the process of training health workers in the co-management of the two infections.
Death rates among people in Africa who are co-infected with TB and HIV are similar to those before effective TB treatment was avaiable
According to Saranchuk, many doctors will still only initiate TB treatment based on a positive sputum test. "That patient will keep getting antibiotics and keep getting sicker, even though they do have TB," he said.
"The TB world hasn't adjusted to the fact that there's this explosion of co-infection going on in Southern Africa," added Rachel Cohen, MSF's head of mission in Lesotho. "It hasn't filtered down yet to nurses at the primary care level, who are the ones faced with sputum-negative patients who are going to die of TB if they don't do something to treat them."
In one of Lesotho's 17 health districts, where MSF is managing HIV/AIDS and TB care and treatment at 14 clinics and one district hospital, nurses are being trained in how to diagnose TB using x-rays and other indicators, but elsewhere in the country only doctors can initiate treatment in sputum-negative cases.
Need for integration
Until recently, there was little coordination between Lesotho's TB and HIV/AIDS programmes. As in most countries in the region (see www.nature.com), patients accessed TB and HIV treatment at different sites and there was little collaboration between health professionals working on the twin diseases.
Now the department of health and social development has a TB/HIV strategy that includes training health workers and lay counsellors in both TB and HIV, routinely offering HIV testing to TB patients, screening HIV patients for TB, and providing TB and HIV treatment at the same site.
But, according to Dr Michael Sekokomala, head of Lesotho's largest TB outpatient clinic at Botsabelo Hospital, in the capital city of Maseru, implementing this strategy still has a long way to go. The clinic lacks enough counsellors to provide HIV testing to all patients, and those who are co-infected still have to make separate appointments to access antiretroviral (ARV) treatment at a nearby HIV/AIDS clinic.
Maneo Lesole, who works at a local garment factory to support her three children, misses up to five days of work a month to attend appointments at both clinics. "They deduct my pay for each day I miss," she said. "After deducting I get maybe 500 maluti (US$68), instead of M650 (US$88)."
Programme strategies for ensuring that patients adhere to their TB and HIV/AIDS drug regimes also differ. Directly Observed Short-Course Treatment (DOTS), in which volunteer community health workers are trained to monitor TB patients while they take their medication, is the norm; HIV patients undergo intensive adherence counselling to make sure they understand the importance of taking their medication every day, without supervision.
Lesole, who received ARV-adherence counselling before she began TB treatment, quickly informed the community health worker assigned to monitor her TB medication that she was used to taking drugs on her own.
MSF favours a more patient-centred approach to TB-drug adherence, based on its experience of ARV treatment. Patients and their "treatment supporters", who can be family members, attend 'TB school', where they learn about possible side-effects, the consequences of not completing their treatment and what they can do to avoid infecting household members.
"We've learned that empowering patients is the key to long-term adherence," said Cohen. "When people really understand about the risks of drug resistance, they're going to take their medicines every day."
Shoeshoe Matsoele, deputy manager of Lesotho's TB control programme, believes the DOTS approach can be adapted to incorporate ARV adherence. She sees no reason why volunteers trained in DOTS, whether community health workers or family members, cannot also be trained to monitor ARV drug adherence.
Drug resistant TB threat looms
In neighbouring South Africa, multidrug-resistant TB (MDR-TB) is on the rise. MDR-TB is often the result of TB patients failing to finish their 6-month course of drugs and is particularly dangerous and difficult to treat in people living with HIV.
Even more alarming, virtually untreatable extremely drug-resistant (XDR) strains of TB emerged in South Africa's KwaZulu-Natal Province in 2006 and have since spread to other provinces, leaving more than 200 people dead so far, most of them HIV-positive patients.
|XDR worries us very much, because if we can't manage MDR, how can we manage XDR?
As culture testing is the only sure way of diagnosing MDR-TB, Lesotho is at a severe disadvantage in assessing the seriousness of its MDR-TB problem and dealing with it.
"We don't know how many MDR cases we have," said Dr Sekokomala. "We just have MDR suspects, so XDR worries us very much, because if we can't even manage MDR, how can we manage XDR?"
Sekokomala is convinced that XDR-TB is already present in Lesotho because of the number of patients he has lost while they were being treated. The lack of infection control in Lesotho's TB wards and clinics is particularly worrying: staff at his clinic have now received protective masks, donated by Partners In Health (PIH), an international medical non-profit organisation, but an HIV-positive nurse died of TB before they arrived, despite being on treatment.
The Lesotho government is still finalising emergency guidelines for dealing with MDR and XDR-TB, and recently entered into an agreement with PIH to open a 40-bed isolation ward for MDR-TB cases at Botsabelo Hospital. It is expected to open in May of this year.
In the meantime, Sekokomala is forced to admit patients with suspected MDR to the TB ward at Queen Elizabeth II Hospital. "There's only a corridor separating the TB ward from the children's ward, and children play in that corridor," he said.
Dr Jennifer Furin, director of PIH in Lesotho, has been impressed by the government's rapid response to the threat of MDR and XDR-TB. Her biggest concern is not the lack of an isolation ward, but the potentially high number of unidentified MDR-TB cases: "In reality, these patients are everywhere and they're coughing, and there's really no way to isolate them."
This report is part of a PlusNews In-depth: 'The New face of TB: Drug Resistance and HIV'