In-depth: TB and HIV: Deadly allies

LESOTHO-SOUTH AFRICA: Cross-border health crisis hits mineworkers

Khoro Lati, a former mine-worker, is being treated as an outpatient for multi-drug resistant TB

Morija, 19 February 2009 (PlusNews) - Two years ago Mopeli Mofoka, 39, left his wife and child in Maseru, Lesotho's capital, and joined the more than 50,000 men pushed by poverty and unemployment in their home country to seek work on mines in neighbouring South Africa.

It was his second stint as a miner; the first had been 15 years earlier. This time he was hired as a sub-contractor, which meant that despite testing positive for HIV during his preliminary health screening he did not have access to the on-site health services available to mine employees.

When his health began deteriorating 18 months later, he went to a local public hospital but was turned away because he lacked a South African identity document.

His only option was to return home, where he is receiving treatment for tuberculosis (TB) at a government clinic run in partnership with international medical aid organisation Médecins Sans Frontières (MSF) in Morija, about 50km south of Maseru, the capital.

"[My employer] said they'll take me back when I'm better," Mofoka told IRIN/PlusNews. "I think I'll be good by April, when I finish the TB treatment."

The problem, according to MSF doctor Kirill Kojemiakine, is that not all the miners treated for TB in Lesotho finish their six-month course of treatment before returning to work. "Many TB patients who are smear-positive, meaning they're still infectious, take one week of treatment and then default and go back to South Africa," he said.

Interrupting treatment for either TB or HIV can lead to the development of drug resistance. Strains of TB that are resistant to first-line TB drugs, and thus more difficult to diagnose and treat, are becoming increasingly common among migrant miners and their families.

A 2008 study found that at least 25 percent of drug-resistant TB patients treated in Lesotho since August 2007 had worked in mines in South Africa. The full extent of Lesotho's multidrug-resistant (MDR) TB problem is unknown, said Kojemiakine, because the majority of such patients die before they are diagnosed or can start receiving appropriate treatment. International NGO, Partners in Health, which is partnering with Lesotho's Ministry of Health to provide treatment for MDR-TB patients has estimated that 950 new MDR-TB cases will be diagnosed in Lesotho every year.

Lack of coordination

The movement of mine workers between Lesotho and South Africa has had public health repercussions in both countries, but they have been most keenly felt in the tiny mountain kingdom of Lesotho, which has a population of just 1.8 million.

"You have a man leaving his family behind, and when they get across [the border], they develop other relationships," said Mojapela Majoro, regional manager for TEBA Ltd, a service organisation that recruits mineworkers for the South African mining industry.

An estimated 23 percent of Lesotho's population is now living with HIV, and the incidence of TB - a common HIV-related opportunistic infection - is the fourth highest in the world.

A lack of coordination between Lesotho and South Africa in developing TB and HIV policies, and the difficulty of tracking patients, many of them miners who move back and forth between the two countries, has contributed to Lesotho's growing incidence of MDR-TB.

Unlike South Africa, where MDR-TB patients are isolated in special facilities while they undergo treatment that can take up to two years, Lesotho has just one such facility in Maseru with 20 beds. Patients are only kept there for an initial one or two months, after which they are treated as out-patients, with community health workers making twice-daily visits to administer the necessary cocktail of drugs and injections.

Photo: Kristy Siegfried/IRIN

AIDS claimed an estimated 18,000 lives in Lesotho in 2007

It's a system that makes it difficult to keep track of patients who are determined to return to South Africa as soon as possible to earn an income to support their families.

The first time Daniel Thabiso, 41, was diagnosed with TB, he left the mine where he was working in South Africa and returned to Lesotho for treatment. He came back in 2002 to work as a sub-contractor but lost his job two years later because of ill health. He was diagnosed with MDR-TB and HIV in 2008 after a second bout of TB failed to respond to first-line treatment.

After a short stay at the MDR-TB facility in Maseru he was sent home and continued out-patient treatment for another four months, but the medication made him vomit and he was eager to join his wife and two children, who had recently moved to South Africa.

"I told the people at the MDR clinic I wanted to go to South Africa and they said they'd give me a referral letter, but I left before it arrived," he told IRIN/PlusNews.

He returned to Lesotho in December 2008 to attend his sister-in-law's funeral, but did not go back to the MDR clinic and, despite his gaunt appearance, is convinced that he no longer has TB after a sputum test he took in South Africa returned a negative result. Sputum tests often fail to detect TB in patients co-infected with HIV and only culture testing can diagnose MDR-TB.

"I'm feeling better, so the TB is gone," he told IRIN/PlusNews, adding that he planned to go back to South Africa in a few days.

For the estimated 90 percent of TB patients in Lesotho who are co-infected with HIV, movement back and forth across the border with South Africa makes treatment espcially complicated.

Even mine employees often have difficulty getting antiretroviral drugs (ARVs) from either mine clinics or government clinics in South Africa; most are sent back to Lesotho with a referral letter.

"We give them a [ARV] drug supply for a few months, but sometimes they come back late and this is one reason for defaulting," said Kojemiakine. "This gap between Lesotho workers and South African workers doesn't bring anything good because it creates [drug] resistance, and this resistance will spread from Lesotho back to South Africa."

Whose responsibility?

The AIDS and Rights Alliance for Southern Africa (ARASA) released a report in July 2008 urging mining companies and the South African and Lesotho governments to start working together to address the lack of cross-border health policies for migrant mine workers.

Noting the "unambiguous" relationship between Lesotho's TB incidence rate and the South African mining sector, the report accused mining companies of failing to take adequate responsibility for controlling TB among migrant Basotho miners, or for mitigating its impacts on their families and communities.

Dr Brian Brink, group medical consultant to Anglo American, one of South Africa's largest mining companies, agreed that the companies have a responsibility to ensure that all their employees have access to health care, but suggested that the root cause of Lesotho's drug-resistant TB crisis was a lack of coordination between health providers at the mine clinics and in the public sector on both sides of the border.

"If someone is too ill to work and is placed on early retirement, you have to make sure that continuity of care isn't broken," he told IRIN/PlusNews. "Whether it's asthma or TB or HIV, there has to be an arrangement made so you don't just drop someone and say, 'That's it.'"

A home-based care programme for Basotho mineworkers living with HIV, TB or other serious illnesses, run by the development arm of TEBA Ltd, the mineworker recruitment organisation, and funded mainly by mining companies, is one example of how such continuity of care can work.

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Patients who are "repatriated" because of ill health by one of the participating mines in South Africa are referred to the programme in Lesotho, which partners with local health providers and non-governmental organisations to ensure that patients receive ongoing treatment and regular home visits from care-givers.

For a period of two years or until the patient recovers, the organisation takes care of all medical fees, monitors treatment and provides life-skills training for those unable or unwilling to return to the mines.

An alarming 47 of 409 patients currently on the programme have been diagnosed with MDR-TB, and stories like Thabiso's suggest that many more Basotho miners are falling undetected through the health care gap that spans the border between South Africa and Lesotho.

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TB and HIV: Deadly allies
March 2009

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