In-depth: TB and HIV: Deadly allies

SWAZILAND: "It's TB that's killing people"

Gwebu follows up on TB treatment defaulters with a motorcycle
Siteki, 24 March 2009 (PlusNews) - Kwanele Dlamini's motorbike can carry him to most rural homesteads in the eastern Lubombo Region of Swaziland, but he has to get off and walk the final rocky stretch to Solomon Ndwandwe's property and then duck a barbed-wire fence.

Ndwandwe, 58, approaches with slow, careful steps from a small plot of sweet potatoes, planted when he still had the strength for such things, and the two men seat themselves on the step in front of the house.

Dlamini is one of two tuberculosis (TB) medication adherence officers working on motorcycles out of the Good Shepherd Hospital in Siteki, the region's main referral facility. He is here to find out why Ndwandwe missed his last appointment at the hospital and what he can do to help him restart his treatment.

The explanation is simple, and one that Dlamini hears often: Ndwandwe did not have the 30 emalangeni [US$3] for bus fare to and from the hospital. "I tried to borrow from elders in the community, but they said 'no' because I already owe them money," he told Dlamini.

Ndwandwe has lived alone since he was retrenched from his job with a sugar company in June 2008, when his wife also left him. His "treatment supporter", a cousin who lives nearby, has also contracted TB and no longer visits him.

Hollow-chested and stick-limbed, Ndwandwe is subsisting on sweet potatoes and the rainwater that drains from his roof. Even if he restarts TB medication, he is unsure how he will survive when the rainy season ends and the potatoes run out. "After I take the medicine, I feel hungry and I'm worried because I have no food," he said.

Dlamini leaves him a bag of corn-soya blend, donated by the World Food Programme, and money for bus fare so he can come to the hospital, but getting Ndwandwe well again will take a lot more.

During the six weeks he stopped taking his TB treatment, Ndwandwe may have developed resistance to the drugs and moved from being a category 1 patient, needing a six-month course of medication, to a category 2 patient, needing longer and more aggressive treatment that includes several months of daily injections.

TB time bomb

Patients like Ndwandwe represent a ticking time bomb in a country already struggling to contain the world's most severe HIV epidemic; the legacy of years when government and donors were so focused on HIV they neglected the twin epidemic of TB.

"TB just hasn't received as much attention as HIV, and it's TB that's killing people," said Themba Dlamini, manager of Swaziland's National TB Programme.

Swaziland now also has the world's highest TB rate, according to the World Health Organization (WHO), but only about 60 percent of cases were detected in 2008, of which 58 percent completed their six-month course of treatment - a big improvement from 42 percent the year before but still way below the 85 percent target recommended by the WHO.

Like about 80 percent of Swaziland's TB patients, Ndwandwe is also HIV positive and will probably need to start antiretroviral (ARV) treatment soon. Despite talk of the need to integrate TB and HIV services, efforts to roll out TB screening and treatment from hospitals to local clinics have lagged behind the decentralization of HIV testing and treatment.

With funding and technical assistance from the Nuffield Centre for International Health and Development in the UK, Good Shepherd Hospital has been among the first in the country to train nurses at local clinics how to screen HIV patients for TB and manage their treatment. The motorcycle adherence officers are another first.

''Some of them can't afford to travel more than 50 kilometres ... some end up not taking the tablets because of hunger. It's very common that you get there and the particular patient has been buried''
"The motorcycle adherence officers are the ones who keep it all together, because one of the biggest issues we've got is around adherence," said Susan Elden, a Nuffield Centre public health specialist who is helping to implement HIV and TB programmes at Good Shepherd.

Kwanele Dlamini, or Good Shepherd's other motorcycle adherence officer, Gcina Gwebu, visit patients if a week has elapsed since they missed an appointment for their treatment of TB, HIV, epilepsy or prevention of mother-to-child HIV transmission (PMTCT). The goal is to catch TB patients before they become "treatment interrupters", like Ndwandwe, and have to be evaluated for drug resistance.

"We let him or her know the significance of taking these medications," said Gwebu. "It makes a big difference; seeing us coming, they're more encouraged."

Médecins Sans Frontières (MSF), the international medical humanitarian organisation, is rolling out a similar programme of decentralising HIV and TB services to clinics in the southern region of Shiselweni.

Themba Dlamini of the National TB Programme said a grant from the Global Fund to Fight AIDS, Tuberculosis and Malaria would be used to implement "one-stop shops for HIV and TB patients" in the rest of the country, to hire more adherence officers and motivate treatment supporters by paying them a stipend.

Patients will still need to travel to Good Shepherd or one of Swaziland's 15 other regional health facilities to be put on treatment by a doctor, to be assessed after the first two months on treatment, and again upon completion.

The efforts to close the gaps in Swaziland's TB control programme are essential, but can only go so far in improving detection and treatment rates in a country where, according to the UN Development Programme, two-thirds of the people live in chronic poverty.

Gwebu told IRIN/PlusNews that most of the patients who default on treatment for TB or HIV complain of financial problems. "Some of them can't afford to travel more than 50 kilometres [to the hospital] ... some end up not taking the tablets because of hunger. It's very common that you get there and the particular patient has been buried."
See also: SWAZILAND: The burden of drug-resistant TB

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