In-depth: TB and HIV: Deadly allies

SOMALIA: TB treatment success against the odds in Somaliland

Photo: Casey Johnson/IRIN
Somaliland successfully treats more than 90 percent of its TB patients
Hargeisa, 24 March 2009 (PlusNews) - Despite rampant poverty, high levels of illiteracy and limited international support, the self-declared republic of Somaliland in the northwest of Somalia has become an unlikely TB success story.

"We adopted the DOTS (Directly Observed Treatment Short Course) system for treating TB in 1995, so someone is always present to ensure patients take their medication," said Dr Ismail Adam Abdillahi, coordinator of the national TB programme. "As a result, adherence is very high and treatment success is over 90 percent."

The World Health Organization (WHO) has set a global target of 85 percent treatment success by 2015; Somalia, part of WHO's Eastern Mediterranean Region, ranks second in the region's 22 countries in terms of treatment success.

"The majority of the population has access to a health facility with TB services that have at least one doctor able to treat TB," Ismail said. "There is no shortage of drugs, which we get from the Global Fund [to fight AIDS, Tuberculosis and Malaria] through World Vision International."

Education has ensured that almost all patients have a basic knowledge of TB, while the establishment of a wide network of TB centres implementing close supervision and monitoring means TB treatment continues to make progress. The global target for TB case detection is 70 percent by 2015, but Somaliland has already achieved a case detection rate of 68 percent.

"In 2008 we diagnosed 4,153 cases; we believe these were most of the people who contracted the disease," Ismail said. Although the country does not have the technology to detect multidrug-resistant TB, he noted that there were very few cases of "chronic" or recurring TB.

This progress has been made despite the fact that Somaliland, which has not achieved international recognition as a sovereign state, is extremely poor - a decade-old livestock ban by Saudi Arabia and several other meat-importing countries in the Middle East has devastated its main source of income.

Although the country has been relatively peaceful since its formation in 1991, it continues to experience some insecurity, which hampers access and limits staff movement to certain areas.

Sustaining the response in a difficult environment

"We also have a lot of IDPs [internally displaced persons] and refugees in Somaliland from the south; when people are in such emergency situations, personal health is not a priority and people do not seek treatment," Ismail said.

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"The war before 1991 also destroyed our health infrastructure, and we still need many more health facilities and staff trained to handle TB." The largest urban centre, Hargeisa city, with a population of more than 500,000, still has only one health centre equipped to treat TB.

"Our regulations are not as strong as they could be, and we do get unlicensed practitioners treating patients and private pharmacies selling TB drugs over the counter, which risks patients getting incorrect information and taking drugs the wrong way," said Dr Abdirashid Hashi Abdi, the Global Fund HIV/AIDS coordinator for the UN Children's Fund (UNICEF) in Hargeisa. "There is also no known data for the level of multi- and extensively drug-resistant TB."

Ismail noted that one of the groups still causing his department some concern were the nomads, who roamed the countryside, never settling anywhere long enough for TB education to reach them, and often grazing their herds far from health facilities with TB services.

"Men who chew khat [a mild stimulant widely used in the Horn of Africa] in small, poorly ventilated rooms for hours are also particularly at risk," Ismail said. "This explains the fact that the ratio of men to women infected with TB in Somaliland is two to one."

Somaliland and Somalia combined have an annual TB incidence of about 324 cases per 100,000 people, with more than half aged between 15 and 34. The disease is strongly associated with poverty, and many TB patients also suffer from malnutrition, making treatment more difficult.

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