In-depth: TB and HIV: Deadly allies

SWAZILAND: The burden of drug-resistant TB

Siphiwe stopped taking her medication four months ago

Siteki, 25 March 2009 (PlusNews) - Siphiwe*, 14, has not been to school for two years but can still fit into her uniform. She has a strain of tuberculosis (TB) that is resistant to most first-line drugs and can take two years or more to treat, but she stopped taking her medication four months ago.

She is reluctant to give a reason, saying only that the tablets were "becoming bitter", but there are a number of possible explanations. She had already endured six months of walking to her local clinic in Siteki in Swaziland's eastern Lubombo Region to receive painful daily injections, and was swallowing 11 pills a day, including antiretroviral (ARV) drugs to control her HIV infection.

TB patients who are resistant to two or more first-line drugs are managed by Swaziland's National TB Programme in Manzini, about 60 kilometres away, which meant that Siphiwe and her aunt, who is also her caregiver, had to beg and borrow money from neighbours to have bus fare for her monthly appointments.

There was also the daily struggle to find food to take with her pills, and the three-kilometre walk to collect water. Her aunt is blind, so these tasks fell to Siphiwe, despite her obvious difficulty in breathing and persistent cough.

"I tried talking to her about taking her pills," said her aunt, "but sometimes she was taking them without food and it made her sick."

Response lagging

Swaziland's capacity to deal with patients like Siphiwe is far behind the need, despite recent efforts to devote more resources to the problem. The World Health Organization (WHO) has estimated that about 200 cases of multidrug-resistant (MDR) TB occur annually in the population of about one million.

Diagnosing drug-resistant TB is difficult and time-consuming; only the national laboratory in the capital, Mbabane, can do the necessary culture tests, which take about eight weeks. So far, only about 100 MDR-TB cases have been detected, according Dr Kefas Samson, a TB specialist with WHO.

Most hospitals do not have the space to isolate drug-resistant TB patients, so they do not admit them. Health workers had been hoping that a new national 200-bed TB hospital in Manzini would cater to them, but so far the hospital has only admitted around 20 patients.

Themba Dlamini, manager of the National TB Programme, said construction of the hospital began before the advent of drug-resistant TB, and until proper infection control was in place they could only admit patients with confirmed cases of MDR and extensively drug-resistant (XDR) TB who were infectious or too sick to be managed at home.

Patients have to come to the clinic to receive the daily injections, but many of them are too weak to walk; some have to be pushed in a wheelbarrow

For now, patients who have other strains of drug-resistant TB or are awaiting the results of culture tests, will continue to be managed as out-patients.

Susan Elden, a public health specialist funded by the Nuffield Centre for International Health and Development in the UK, who is helping to implement HIV and TB programmes at Good Shepherd Hospital, questions the degree to which they actually are being managed.

"Patients have to come to the clinic to receive the daily injections, but many of them are too weak to walk; some have to be pushed in a wheelbarrow," she told IRIN/PlusNews.

While many patients contract drug-resistant TB after failing to complete treatment for primary TB, it is also possible to contract a drug-resistant strain of the airborne disease from another patient.

Measures to prevent MDR-TB patients infecting other members of their household are lacking in Swaziland. Some patients in Lubombo were given tents as a temporary solution, but Elden said they complained of the cold weather and gossiping neighbours, so few used them.

Only a curtain divides Siphiwe's one-room home; she sleeps on a mat next to her 12-year-old cousin on one side, her aunt on the other.

The centralisation of MDR-TB management has also made it difficult to track patients, so that when one defaults on treatment, the information often does not filter down to their local health facility. "I think there's been a big communication breakdown with these patients," said Elden.

Programme still developing

The Ministry of Health is about to release guidelines for standardizing the treatment of MDR-TB patients, but Thabo Kunene, regional TB coordinator in Lubombo, pointed out that local health facilities do not have the infrastructure or the expertise to manage such patients. "There are only three doctors with MDR-TB expertise, and they're all in Manzini," he said.

WHO TB specialist Samson pointed out that Swaziland was still in the process of strengthening and decentralizing its response to primary TB, and it would take time to develop a more community-based approach to drug-resistant TB.

"A community-based component is one of the strong elements in the [new] guidelines, but the programme is still developing," said Samson. "Before you roll out to clinics and communities, it goes with sensitization of staff at that level."

In Swaziland's southern Shiselweni Region, the international medical humanitarian organization, Médecins Sans Frontières (MSF), in partnership with the health department, is preparing to implement a programme to manage MDR-TB patients in their communities.

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The plan includes building small regional facilities to isolate patients until they are no longer infectious; those with adequate infection control at their homes and reliable treatment supporters will then complete their treatment in their communities. "TB villages" will be built a short distance from health facilities for patients with no one to monitor them at home.

"We want to demonstrate that this is the right approach, that this is feasible, even if it's very labour intensive," said Aymeric Peguillan, the MSF head of mission in Swaziland.

In other parts of the country, a grant from the Global Fund to Fight AIDS, Tuberculosis and Malaria - expected to start being dispersed in April - should provide some relief for MDR-TB patients. The grant will provide them with food parcels and transport money, and stipends for their treatment supporters.

Elden argues that it may not be enough to ensure the surivival of patients like Siphiwe. After nearly three months, results of a culture test confirmed that she is multi-drug resistant, but staff at the hospital in Manzini still insist no bed is available for her.

"We in healthcare have created the MDR situation in patients like Siphiwe through poor organisation of care, poor and inadequate monitoring, and poor drug supply," said Elden, adding that until Siphiwe is admitted to the hospital "she will suffer from inadequate care and spread MDR to those around her."

*Not her real name

ks/he/kn

TB and HIV: Deadly allies
March 2009

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