In-depth: The New face of TB: Drug resistance and HIV

SOUTH AFRICA: Joining the DOTS for a TB-free society

Photo: Department of Health

Urgent action needed to scale up DOTS strategy

JOHANNESBURG, 23 March 2007 (IRIN In-Depth) - Tladi Clinic, a small government healthcare facility just outside of Johannesburg, South Africa, is making strides against tuberculosis (TB), despite overwhelming patient numbers and overstretched human resources.

In the sprawling township of Soweto, nurses and volunteers inside Tladi's red brick walls are working hard to tackle an epidemic considered one of the country's most formidable, next to HIV/AIDS.

"In Soweto the numbers are equally alarming, due to cramped living conditions and poor nutrition brought on by poverty. Close to 8,000 people were diagnosed with TB in the entire area at the end of 2006," Nomsa Seditlo, a TB coordinator, told IRIN-PlusNews.

However, as a result of using the Directly Observed Therapy Short-Course (DOTS) strategy, recommended by the World Health Organisation (WHO), Tladi Clinic can pride itself on a 72 percent cure rate among its 3,500 patients, which is well above the national average of about 50 percent.

The DOTS strategy is a labour-intensive intervention, requiring that health workers be present when patients take their pills, and includes education and counselling. Seditlo lauded DOTS as a "good way of ensuring treatment adherence", but expressed concern over the additional strain on already overworked staff.

Soldiering on regardless

Gertrude Thamae, 25, one of only six volunteers working as a DOTS supporter at Tladi Clinic, has been monitoring TB patients in the community for over two years. While her passion lies in helping her community, the pressure of the job is starting to take its toll.

Earning just US$137 per month, her day begins at 8 a.m. with visits to the homes of patients. She sometimes walks up to 3km between each of the ten homes assigned to her.

"If it rains I still have to visit patients, because some of them will stop taking their pills if I am not there to check ... I just use a Checkers packet [plastic shopping bag] to cover my head and hope that I don't catch a cold," she said.

Thamae also has to ensure that patients have proper nutrition. "But its tough because not everyone can afford to eat three meals per day," she told IRIN-PlusNews.

Because nutrition and medication go hand in hand, the clinic also provides food supplements in the form of 2kg bags of instant porridge to patients unable to afford three meals a day.

Photo: IRIN

Treatment buddies making a difference despite pressures

Janice Buckley, a resident of Mayfair, an inner-city suburb of Johannesburg, was just 15 years old when her father became ill with TB and HIV about five years ago, but nothing could sway her decision to become his treatment buddy.

"I had to juggle my schoolwork with caring for my dad. Keeping time in the mornings was difficult, as school started at 8 a.m., and that's when my dad had to take his first batch of pills. The evenings were not so bad because I got back from school at around 4 p.m.," she recalled.

Besides being her father's sole caregiver, she also had to provide constant emotional support and encouragement to him when he showed signs of "giving up".

"There were times when he wanted to quit, and I would literally force the pills down his throat. I also had to make sure that he ate correctly," she said. "It all paid off in the end, and my dad is now the picture of perfect health."

Stressing the importance of treatment buddies, Janice said medication accounted for 50 percent of recovery in people living with TB and HIV, but the other 50 percent came from the support of family and friends.

The difficulty of having to distance herself emotionally from patients she had seen five days a week for as long as 8 months was also a strain.

"Most patients die when they are co-infected with TB and HIV or if they choose to not continue treatment. There is no counselling for us [DOTS supporters] when we witness the death of a patient," she commented.

Early diagnosis nothing to cough at

Thamae said patients who chose to discontinue their treatment often did so because they feared stigma and discrimination. Although Soweto is heavily burdened by the pulmonary illness, understanding and acceptance can be hard to find.

Seditlo agreed. "Even if someone has all the symptoms of TB, they would rather not seek treatment for fear of possibly being HIV-positive too."

Doctor Neil Martinson, a researcher at the Perinatal HIV Research Unit at Chris Hani Baragwanath Hospital in Soweto, stressed early detection and treatment as one of the best hopes for a TB-free society, but warned that these interventions could amount to little unless similar emphasis was also placed on HIV prevention and stigma eradication.

"Tuberculosis and HIV are a deadly combination, and about a quarter of all people diagnosed with TB in high HIV-prevalence settings will die in the first couple of months after being diagnosed," he said.

In South Africa, which has the second highest HIV caseload in the world, the WHO lists tuberculosis as the number one cause of all AIDS-related deaths.

A recent study in Senegal showed that the risk of patients defaulting on taking medication was more than halved by giving newly diagnosed TB patients more counselling, providing treatment nearer home, and allowing them to choose a treatment supporter to supervise pill taking, as with DOTS.

"DOTS is vital, as many TB sufferers do not complete their six-to-eight-month course of medication once they start feeling better, leading to the development of a multidrug-resistant TB that is extremely difficult to treat," Martinson noted.

Aware of the pressures endured by Tladi clinic's three nurses and six DOTS supporters, TB coordinator Seditlo said her office was trying to encourage the families and friends of infected patients to act as "treatment buddies".

"But while this might sound easy in theory, its a lot more difficult in practice, as family members usually have their own daily routine and sometimes relationships at home are shaky," Seditlo commented.

Seditlo and the staff of the 10 clinics in her area are planning to embark on a community-wide campaign on 24 March, World TB Day, to educate people about the importance of preventing and treating TB infection, and to encourage more people to volunteer as DOTS supporters.

"We have so far managed to reduce our treatment defaulter rate from 17 percent three years ago to 3 percent at present, and with greater collaboration between all stakeholders, the possibilities of achieving full DOTS coverage are endless," Seditlo said.

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This report is part of a PlusNews In-depth: 'The New face of TB: Drug Resistance and HIV'

The New face of TB
Drug resistance and HIV

March 2007
C O N T E N T S

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