You are viewing : Vol. 5, Issue 3 Oct - Dec, 2008

HIV and TB: A double tragedy!

Allan Omalla

A state of exhaustion and sheer desperation is evident across the face of already pale Namiro (not real name) as she anxiously waits her turn to receive TB medication for her ill infant from the sole nurse trained to handle the disease condition. Her general outlook is farther dampened by the worried expressions of every one in the queue that is not sure if the drugs in stock will last long enough for them to get their prescription. Strapped across her chest, her four-month-old baby chokes from a persistent clogging cough as she tirelessly wipes off blood oozing from its mouth. With fatigue in her eyes she tries to calm herself and hope for the best as her infant struggles with endless fever and chills coupled with a long relentless wasting.Such is an insight into Sub Saharan Africa where the pangs of abject poverty are felt to the extent that basic needs (health, education, food and shelter) of the population are hardly met.

Worse still, its people still have to contend with the burden of HIV/AIDS as this region has the largest population of people living with HIV worldwide. People with advanced HIV infection are vulnerable to a wide range of infections and malignancies that are “opportunistic” because they take advantage of a weakened immune system. One of the worst of these infections is Tuberculosis (TB). HIV and TB form a lethal combination, each speeding the other’s progress. HIV weakens the immune system. Someone who is HIV-positive and infected with TB bacilli is many times more likely to become sick with TB than a TB bacilli-infected HIV-negative person. In it’s own right, TB boasts of claiming the lives of the majority of HIV positive people thus causing an uneven impact worldwide with its incidence tripled in Sub Saharan Africa.In the 20th century scientists were able to control the spread and prevalence of TB using anti-TB drugs and an effective BCG vaccine.

With the advent of HIV this achievement is seriously threatened by the ‘re-emergence’ of the disease with renewed ‘vigor’ in especially resource-poor settings that are already facing very serious challenges from handling HIV alone. In the past, administration of anti-TB drugs using the DOTS therapy (Direct Observed Treatment Short course) was sufficient to cure TB. Of late Mycobacterium tuberculosis, the bacterium that causes TB, has evolved to include drug resistant strains as a result of inadequate treatment and poor adherence in some patients. These strains are classified as resistant to first line anti-TB drugs treatment (MDR-TB) and resistant to second line anti-TB drugs (XDR-TB).

While drug-resistant TB is generally treatable, it requires extensive chemotherapy (up to two years of treatment) with second-line anti-TB drugs which are much more costly than first-line drugs, and which may produce adverse drug reactions that are more severe, though manageable. Adherence to treatment is even more challenging when the patients are on both HIV and TB treatment concurrently thus increasing the likelihood of resistance. The sheer number of pills the patient has to take requires a lot of self-discipline to endure. In most of Africa diagnostic capabilities for drug resistant TB are missing. Most people with XDR-TB die before it’s realized that they do have this extremely resistant strain. Even when drug resistance is suspected, the drugs needed are hardly available. This leaves patients at the mercy of philanthropic organizations and foreign government initiatives.

There is an even greater need for government intervention in curbing the problem of few medical personnel trained to handle TB and HIV cases, not to mention attempts to improve collaboration between existing TB and HIV programmes. It is critical that everyone diagnosed with TB be tested for HIV and vice versa since each greatly impacts the other. HIV makes TB diagnosis more difficult as patients present with atypical symptoms and more severe forms of TB. The gravity of the menace TB poses to the health of HIV-positive persons, and its burden to our already overwhelmed health-care system cannot be over-emphasized. The emergence of extensively drug-resistant (XDR) TB, particularly in settings where many TB patients are also infected with HIV, poses a serious threat to existing TB control mechanisms and confirms the urgent need to make them stronger. Greater effort should therefore be put into creation of community TB care projects as this has been shown to mobilize civil societies and ensure political support and long-term sustainability for TB control programs. If this is not done, we risk overturning even the few achievements made in the fight against TB.