Overcoming obstacles in managing TB and HIV infections

Okeoghene Oghenekaro, Nigeria 
(First published in National Mirror, Nigeria on 3 September 2013)
The incidence of tuberculosis and HIV seem to be rising in Nigeria, as it has been recorded that more than 3.4 million people are now infected. More agonising is the fact that those diagonised with the diseases are constantly stigmatised in the society. This piece examines efforts being made to mitigate their effects.

Georgina Ahamefule, an auxiliary nurse at a medical centre since 1989, had her appointment terminated in 1995 because she tested positive to the Human Immuno-Deficiency Virus, HIV. After a 12-year legal battle with her employer, a Lagos High Court ruled that her termination was “illegal, unlawful and actuated by malice and extreme bad faith’’.

Ahamefule was awarded N7 million as damages in a verdict given by Justice Yetunde Idowo. This is just one lucky case out of several where people have been stigmatised in their places of work and the society generally for being HIV-positive. Miss Patience Peters, who is co-infected with HIV and Tuberculosis, admits life has been tough with her.

“When people find out I have HIV, they stay away from me, so disclosing my status has really been a problem for me. I feel that by the time people know I have TB also, they will avoid me altogether. I had to quit my job as a salesgirl and rely on my family for support but I must tell you it has not been easy. People look at me with disdain and avoid me completely.’’ HIV and TB are closely linked because TB is frequently the first opportunistic infection in people living with HIV, according to experts.

The International Union against Tuberculosis and Lung Disease says more than 11 million out of the 34 million people with HIV also have latent tuberculosis infection. They are more likely to develop active TB than people without HIV. It states that tuberculosis remains the leading cause of death in people living with HIV with more than one million needing simultaneous treatment for TB and HIV, adding that about one in four AIDS-related deaths in 2011 were attributable to TB. Experts have noted that stigmatisation is still a huge cause for concern especially in developing countries; however, governments have started taking steps in addressing the issue.

In Nigeria, a bill seeking to prevent discrimination against people living with HIV and AIDS is before the Senate. The Director-General, National Agency for the Control of AIDS, NACA, Prof. John Idoko, says that 3.4 million Nigerians are now living with HIV. “Most successful initiatives recognise the role of legislation as a tool against stigma and discrimination, hence the effort of the Senate and House of Representatives to pass the anti-stigma bill.

Idoko, says stigma is the major reason people do not get tested and those who do rarely disclose the results to their partners. “Stigma is the reason why people will not adhere to the drug regime and reason why we have not broken the silence and denial,’’ he says.

Idoko is of the opinion that if the bill is passed, it will strengthen legal protection for the vulnerable group and ensure their access to prevention, treatment and care. According to Dr. Valérie Schwoebel of the International Union against Tuberculosis and Lung Disease, what happens in places where HIV and TB co-infection is highly prevalent is that having TB may be viewed as a sign that the person is HIVinfected.

“These perceptions, as well as the stigma attached to TB, may be more frequent in some countries than in others, and within the same country, may vary widely according to levels of education. The effectiveness of the TB treatment is becoming well known among the communities; however, this may help combat this prejudice.’’ Dr .Paula Fujiwara, says he cannot say if the stigma is more in a positive person co-infected with TB.

“However, I think that the HIV community has done a much better job of getting people to know their status and not hide it, and to live positively. Anecdotally, I have seen that people may be afraid of stating they have TB disease because they know the link between TB and HIV.’’

Fujiwara calls for increased education on TB and HIV and how to prevent them, to reduce stigma and discrimination. Apart from stigmatisation being a major challenge to effective management of HIV and TB, experts are of the opinion that there are still barriers to effective HIV/ TB care especially in developing countries. According to the Union, the main obstacles to managing persons with TB and HIV are weak coordination between TB and HIV programmes and slow integration of collaborative TB/HIV services into the general health care.

These challenges may have an adverse impact on patients’ treatment access and outcomes. Schwoebel, says the key element is the coordination between the TB and the HIV and AIDS national programmes, both of which exist in most countries.

She says in order to achieve this, good communication and collaboration mechanisms up to the highest level is required. Dr Orhue Nosa, a Consultant Public Health Specialist, says that management of persons co-infected with HIV and TB in Nigeria can be said to be effective as a general statement. He however, says the problem is with implementation, noting that more needs to be done to ensure treatment drugs are available as at when due.

‘’HIV and TB treatment is largely available in the urban and semi-urban areas, and as a result, patients in the rural areas go there for treatment after they have tried traditional forms of treatment without success. In rural areas, it will be difficult to find a doctor who handles TB and HIV because of the nature of the infections, so experts are usually needed in the rural areas.’’

Nosa calls for the creation of HIV and TB budget line in government hospitals for proper management of the diseases. “The Ministry of Health does not handle patients directly, it is the hospitals and primary health centres that deal with these patients. These funds will be channelled into the management of HIV and TB and will cover things such as admission and blood transfusion which many patients cannot afford.’’ Fujiwara says: “At the International Union against Tuberculosis and Lung Disease, we have extensive experience in this and have published a guide on scale-up of TB and HIV activities entitled ‘Implementing Collaborative TB and HIV Activities: A Programmatic Guide”.

The guide is aimed at exploring the feasibility of delivering integrated HIV care for adult TB patients living with HIV and AIDS and the usefulness of TB control programme in the response to HIV and AIDS. The union says the rationale for this model was rooted in both patients and health systems observations that TB was frequently the first opportunistic infection in people living with HIV, “Thus TB services are an important entry point for HIV diagnosis and care and offer the opportunity to manage both diseases simultaneously at least for the duration of the anti-TB treatment.

In many countries, particularly in the peripheral areas, the same health worker has the responsibility for providing care for the two diseases. “Collaborative HIV and TB activities present an opportunity to strengthen TB and HIV services as well as the entire health system in terms of service provision, procurement and distribution of medications and supplies.’’

The guide says that some of the advantages of integrated TB and HIV services is that ‘’patients receive comprehensive care where one time visit is sufficient and the patients get the entire test done there. Experts agree that for effective diagnosis and management of TB and HIV, the issue of discrimination must be addressed nationally and holistically. There should also be room to scale up effective TB and HIV treatment where they do not exist especially in the rural areas and improve effectively the already existing programmes and services. This, they say, will ultimately reduce the number of people who die as a result of co-infection of TB and HIV.

Okeoghene Oghenekaro, Nigeria 
Citizen News Service - CNS
(First published in National Mirror, Nigeria on 3 September 2013)