Malawi’s HIV/TB treatment challenge

Sam Banda Jnr - CNS
The world, on December 1, joined hands to commemorate the World AIDS Day which every year gives an opportunity to people to renew their commitment to the fight against HIV, advocate for the rights of people living with HIV (PLHIV), and remembers brothers and sisters who died of AIDS related conditions. Malawi is one of the countries in sub-Saharan Africa which is severely affected by the HIV-epidemic. The TB-HIV co-infection is one of the prime challenges that this Southern African country continues to battle and the NTP Programme Manager James Mpunga notes that the high mortality rate of the TB-HIV cases is mainly due to diagnostic challenges. TB is the most prevalent opportunistic infection in HIV patients and Mpunga says it contributes significantly to HIV associated deaths in Malawi and Africa as a region.

“Most patients in 2000 were diagnosed with HIV or TB very late and hence treatment outcomes were not good. Treatment of dually infected patients was difficult as treatment guidelines and protocols were just being introduced,” said Mpunga.

 He said that questions on when and how to initiate both HIV and TB drugs were also still being answered and stigma among community members and health workers alike led to patients not accessing either TB or HIV treatment thereby contributing to high mortality.

“The low immunity in HIV infected individuals means that diseases which would otherwise not have been virulent become so and cause disease. This is clearly demonstrated by the huge rise of TB cases in the late 1980s when the first HIV case was reported in Malawi. It resulted in dramatic rise in number of TB cases; from 5,000 in 1985 to 20,000 in 1995 and that the mortality rate increased equally, ” he said.

Situation as of now

Mpunga says that the country has over the years come up with strategies to fight the dual epidemic as it is sometimes called. He says Ministry of Health has put in place TB/HIV operational framework that emphasizes on integration in management and care of TB and HIV and that apart from setting structures at national, zonal and district levels, the country has also strengthened hospital coordination between TB and HIV services.

Mpunga said this is done through some of the pillars among them to decrease burden of HIV among TB patients through HIV testing and counselling for TB patients. “Under this pillar, HIV testing and counselling in TB patients is provided within TB settings. The NTP has registered success in this area,” he said.

According to him, in the year 2012, out of 20, 463 TB patients reported, 19,039 (93 percent) were tested for HIV, adding that HIV prevalence among TB patients has gone down from 77 percent in 2000 to 59 percent in 2012.

“Antiretral viral therapy (ART) uptake among the HIV positive TB patients is at 81 percent and Co-trimoxazole preventive therapy (CPT) was provided to 88 percent of HIV-positive TB patients in 2012. Thus TB-HIV collaborative activities have improved over the years,” he said.

Mpunga said that the other pillar is that of decreasing the burden of TB among PLHIV through TB screening of HIV patients. He said fewer TB patients are being identified through this pillar and that this is an area which is currently being strengthened. He said currently HIV clinic staffs are also being oriented and supported to ensure that all PLHIV are screened for TB within the HIV clinics.

Mpunga also said they were strengthening evidence-base for policy development around TB and HIV and that surveillance is being done and research in this crucial area is on-going, working alongside research institutions and partners.

Challenges in treating HIV infected TB patients

Mpunga reveals that despite making strides with the pillars, there are challenges in treating HIV infected TB patients citing, among others, inadequate skills among TB officers to discuss HIV issues with TB patients.

“The Ministry is currently training all TB officers to provide HIV testing and counselling within TB clinics; on the HIV side, providers are also being oriented on TB management within HIV clinics,” he said. The NTP Manager also revealed that there were infrastructural and human resource challenges in most districts in the country for integrated management of TB/HIV.

He said TB patients are usually referred to another clinic away from the TB Clinic when they need to be tested for HIV. He also said there are sometimes stock outs of HIV test kits in some HTC sites although the Ministry has since addressed this issue.

The National AIDS Commission in its press statement said that today, the National HIV/AIDS response has coordination structures for all sectors-- public, private, the faith community and civil society-- including networks and organisations of people living with HIV.

The statement said as a result of this coordination, Malawi has managed to (i) test seven million people, half the national population, who now know their HIV-sero status, (ii) reduce new HIV infections by over 70 percent and (iii) reduce national HIV prevalence rate from 16.5 percent in 1994 to 10.6 percent in 2010.

Voices from The Union

Dr Valérie Schwoebel from the International Union Against Tuberculosis and Lung Disease (The Union) notes that TB  is a major cause of death in PLHIVs who have a five to ten times higher risk of TB than HIV-negative individuals.

“It is thus very important to do everything possible to prevent TB among them. There are three main measures that can be implemented which are called ‘the three Is’ : Infection control, Intensified case-finding and Isoniazid preventive therapy,” says Schwoebel.

Dr Schwoebel says that, “Infection control consists in taking precautions in order to reduce the transmission of the TB bacilli, which are disseminated in air by TB coughing patients-- diagnose and treat TB early in the family and contacts of the HIV-infected persons, implement airborne infection control measures at health facilities such as ventilation and separation of coughing patients from others.”

On “Intensified case-finding” she said this means that searching for TB should be always part of the medical follow-up of  PLHIV, adding that health workers should always be on the alert for TB at all times, and that treatment services should be easily available and accessible.

Dr Schwoebel said “Isonazid preventive therapy” is a treatment that can prevent the development of active TB disease in PLHIVs already infected by the bacilli but not yet sick.  She said the treatment lasts at least six months and it must be delivered in settings where careful evaluation and follow-up of patients is organized.

“For some patients who are taking antiretroviral therapy for only a few months, symptoms of TB may worsen transitorily due to the recovery of their weakened immune defence mechanism, but this may be managed and will not prevent the cure. Some antiretroviral drugs will be poorly tolerated with the TB treatment, but they could be replaced,. But the real challenge is the early diagnosis of TB in order to give the patient all his/her chances to get cured” explains Schwoebel. Schwoebel said to scale up TB-HIV collaborative activities, the key element is the coordination between the TB and the HIV/AIDS National programmes, both of which exist in most countries including Malawi.

Dr Anthony Harries, Senior Advisor, International Union Against Tuberculosis and Lung Disease (The Union) says: “ HIV-associated tuberculosis can be controlled by better scale up and implementation of tools that are currently available. For example, we need to get more HIV-infected people earlier on to antiretroviral therapy as this is a most important way of preventing tuberculosis. In the high HIV-TB burden areas of Southern Africa, the TB preventive effects of antiretroviral therapy can be further be increased by the addition of isoniazid preventive therapy. We have made good progress over the years in our fight against HIV-associated TB, but only by attaining universal coverage and meeting ambitious targets set by the international community will we achieve victory,"

Sam Banda Jnr, Citizen News Service - CNS
December 2013