SAfAIDS Discussion Forum
Review
‘HIV and AIDS and TB Co-infection: A Deadly Marriage’
Jameson Hotel, Harare, 22 May 2008
SAfAIDS; 17 Beveridge Road, Avondale, Box A509, Avondale; Harare; Zimbabwe
Tel: +263 4 336193, 336194, 307898, 335015, 335005; Fax: +263 4 336195
Email: info@safaids.org.zw ; Website: www.safaids.org.zw
‘HIV and AIDS and TB Co-infection: A Deadly Marriage’
1. Introduction
The Southern Africa HIV and AIDS Information Dissemination Service (SAfAIDS) facilitated a Discussion Forum on TB and HIV Co-infection in Harare on 22 May, 2008. The purpose of the Discussion Forum (DF) was to review government policies with regards to TB infection and its co-existence with HIV. The DF also focused on how the medical fraternity and community based organisations are responding to the dual TB and HIV epidemic.
The DF was attended by more than 80 representatives from civil society, People Living with HIV, HIV and AIDS activists, AIDS Service Organisations, Community Based Organisations, private sector organisations, Faith Based Organisations, media practitioners and other key stakeholders.
The DF coincided with the Global AIDS Week of Action (GAWA) and so began with a candlelight memorial in recognition of this important week. The International AIDS Candlelight Memorial this year was held in Lilongwe, Malawi.
2. Background
Since the advent of HIV and AIDS, TB has become the leading cause of death among People Living with HIV and AIDS in Zimbabwe. According to UNAIDS (2007) Zimbabwe is one of the 22 ‘high burden countries’ which are classified as having the highest rates of TB and HIV in the world, with approximately 70% of TB patients co-infected with HIV. TB cases have increased dramatically in the last five years, in line with the rise in HIV prevalence.
The DF comprised three key presentations followed, by open discussions where DF participants were given the opportunity to raise issues, and have their concerns addressed by the presenters through a question and answer session. The presentations provided participants with information on TB and HIV co-infection from both the medical and community perspectives. The three key presentations highlighted the policy, medical and community perspectives, to HIV and TB co-infection in Zimbabwe.
3. Overview of Presentations
3. 1 Overview of TB and HIV Co-infection – Mrs Lois Chingandu, SAfAIDS Executive Director
Mrs. Chingandu provided the audience with an overview and situational analysis of TB and HIV co-infection in Zimbabwe. She noted that even though there is evidence of the existence of the dual epidemic, there exists no integrated government policy that simultaneously tackles TB and HIV. An integrated response to TB, HIV and AIDS at the policy level is urgently needed to tackle this ‘deadly marriage’. She also raised her concerns over the lack of systematic monitoring of drug resistant TB which -has led to the current gap in data indicating the number of MDR TB cases recorded in Zimbabwe.
3.2 TB and HIV: A Cursed Duet – Dr G. Kadzirange (Physician)
Dr. Kadzirange, a Zimbabwean physician, gave the audience a medical perspective on TB and HIV co-infection. TB and HIV co-infection was referred to as ‘the cursed duet’ because of the way each condition impacts negatively on the other. He argued that TB can lead to immunologic worsening in HIV positive patients and, on the other hand, HIV can cause immunosupression and delayed diagnosis of TB in co-infected patients. He further noted a worrying trend whereby patients who were TB positive produced TB negative sputum tests. He put forward a number of other diagnostic challenges including the fact that patients are repeatedly being given TB drugs, even if their tests show no sign of active TB. This could have adverse effects on drug resistant strains of TB.
Dr Kadzirange highlighted that TB and HIV services are run separately within medical institutions in Zimbabwe, with no collaboration or co-ordination to address the two, despite the strong link that existing between them. Not all TB patients are tested for HIV, and few HIV positive patients get automatically screened for TB. This needs to be addressed as a matter of urgency so patients have access to integrated services. Both diseases, perhaps because of the strong links to each other, are now cloaked in stigma and this further hampers intervention efforts.
He continued to share that the availability of adequately trained healthcare workers was a critically important issue to both TB and HIV programmes. He argued that it was necessary to assess the feasibility of using non-professional healthcare workers in auxiliary roles to support the treatment and care of TB and HIV patients. With appropriate training and the provision of required technology, treatment supporters and community care workers could become valuable assets in overcoming capacity gaps in the fight against TB and HIV co-infection.
3.3 TB and HIV Co-Infection: Experiences of Seke Rural Home Based Care - Mrs E. Ngwerume (Director of Seke Rural Home Based Care)
Mrs. Ngwerume the Director of Seke Rural Home-Based Care (HBC) programme brought the community perspective to the DF. She gave an overview of the challenges faced by home-based care-givers and programmers in view of TB and HIV co-infection. Seke rural HBC programme employs community based volunteers (CBVs) who are provided with TB and HIV training in their programmes. In line with the government
policy, the CBVs recommend the DOTS policy to their patients, and the care-givers do follow-ups on their patients to ensure adherence.
She described HIV, AIDS and TB as diseases of poverty. There exists a strong link between poverty and high rates of infection of both HIV and TB in poorly resourced settings. Poverty is associated with poor nutrition, lower levels of education, limited access to information, poor adherence and poor access to the health services thus it worsens the medical condition of the patients in poor communities. This is compounded by the fact that the extended family has to take on the role of caring for the sick. Therefore a lot of time is spent looking after patients, and not on productive activities that generate income for the upkeep of the families.
According to Mrs Ngwerume the detection of TB in general, and of TB/HIV co-infection in rural communities, is problematic and complex. In rural communities many people do not go for TB screening early when they develop symptoms as they attribute their symptoms to malaria or witchcraft, among other things. CBVs in the Seke HBC programme encourage patients found to be suffering from TB to go for HIV testing. This Provider Initiated Counselling and Testing service allows for early HIV intervention within the community. Although Seke’s community based program has had a lot of success in HIV and AIDS stigma and discrimination reduction, there is still stigma surrounding the disease and many patients do not go for TB testing as they may see this as the first sign of being HIV positive.
4. Discussions Highlights
The presentations provoked meaningful discussions at the DF. The extensive discussions brought to the fore, pressing issues and highlighted the challenges which will need to be tackled in order to successfully address TB and HIV co-infection.
4.1 Integrated policy on TB and HIV
Participants at this DF acknowledged that there is a lack of integrated policy by the government that tackles both TB and HIV and AIDS holistically. This has translated into piecemeal responses to the ‘cursed duet’ at various levels. At the City Health level, TB patients are being tested for HIV more regularly but HIV patients are still not being tested for TB on a routine basis. Although this is not comprehensive enough it is a very important step in reducing the number of deaths from TB through early detection. It was suggested that HIV and TB testing services should be available at the same place. This idea of ‘co-location’ integration would encourage dual testing and ultimately strengthen the response to TB/HIV co-infection.
There is a need to review and integrate the approach to both TB and HIV at policy level. A comprehensive policy which addresses the two diseases holistically is paramount. There is a dire need for advocacy to lobby the government and civil society to implement an integrated approach to HIV and TB. It was also noted with disappointment that, during the call for Global Fund Round 8 recently, the TB component had to be re-advertised as not enough submissions had been received. This seems to suggest that most organisations are focusing on HIV, and not TB or co-infection issues.
A representative from HIVOS mentioned that, from a donor-perspective, there seemed
to be a shift towards general healthcare funding as opposed to funding which is focused
towards a particular disease for example HIV and AIDS, TB or malaria. This integrated approach to funding is being seen as a crucial step towards harnessing a more holistic approach to disease management and encouraging the integration of diseases at all levels.
Although many significant points of discussion arose at this forum, the main issue raised was that TB and HIV must be integrated at all levels. There are national documents on TB which do not mention HIV and AIDS and vice versa even though the two diseases are so strongly interlinked. A representative from NAC did mention, however, that there are communication gaps that exist between civil society and the programmes that government is currently implementing. NAC needs to improve its communication strategies in this regard because some of the points of action raised are being attended to by NAC.
4.2 Follow up on HBC Clients
One participant observed that although patients on HBC are sent home to receive psychosocial support, this must be complemented by follow-up by healthcare workers who are better positioned to monitor their progress and provide ongoing medical advice. The reality at present is that HBC is more of ‘patient dumping’ especially in Harare and most urban centres where patient burden is very high. There is a need for CBVs across the country to do follow ups on patients in their homes. The health system in the country has collapsed and is failing to cope with the TB and HIV burden but there is need to compensate for this with regular follow ups through CBVs since HBC involves moving patients from the skilled hands to the least skilled and poorly resourced. The only way HBC can be successful is through regular follow-ups.
4.3 Incentives for CBVs
It was also noted that CBVs are overwhelmed with work but there is little or no recognition. Apparently there is no standardised and accepted method of compensating CBVs for their voluntary work. Participants noted the resistance from programme people in introducing incentives for CBVs, even when donors are willing to fund such incentives. Some mentioned the difficulty of sustaining monetary incentives to CBVs as they are dependent on donor approval as compared to the non monetary incentives which are currently being provided and which most donors are willing to support. Programmes like Seke HBC use non monetary incentives because they are sustainable.
4.4 Male Involvement
Male involvement in HBC programmes is still a challenge since men tend to become involved only when they are very sick. This has led to the feminisation of care in the era of HIV and AIDS. The main reasons for this are stigma and men not traditionally being involved with caring. Seke HBC is currently trying to integrate them gradually into programmes even though women still dominate.
4.5 TB and HIV in Children
It was also noted that TB and HIV co-infection among children is difficult to deal with. Children, even when they have symptoms of TB, are less likely than adults to seek help
early. In response to this, Seke HBC programme is teaching its own CBVs in paediatric care and counselling to overcome this problem. Children that are on ART in the rural settings usually come from poor families and they often have problems taking their
medications as they suffer loss of appetite. If they do not eat, they become weaker and the ARVs are less effective, leaving them vulnerable to opportunistic infections. It was
recommended that the government needs to have feeding programmes for children at hospitals as it has been found that children on ART who are provided with regular healthy meals have a very high success rate.
4.6 Nutrition
In general, nutrition is a very important component in the fight against TB and HIV co-infection. HIV positive patients should be provided with dietary and nutrition advice, taking into account their resource setting and what foods the patient is able to access.
4.7 TB Diagnosis
On the issue of individuals that show TB symptoms, but are found to have negative sputum tests, the common practice is that these patients are put onto TB treatment, despite negative results. There is, however, a danger of over-treating the disease and exacerbating MDR/XDR TB under this practice. These clients may be suffering viral or parasitic infections which are inadvertently treated as TB. Unfortunately the misdiagnosis is sometimes missed as the patients may recover on TB medication. It is important to note that TB patients who develop asymptomatic TB are also not being detected by medical facilities and families of TB patients are no longer routinely tested. There is a need to improve the state of our health systems so as to detect all types of TB.
5. Recommendations
The following key recommendations emerged form this DF:
- Integration of TB and HIV and AIDS at all levels (policy, diagnosis, programmatic,
etc) is essential. HIV and AIDS policy papers must take TB into account and vice versa.
- At the diagnosis stage, TB and HIV testing facilities should be available at the
same place. Although many TB patients are now offered HIV testing, it is not yet routine for PLHIV to be tested for TB. This is crucial if effective treatment of TB and HIV co-infection is to be implemented at an early stage.
- Increased focus on children and ART through support to programmes by
government and donors that supplement children’s diets to ensure that ARVs are effective. The focus on children should also be expanded to include the provision of resources for child care-givers.
5.4 The most effective way of motivating CBVs is through the provision of both monetary and non-monetary incentives. Donors and funders are willing to provide incentives. All programme implementers must include a budget for CBV incentives so that this becomes the norm.
5.5 Follow up is vital if HBC is to be a successful strategy for care and support of PLHIV. CBVs should also receive training on how to recognise symptoms of TB
so that they can encourage community members to seek medical advice.
- There is need for a renewed focus on the diagnosis of TB. Too many patients
are not being treated as their sputum tests show negative or, conversely, are being treated for TB when they do not have TB. This ‘over-treating’ could have serious effects for MDR/XDR TB. Some patients are being retreated for TB multiple times due to inaccurate patient records.
- The prevalence of MDR/XDR is not accurately measured and recorded in
Zimbabwe. This needs to be addressed so that provisions can be made depending on the extensity of MDR/XDR TB.
- Donor funding should not be specific to HIV and AIDS programmes only but
should cover all health aspects, including malaria and TB to avoid shortage of resources. The move by donors towards health funding, as opposed to the funding of diseases may encourage integration of TB and HIV/AIDS.
- DF’s should be held at regular intervals so that organisations are informed of new
developments and trends in HIV and TB at national, regional and international levels.
6. Conclusions
It is clear that the DF fuelled interest and further debate on the issue of TB and HIV co-infection. It received publicity in both print and electronic media. Prior to the event ‘The Sunday Mail’ carried out a ‘teaser’ which notified people about the event. After the DF, The Sunday Mail and The Herald featured several articles on HIV and AIDS and TB. The Sunday Mail shared that there had been a lot of demand from readers requesting more information on TB and HIV, which had prompted them to publish the articles.
For more information, please contact:
SAfAIDS
17 Beveridge Road, Avondale
Box A509, Avondale
Harare
Zimbabwe
Tel: +263 4 336193, 336194, 307898, 335015, 335005
Fax: +263 4 336195
Email: info@safaids.org.zw
Website: www.safaids.org.zw
“HIV and AIDS Information: The Power to Make a Difference”
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