SWAZILAND:
Patients Fail to Adhere to TB Treatment
Mantoe Phakathi
MBABANE, Jan 9 (IPS) - Every five minutes she gives a hacking cough. Ndlaleni Ndzinisa (70) says she has continuously suffered from tuberculosis for the past five years. Because she cannot afford to pay for transport to the nearest hospital, she has repeatedly failed to adhere to her tuberculosis (TB) treatment.
Ndzinisa’s doctor, Franklin Ackom, says it is highly unusual that she has not been diagnosed with the difficult-to-treat, multi-drug-resistant TB (MDR-TB) and extremely-drug-resistant TB (XDR-TB), which are strains that are resistant to treatment by first-line and second-line drugs, including Isoniazid and Rifampicin.
"It’s against my will," said Ndzinisa, who lives in the small village of Lulakeni, in southern Swaziland. "I cannot afford the transport fees to the hospital to refill the tablets [for my prescription] every month." As a result, she defaults from her treatment plan and does not get fully cured from the disease.
Ndzinisa’s case is not unusual. So far, 40 cases of MDR-TB and two cases of XDR-TB have been reported in the country’s southern Shiselweni province, where Lulakeni is located. National TB programme manager at the Ministry of Health and Social Welfare, Themba Dlamini, partly attributes this to patients’ failure to access medical services because of high transport costs to hospitals.
As a result, Swaziland has been unable to meet the World Health Organisation (WHO) TB treatment goal of 85 percent. To date, the country’s treatment success rate is at 42 percent only - half of the WHO target. In addition, Swaziland’s TB detection rate stands at 57.7 percent, more than ten percent below the detection target stipulated by WHO.
To improve the situation, international non-governmental organisation Médecins Sans Frontières (MSF), decided to bring HIV/AIDS and TB services closer to the communities in the southern region of Swaziland. According to MSF Swaziland head of mission, Aymeric Péguillan, TB is the leading opportunistic disease among HIV-positive patients in the kingdom, which is why the two diseases should ideally be treated together.
Co-infection risk
Swaziland has the highest HIV/TB co-infection rate in the world: 80 percent of HIV-positive Swazis are also infected with TB. According to Dlamini, about 30,000 new TB infections have occurred in Swaziland, which has a population of one million, over the past three years.
"We need to provide accessible HIV/AIDS and TB services at one place because these two are inseparable," said Péguillan.
Beginning in January, MSF will assist three local clinics in the remote Shiselweni province to provide combined TB and HIV/AIDS services to co-infected patients. Currently, most HIV/AIDS and TB services are offered in hospitals only, which are difficult for Swaziland’s rural population to reach because they are located in cities.
According to Péguillan, the three clinics will offer TB and HIV/AIDS counselling, testing, TB treatment as well as antiretroviral (ARV) therapy.
Péguillan said MSF hopes to broaden the programme to include three more rural clinics within the next three months. Ultimately, the organisation plans to work with all 19 health clinics of the region.
"By the end of 2009, we will cover all clinics in the region," reckoned Péguillan. "This will make it much easier to treat HIV/TB co-infections, because services will be offered at one place and close to people’s homes." Up until now, clinics offered limited HIV/TB services and patients had to be referred to far-away hospitals for treatment.
The HIV/TB co-treatment links into an already existing MSF health project in Shiselweni. Since the beginning of last year, MSF has been providing rapid HIV testing as well as sputum tests for TB to nine clinics in the region. The organisation then transports the samples to the hospital laboratories.
"The idea is that the sample should travel but not the patient," explained Péguillan. "This way, we minimise the time and costs of accessing health services."
Supplying clinics
MSF also supplies clinics with TB drugs and ARVs that are usually only available in the country’s hospitals. However, providing medication alone is not enough to enhance health service provision, as most clinics in the country do not have the capacity to manage HIV and TB patients and monitor their treatment plans.
"What we see is that many clinics in Swaziland are not structured to provide many different and complex services," said Péguillan. "Clinics are mainly meant to provide basic healthcare, such as immunisation and family planning."
One of the reasons is the lack of skilled health care personnel. Clinics in rural areas are generally staffed with two nurses and one nursing sister only. There are no doctors available.
MSF believes one way to solve the problem is to train community members in HIV and TB counselling and testing to assist health workers in the clinics.
"Nurses should focus on the medical part [of the clinic operations], while counselling and testing should not take too much of their time," explained Péguillan. "We therefore need to increase the capacity of communities to help in the fight against TB and HIV/AIDS."
As part of this strategy, MSF is advocating for the training of ‘expert clients’ - people who have publicly disclosed their HIV status - to promote positive living with HIV and TB as well as treatment literacy.
"Unfortunately, working with expert clients is not sufficiently recognised in Swaziland," lamented Péguillan.
While local health service providers are appreciative of MSF’s efforts to vamp up health service provision in the Shiselweni region, they say they are concerned about long-term sustainability of the programmes and would like to see the Swazi government make a firmer commitment towards HIV and TB treatment and care.
"It is up to government to take over and sustain health programmes once MSF leaves the country," Dlamini told IPS. "Government must take responsibility for bringing the services to the communities. It needs to expand the decentralisation strategies MSF has been implementing to the other three regions of the country."
(END/2009)
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