Concurrent HIV/TB infection: the hurdles a patient faces

Today is World TB Day, which is meant to raise awareness about TB, a disease that is curable but continues to kill three people every passing minute. Annually, Uganda gets 50,000 new cases of TB, and half of these patients, also have HIV.

Having a conversation with this man is quite difficult. The treatment for multi-drug resistant tuberculosis has affected his hearing.  All visitors to the TB ward wear a respirator (mask) to prevent them catching infection though the safety measure does not give 100% protection, and the patients too are required to wear a mask. With both of us in masks, I had to lean dangerously closer in order to hear him narrate his story.

Even when seated right next to him, I had to raise my voice, and often repeat the same statement at least twice before he could respond appropriately.

Cassiano Okule is 44years old. Last year, he contracted multi-drug resistant TB. The hotelier is also living with HIV.

"Last year, I became anaemic. When tested, I was found with multi-drug resistant tuberculosis and had to get admission to the tuberculosis ward at Mulago Hospital, on 1st April 2015," Okule recalls.

And that is when the daily painful injections started, alongside 12 tablets each day. He was admitted for four months, after which he was discharged but continued getting treatment from Kisugu health center. He lost his job and is currently staying with his uncle. "When the illness intensified, I stopped working, but now I feel strong enough and I am ready to find a job," he says.

However, he still complains of poor hearing, joint and chest pain, in addition to  lack of appetite. He says that apart from the painful injections, he found it really hard to adhere to his medication because the drugs for the TB and those for HIV as well were too many for him to take.  However, with counselling, he made a decision to stick to the medication, and as well found a suitable schedule for it.

"I take 12 tablets a day. The HIV medication makes me dizzy, so I take it right before bed, and then take the ones for TB in the morning," he explains.

Okule adds that prior to starting on the TB treatment; he was only 54kg and had no appetite. "I now weigh 72kg and feel healthier," he says, and quickly adds, "Everyone should test for HIV and Tb, and I was going to die but not anymore, because of the medicine."

At the end of the interview, he tells me that he doesn't want his picture in the newspaper. He suggested posing in a way that no one can recognise it's him in the picture.

"I don't want everyone to know I am sick, but I want  everyone to go test for HIV because it's the only way they will live, in case they are sick," he concludes.

Half the TB patients have HIV

According to Dr Alphonse Okwera, the Head of the National TB referral Treatment Centre at Mulago Hospital, Uganda gets about 50,000 new cases of tuberculosis every year, 15% of whom are children.

The TB burden is worsened by the concurrent infection with HIV. About 50% of the TB patients in Uganda are as well suffering from HIV/AIDS, according to Dr Anna Nakanwagi-Mukwaya, the country director of International Union Against Tuberculosis and Lung Disease.

In a lifetime, you have a 10% chance of contracting tuberculosis through inhalation but for one with HIV, the risk rises to 50%.

She further stresses that the TB burden in Uganda is still high mainly because of the HIV/AIDS epidemic. Latest statistics from the Uganda Aids Commission show the national HIV prevalence stands at 7.3 per cent up from 6.3 per cent in 2012. On the other hand, annually, new TB cases in Uganda amount to 50,000, according to Dr Alphonse Okwera, the Head of the National TB referral Treatment Centre at Mulago Hospital.

"The two epidemics, that is to say HIV and TB, overlap, because HIV is the highest risk factor for acquiring TB. That is why TB remains a problem, as long as we don't control HIV, TB is not about to leave," Nakanwagi emphasizes.

TB patients

HIV/TB co-infection therapy

 "TB kills faster than HIV," Okware points out. Hence, he goes on to explain that when a patient with HIV is diagnosed with TB, and they are extremely ill with TB, treatment for TB should commence immediately, and ARV therapy withdrawn for a minimum of two months. The break from ARV therapy is to let the body adjust to the TB treatment and efficiently utilize it.

However, he adds that in cases where the both conditions, TB and HIV are ravaging, still, TB treatment should commence and go one for at least two weeks, before ARV therapy kicks in.

What's more patients with HIV and TB are likely to face more challenges because they have to get HIV drugs in addition to the TB drugs. This may lead to poorer adherence or failure to take all their medication among these patients and yet because of their immune suppression, are likely to get more severe forms of TB.

Nakanwagi says that patients are usually counseled at the onset of the treatment, such that they can complete treatment.

Drug resistant TB among HIV patients

The emergence of Drug resistant TB is believed to be linked to poor adherence to prescribed TB treatment, social barriers such as stigma, discrimination, poverty, poor Direct Observation of Treatment (DOT) by treatment supporters and non-compliance to the guidelines from prescribers partly due to drug stock-outs in some facilities.

Okware warns that cases of HIV patients with MDR-TB are extremely fatal if not diagnosed early. He tells of a research in South Africa, where 53 patients who were diagnosed with MDR-TB and HIV all died two weeks later after diagnosis because they had not received treatment.

Okware warns that drug-resistant TB is often associated with higher mortality rates in patients living with HIV, hence the vital need for early diagnosis. He further cites a study done in 1999, showed a high death rate among people with HIV and multi resistant TB.

"Without treatment, a patient with multi resistant TB and HIV can pass away even within two weeks," Okware warns.

Strategies in place

Dr Frank Mugabe, the acting head of the TB and Leprosy Programme at the Ministry of Health notes that the ministry of health has intensified on finding TB patients such that treatment can be started early. Currently, screening forms are given to all patients at the outpatient HIV clinics in the various hospitals.

Furthermore, Mugabe notes that close contact investigation of confirmed patients is taking place, to catch more TB cases.

"When a patient has TB, we investigate all their close contacts for infection as well," says Mugabe.

The ministry has also availed 1,300 diagnostic facilities with basic microscopes at sub county level as well as 105 gene expert machines to different hospitals to test for TB.

Chances of contracting TB

Nakanwagi notes that poor ventilation and over exposure to the germs increase the chances of contracting TB. On average a TB patient can infect 10-15 other people in a year. The consolation is that once treatment has been started, patients cannot infect other people, if the medication is being taken as recommended.

How do I know I have TB?

Okware notes that symptoms include a prolonged cough that does not heal when you take the common treatments. Sometimes the sputum has blood. The patient may also sweat a lot at night and have general body weakness. Everyone who has cough lasting more than four weeks should take a TB test. The test can be done at Health Centre III facilities at sub-county level.

He advises that if you have TB or are looking after a person with the disease, avoid over crowded, enclosed and unventilated spaces. Closed places with air conditioning are dangerous. The bacilli are killed by sunlight. Air and wind also disperse it. Open the patient's room for sun rays and wind to enter. Also cover your mouth when you cough. Do not spit everywhere. Flush or cover sputum with soil.

If you test positive for TB, test all other family members. All those who test positive must also check for HIV before taking TB drugs to avoid reaction.

Prevention

The BCG vaccine given to babies immediately after birth makes us immune to TB. Adequate ventilation helps to prevent the spread of TB from person to person.

Family members should support the patients to start treatment immediately so they do not infect others. The treatment is free; all you need is to take the patient to hospital.