Malawi tames the deadly opportunistic killer

With graveyards in Southern Africa's nation of Malawi fast becoming most frequently visited places for burying people dying of ‘prolonged coughing,’ a heightened sense of urgency surrounds efforts to rein in TB. But with the advent of HIV, is it possible to win the battle against TB, which is mistakenly seen as a death sentence for people with Aids? CHARLES BANDA investigates.

35-year-old Nabanda Masinga fails to hold back her tears, when in an interview she recounts the long and painful death of her husband. “My husband died after a long suffering. Persistent coughing, recurrent fever, chronic diarrhoea, skin rashes, loss of weight, lack of appetite and night sweating tortured him during seven months of his illness,” she narrates while seated on the verandah of her house in Mulanje in Southern Malawi. Nabanda believes that what killed her husband is self-stigmatisation and fear of unknown. She explains that her husband blatantly refused to go for TB diagnosis and treatment, when all the signs and symptoms he had were pointers that he was suffering from TB. "The problem is that my husband believed that anyone with TB is HIV positive. As far as he was concerned it was a waste of time for a person suspected to be HIV positive to go for treatment as the Aids-causing virus has no cure,” she says disclosing that her husband never went to hospital for either TB or HIV tests. Nabanda reveals that she too developed similar signs and symptoms like those of her husband, but she took courage and went for both HIV and TB tests. “I was diagnosed TB smear positive but HIV negative. Even after those results, I failed to convince my husband to go the hospital,” she explains. Like all TB patients who seek early medical help, she was put on the Directly Observed Treatment Short-Course (DOTS), which obliges patients to take their medication in front of doctors or nurses for the first two months and continue on their own in the remaining six months. Luckily enough for her she got cured and she is among the 500,000 Malawians who have received TB between 1984 and last year. “I am a healthy person now. But I still weep for my deceased husband who died after refusing to go for TB treatment. If he had accepted to go for TB treatment, he would have been cured and would have been alive,” she says. Nabanda is not the only one to lose her husband to TB as statistics from the National TB Control Programme shows that 3 out of 10 TB patients die of this curable disease because of their failure to seek early treatment. The programme’s director Felix Salaniponi says self-stigmatisation coupled with ignorance is responsible for death among such TB patients. According to Salaniponi, what in the past was a straightforward war against TB has become complicated following the emergence of HIV and Aids. The marriage between TB and HIV has resulted in the general belief that all TB patients have HIV. The consequence of this wrong belief is that it is fuelling many cases to delayed TB diagnosis, as those with TB are afraid to be labelled as HIV/Aids infected. Some like Nabanda’s husband have completely shunned treatment because of their failure to understand the facts about the twin epidemic of TB and HIV. Such people fail to understand and appreciate that although TB is the leading killer of people living with Aids, not all people with HIV/Aids die of TB. Regrettably many people dying of TB are classified as Aids victims and this misconception masks the true and immediate cause of death. The confusion and stigmatization caused by the twin epidemic have several complications. Firstly the significance of TB on Aids is lost through classifying death as caused by Aids because Aids is not a single disease. As a matter of fact it is a syndrome of many opportunistic infections, while TB is just leading opportunistic fellow. Secondly by classifying death as being caused by Aids, it makes people lose hope because Aids is incurable while TB is curable even in individuals living with HIV. “HIV/Aids has therefore complicated the fight against TB because it has increased TB cases and death rate. HIV/Aids has also increased the demand of resources in terms of human, financial and logistic in terms of coping up with this scourge,” says Salaniponi, adding that up to 77 percent of TB patients in Malawi are HIV positive. The TB programme director however says although some people are shunning TB treatment because of self stigmatization and unjustified suspicion, the country on overall basis is making progress and can be described as a star performer in implementing DOTS, which is arresting the fast transmission of the disease. “By using DOTS in Malawi, there is evidence that the TB cases have not been increasing in the last three years and in some districts, they are actually on the decline,” says Salaniponi. Between 1984 and 1994 there was an increase of TB figures from 5,000 to 19,000 reflecting a 300 percent rise while between 1994 and 2004 there was an increase from 19,000 to 22,000 reflecting a rise of 27 percent. But in the last three years, from 2001 to 2004, TB cases have remained around 27,000. TB, primarily an illness of the respiratory system spread by coughing and sneezing, kills nearly two million people a year worldwide. Globally, there are fears that the disease will continue to be a nightmare because as former South African President Nelson Mandela said: "TB is too often a death sentence for people with Aids. We can't fight Aids unless we do much more fight TB as well." So the question is: How is Malawi which boasts of taming TB through the effective implementation of DOTS tackling the twin epidemic of TB and Aids? “We are tackling TB and Aids using a collaborative approach. This entails that patients who present with HIV as a health problem are also screened for TB and patients who present with TB are also screened with HIV,” says Salaniponi. “The TB patient by criteria is eligible for the provision of ARVs, therefore the TB patient receives ARVs,” he adds stressing that a person suffering from HIV and Aids who contracts TB actually gets cured of the respiratory disease. Numerous studies carried out in the last few years show that preventive treatment of TB in people who are HIV positive helps them live longer. If these studies are to be believed, then one would expect HIV/Aids mortality in a country with very good TB treatment coverage like Malawi to have been reduced greatly. Unfortunately, the situation is exactly the opposite, and a lot of HIV positive people continue to die of TB infection. This begs the question: Can there be another factor that is contributing to TB treatment failure in HIV positive patients? Experts say the answer is definitely yes. “A low socioeconomic status among the population, coupled with a poor healthcare system in general, is the likely explanation for high HIV mortality rates due to TB,” a study by Bertha Simwaka, a senior researcher at the Equi-TB Knowledge Programme in Malawi reveals. According to the study, a symbiotic relationship exists between TB and poverty. “New TB infection is not just the product of poverty, but also creates poverty,” reads the report of the study. The study found that over 67 percent of deaths among HIV/TB-infected patients were due to treatment failure caused by lack of proper nutrition to support the immune system. By deduction, lack of good nutrition renders the TB and Aids collaborative approach in the fight against the twin epidemic useless. Government officials however say they are aware of that and are addressing that problem. “Government is committed to fighting TB, HIV/Aids and lack of nutrition,” says Health Minister Hetherwick Ntaba. The country is addressing the problem of malnutrition among TB patients by providing them with fortified food once they are admitted to hospitals and even after being discharged from the hospital, Ntaba said. “It is a policy that TB patients who are on treatment get fortified food such as Likuni Phala,” he said adding that a study at Thyolo Hospital showed that such food packages reduce premature deaths of TB patients caused by malnutrition by 50 percent. The successful implementation of DOTS, the collaborative fight against TB and Aids; the provision of fortified food to TB patients, have according to Salaniponi resulted in cutting down transmission chain and the reduction of death for TB patients in the last years. But he admits that though Malawi is a star performer in implementing DOTS, by epidemiological characteristics of TB problem, the country is still burdened with disease. “The war on TB will easily be won, once many people are sensitized and have realized that TB is curable regardless of one’s HIV sero-status,” says Salaniponi. It is probably then that people like Nabanda’s husband will seek early TB treatment.