The TB-HIV co-infection rate in Lesotho is as high as 90%. What are the challenges of treating TB and HIV co-infection?
Both diagnosis and treatment are complicated by coinfection. You may think that the patients don't have TB because they have smear-negative TB, the x-ray doesn't show it and their immune system is already so low that the classical symptoms are masked. But two months after you start the patient on ARVs, they come back very sick. And that is the problem. If you treat a patient both for HIV and TB there are added side effects and sometimes you can't tell if they are from the TB or from the ARVs. You have to be very careful to make sure your patient understands that both diseases are very important and need to be managed properly.
Are these challenges different when you come across patients infected with MDR-TB and HIV?
The diagnosis of MDR-TB takes longer than for ordinary TB, up to eight weeks. But there is not much difference in diagnosing MDR-TB patients with HIV or without it. In terms of the outcome, the difference is that patients who are HIV negative tend to do much better on MDR-TB treatment than patients who are HIV-positive. Of the patients that we have diagnosed we have found that the ones that are HIV negative aren't as sick and even if they are very sick, they pick up very quickly. But the patients who are HIV positive can take a long time to recover and the survival rate is not as good.
In Lesotho, MSF provides integrated HIV and TB care. What are the advantages of such an approach?
It is good to have a one-stop shop, where the patient can come for TB and HIV services in one place. We try hard to ensure that the patient doesn't have two different appointment days. A lot of our patients live very far from the clinics; some have to walk up to six hours to reach us. You don't want them coming one week for TB and the next week for HIV, because they just won't be able to come. Some of the adherence strategies that are used in the management of HIV are also useful for the management of TB. If we have it all integrated under one service, we are able to incorporate the patient education that is done for HIV into TB management. It has been proven that patients adhere much better to HIV treatment than they do to TB treatment. And that is because in TB treatment, patients are meant to comply with treatment, whereas in HIV treatment the patients are made to adhere to treatment.
And how does adherence differ from compliance?
With adherence you educate your patient, there is commitment from the patient, there is involvement of the patient. You don't just tell them which pills they have to take, which is what is done with compliance: you tell the patient this is what you have to do and the patient often has no clue why. With adherence, for example, you tell the patient what side effects they may expect to encounter and what they should do if side effects occur. And for that reason, because patients are involved and educated, they do much better in terms of adherence. So we want to incorporate that into TB treatment too.
Alessandra Vilas Boas