The HIV prevalence in Lesotho is the third highest in the world, with 23.2% of the adult population infected. The high HIV/TB co-infection rate makes it a challenge to diagnose and treat TB and , even more so, MDR-TB. MSF’s project in Lesotho provides decentralized and integrated HIV and TB care and treatment in one district hospital and 14 rural health centres. Dr. Pheello Lethola. MSF’s HIV/TB doctor, explains how MSF is confronting these challenges in Lesotho.

The TB-HIV co-infection rate in Lesotho is as high as 90%. What are the challenges of treating TB and HIV co-infection?
It is the fact that you have two diseases within one patient: this creates problems both with diagnosis and with treatment. Patients with HIV also have higher rates of extra-pulmonary TB.

It is very important that we find out if an HIV patient has TB before we start them on antiretroviral treatment. If we don’t, patients tend to be far sicker than if you treat them for their TB first and start them on ARVs after they stabilize. But it’s hard. 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. Then there is the pill burden and the question of adherence, as it is more difficult for the patient to adhere because it just becomes too much, having to take all those pills every day. And when they stop the treatment, they often don’t stop just one or the other, but both. So you have to be very careful to make your patient understand that both diseases are very important and need to be managed properly. And it is important for the patient to come back to the clinic and report when there are problems rather than stop the medication.

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. To diagnose MDR-TB, we still do smear and grow sputum and then test it for drug-sensitivity, because it is important to know which drugs the patient is resistant to, as there are different resistance profiles.

But 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, by the time they come for a consultation, they 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 6 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 come.

But 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, by the time they come for a consultation, they 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.

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.

Do you expect an increase in the cases of MDR-TB?
There is definitely an increase. We have nine confirmed cases of MDR-TB now, but we have a lot of suspected ones. Every two or three weeks we find a new case. The numbers are going up. So we definitely anticipate an increase.

What can be done to contain it?
First and foremost is infection control. We work in an environment where the rooms are tiny, with small little windows. Patients come coughing into the room and leave a lot of bacilli around for us to share. The patients that are diagnosed with MDR-TB are the same patients that you saw yesterday and that were coughing all over everybody and by then you didn’t know they were resistant. Then you start to use a mask around the patient, but you have been exposed to it already. We have already improved a lot and it wasn’t easy to get where we are now. Part of my work is to train all the nurses, counselors and other staff at the hospital and the clinics on infection control measures. It was amazing to see it, from where we were to where we are now. In the past there would be a heater in the room, the windows would be closed, people would come coughing and wouldn’t cover their mouths. And now we have moved to a stage where we try and separate. People sit outside as long as the weather permits, the rooms need to have the windows open.

Are you afraid of becoming infected yourself?
Yes, definitely. It is hard not to, especially when you are working in a tiny room. This work is very challenging, sometimes quite hectic but overall very fulfilling. I think there is still a lot to be done. There are lots of lives to be saved out there. We are still trying to get people to be aware that these medical services are available and free, so that they can come and know their status, access treatment and get all the help they need. With HIV and TB, and especially MDR-TB, there is no time to waste.