28 Oct 2009 | Interview

 

I am working in a tuberculosis project in a rural district of Swaziland called Shiselweni. MSF is working in 17 clinics and 3 health centers in this region and I am rotating between the three health centers, where most of the tuberculosis patients are managed. On a daily basis, nurses manage the TB patients and refer the most severely ill to me. The cases I see are usually infected with multi-drug resistant TB, which means they would have already been treated with standard TB drugs without success. Other patients I treat have HIV/AIDS-related complications.

 

Participants to the International Consultative Workshop on "An emergency response to the combined DR-TB and HIV-AIDS crisis in the southern African region", which was open by Benedict Xaba, Minister of Health, Kingdom of Swaziland (sitting 5th from left), on October 28th, 2009

 

As Shiselweni is a rural district, distance is always a huge problem. Patients live on farms away from towns, many of them have to travel for hours to get to a health facility and they can spend their whole monthly earning on just one trip. This is unsustainable for them: when a patient needs multiple visits just to be diagnosed and then, when they undertake a treatment regimen of 6 to 8 months (for drug-sensitive TB) or up to two years (for drug-resistant TB). MSF's strategy, which is to provide de-centralised care, is not rocket science, it is based on what many other countries do: to manage TB and HIV. We focus on providing treatment and follow up in local health clinics, as close as possible to the patient's home. In addition to the challenge of treating patients in a rural community there is also a significant shortage of doctors. This is one of the challenges that we need to address today as there are many patients and not enough doctors. At the moment in this country the HIV/AIDS protocol demands that a doctor initiates patients on anti-retroviral treatment (ART). MSF believes that the initiation of treatment could easily be managed by an appropriately trained nurse. We need to work with the authorities to try and adopt a protocol that allows nurses to start ART for HIV positive patients.

 

83% of TB patients in Swaziland are co-infected with HIV. The country has the highest level of HIV infection in the world (affecting one out of four adults). This complicates the clinical picture of TB, diagnosis becomes more difficult and there are more severe side- effects to the drugs.

 

 

In most of the conflicts or natural disasters where MSF intervenes around the world, the number of people dying is significantly less than what we are seeing today in Swaziland. One out of four sexually active adults has HIV/AIDS and life expectancy has fallen to 32 years of age. Currently, 18% of people infected with TB will die in this country. This is an extremely high figure. Most of the patients die in the first two months, because they are also infected with HIV and were not put on anti-retroviral treatment fast enough or because they are infected with drug-resistant TB and were not diagnosed early enough. We need to find ways to address some of these challenges and that is why we are holding an International Workshop here in Swaziland today.