Swaziland: Dual HIV and tuberculosis epidemic demands urgent action
November 28, 2010
Mbabane, Médecins Sans Frontières (MSF) today launches a report on the fight against a dual epidemic of tuberculosis (TB) and HIV that is devastating the southern African kingdom of Swaziland, cutting people’s life expectancy from 60 years to just 31. The small kingdom of just over a million people is at the epicentre of a co-epidemic affecting the whole of southern Africa. In its report, “Fighting a dual epidemic: Treating TB in a high HIV prevalence setting in rural Swaziland”, the international medical organisation draws upon its experience since 2007 in the Shiselweni region to define the urgent practical action that must be taken in response to this major health emergency.
“Swaziland has the highest HIV prevalence in the world among adults. Disturbingly, more than 80 percent of TB patients are also co-infected with HIV,” says Aymeric Péguillan, MSF’s head of mission in Swaziland. He continues: “Life expectancy has halved within two decades, plummeting from 60 to just 31 years. People are dying in large numbers, and tuberculosis is currently the main cause of mortality among adults. As a result, many children are being made orphans and the adult workforce is declining.”
Swaziland also has an alarmingly high prevalence of multidrug-resistant TB, which accounts for 7.7 percent of all new TB cases – as revealed by the joint MSF/National TB Programme 2009-10 Drug Susceptibility Survey – which places Swaziland amongst the group of countries with the highest prevalence of multidrug-resistant TB.
Tackling this crisis is being hindered by an acute shortage of local health staff, inadequate diagnostic facilities, and by patients failing to complete their treatment, often because of the prohibitive cost of making long and frequent journeys to distant health facilities.
Since November 2007, MSF and the Ministry of Health of Swaziland have followed a decentralised, integrated and patient-centred approach to fight the co-epidemic in Shiselweni, the country’s poorest and most remote region. As a result, innovative ‘one-stop services’ for HIV and TB care are today available in 21 health facilities. The number of people tested for HIV each month has also more than tripled in 18 months, reaching 1,617 in June 2010.
“Decentralising integrated HIV and TB services all the way down to rural clinics and communities has dramatically improved patients’ access to care, and significantly reduced the number of patients defaulting from treatment,” says Péguillan. “Until 2008, the management of the TB epidemic was extremely centralised. Patients had to travel to the national TB centre for treatment, or wait for the sporadic visits of a medical team. Today, in Shiselweni, patients can access HIV and TB services closer to their homes.”
Other innovative approaches have been implemented with great success, in particular task-shifting. Given the dire shortage of health professionals, delegating responsibilities to lower cadres of workers – from doctors to nurses, and from nurses to lay community workers – has proved to be an effective model of care delivery.
The challenge now is to build on these successes. MSF’s report, Fighting a dual epidemic: Treating TB in a high HIV prevalence setting in rural Swaziland, highlights measures that urgently need to be expanded nationwide, including improved infection control measures and the implementation of new diagnostic techniques. MSF strongly advocates for an expansion of task-shifting amongst health workers to manage the growing number of people with HIV in need of treatment, which is set to increase in line with the latest WHO recommendations*.
“Introducing these measures is vital. The scale of the co-epidemic in Swaziland demands urgent political commitment translated into immediate action. We can save thousands of lives if we act now,” says Péguillan.
In 2006, the then Prime Minister of Swaziland made an urgent request for external help to fight the HIV and TB crisis sweeping the country. Since late-2007, Médecins Sans Frontières (MSF), together with Swaziland’s Ministry of Health, has been providing HIV and TB care to patients in Shiselweni. By the end of June 2010, out of almost 20,000 HIV-positive people in need of treatment in Shiselweni region, close to 11,000 patients were on antiretroviral treatment, including 2,845 managed at clinic level. An average of 2,450 patients have been initiated on anti-TB treatment annually since January 2008. A total of 140 patients have been initiated on treatment for drug-resistant TB treatment since January 2008.
* In 2009, the WHO recommended earlier initiation of treatment for patients, from a CD4 count of 200 to a CD4 count of 350. The CD4 count refers to the number of infection-fighting white blood cells in a cubic millimetre of blood, and indicates the state of a patient’s immune system.