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South Africa's hidden epidemic

By Nicole Itano in Johannesburg

Millions of African children are orphaned as a result of Aids, but tuberculosis is also a threat [EPA]

When the Themba Lethu HIV/Aids Clinic opened at Johannesburg's Helen Joseph Hospital in 2005, the focus was on saving lives by getting people on antiretroviral therapy (ART) as quickly as possible.

But as the numbers taking ART started to climb, doctors began noticing a second, hidden epidemic: tuberculosis (TB).

Patients being treated for Aids were still dying of tuberculosis in large numbers.

Worse, the raging HIV/Aids epidemic seemed to have masked the growing tuberculosis problem.

Tuberculosis resurgent

Once on the wane, tuberculosis is again resurgent, especially in countries facing major HIV/Aids epidemics.

In 2006, it killed an estimated 1.7 million people, according to the UN. An estimated two million died of HIV/Aids, but for many the immediate cause was tuberculosis; TB is the number one killer for people with Aids.

Unlike Aids, TB - once known as the white plague - is a curable disease, but proper treatment is complicated and requires at least a six-month course of antibiotics.

However, HIV attacks the immune system, making people more susceptible to infections like TB, and as a result, there are high-levels of co-infection.

At Helen Joseph Hospital, for example, more than 90 per cent of patients admitted to hospital wards for TB were also HIV-positive.

Of all patients diagnosed with TB, 65 per cent are also HIV-positive.

As South Africa focused on combating HIV/Aids, its tuberculosis rates quietly soared. The country now has one of the worst epidemics in the world.

By 2006, the TB incidence rate in South Africa - the number of new cases each year - had become the second highest in the world, a staggering 940 cases per 100,000, according to the World Health Organisation (WHO).

Only neighbouring Swaziland, another Aids-stricken country with a population of just over a million, has a higher rate.

'HIV driving TB'

Most of the children at this Johannesburg orphanage lost their parents to Aids [EPA]

Though the two epidemics are feeding off each other, little effort has been made to co-ordinate treatment of the two diseases.

"TB is the step-child of HIV," says Dr Johnson Mahlangu, who runs the TB focal point at Helen Joseph.

"HIV is really driving the TB epidemic, but health systems are not geared up to manage the two diseases together."

HIV/Aids are often treated at specialised clinics, like Themba Lethu, many of which receive funding and support from international donors and local non-governmental organisations.

Primary health care providers usually treat tuberculosis. As a result, patients infected with both must go to two separate clinics and see two separate sets of health care providers.

"The two just aren't talking to each other," says Mahlangu, who works for Right to Care, a non-governmental organisation.

Co-ordinated care

At Helen Joseph, with support from Right to Care, and the US president's Emergency Fund for Aids Relief, doctors are taking an innovative approach to integrating care for the two diseases.

A year ago, Right to Care opened the new TB focal point next door to the Themba Lethu clinic. Patients at Helen Joseph who are being treated for one disease are now tested for the other. And care for patients who test positive for both can now be co-ordinated.

Both clinics have also been outfitted with a special ventilation system and UV lights that help kill the infectious mycobacterium that cause TB.

"One of the biggest challenges is that if you have patients who are HIV-positive and you mix them with TB patients, you're going to really increase the risk of infection," says Mahlangu.

Tuberculosis is spread through the air, especially in confined spaces.

The TB unit has also succeeded in dramatically increasing the number of patients who follow through with treatment.

Before the focal point opened, 50 per cent of patients diagnosed with TB at Helen Joseph disappeared from the health system before receiving treatment. Now, each is tracked to ensure they enrol in and complete TB treatment.

However, though the South African government says it is committed to integrating TB and HIV treatment around the country, Helen Joseph remains a rare model.

Stripped defences

Norah Mahlangu (no relation to the doctor), a 27-year-old mother from the township of Soweto, was diagnosed with HIV in 2004.

The virus stripped away her body's defences, but it was tuberculosis that nearly killed her.

Before she could start antiretroviral therapy, she needed treatment for her TB. She nearly did not make it through.

Norah was lucky. She had help from Susan Moloto, a nurse at Soweto Hospice who understood the relationship between the two diseases and helped her access treatment.

Now her TB has cleared up and she has started taking antiretroviral drugs.

Soweto Hospice even gives her extra food, an essential but often overlooked part of her treatment. Both the antibiotics taken for tuberculosis and antiretroviral drugs can make patients feel sick if taken on an empty stomach.

No one in Norah's house has a job - something that is not uncommon in South Africa, especially in the poor communities hardest hit by tuberculosis.

"She completed the whole TB treatment, which is very hard," says Moloto. "Now she's better."

Drug-resistant strains

Susan Moloto, left, a nurse at Soweto
Hospice, visits Norah at her home

In South Africa, as in many of the African countries were HIV/Aids is widespread and tuberculosis resurgent, completion rates for tuberculosis treatment have fallen in recent years.

Only about 70 per cent of people successfully finish their treatment. The rest die or stop taking their drugs. Many more are never even identified as being infected.

The poor quality of TB treatment costs lives but is also causing the rise of dangerous new strains of drug resistant tuberculosis.

Doctors are increasingly worried about multidrug-resistant tuberculosis (MDR-TB), which is resistant to the two most powerful drugs used to treat the disease.

Globally there were half a million new cases of MDR-TB last year, about five per cent of all new tuberculosis cases. But HIV-positive people are twice as likely to be infected with resistant strains, and are more likely to die if they are.

Even more alarming for many health care professionals is the recent emergence in South Africa's KwaZulu-Natal province of a deadly strain of tuberculosis that is virtually untreatable with known drugs.

Struggling to diagnose

South Africa is struggling to even properly diagnose MDR-TB.

At Helen Joseph, for example, tests for TB are returned from the laboratory in less than 24 hours. But it can take up to two months to determine whether someone is infected with MDR-TB.

By then, the patient is often dead or has disappeared. They have also had months to spread the resistant strain to other people.

Dr. Louisa Ferreira, who runs the paediatric ward at Soweto Hospice, says she is seeing an increasing number of MDR-TB cases in her own small ward and in local hospitals.

For now, TB is still in the shadow of HIV/Aids, but she and others say the threat it poses is enormous.

She said: "It may be bigger than HIV."

Source:

Al Jazeera

South Africa's traditional healers help fight HIV

By Rebecca Harrison

MTUBATUBA, South Africa (Reuters) - Tryphina Ngwenya slides a pink condom over the magic wooden stick normally used to conjure up ancestral spirits, unleashing a ripple of laughter among her audience of traditional South African healers.

"You see it's easy -- there's nothing poisonous or dangerous about condoms," she told the group of some 80 sangomas -- as traditional healers are locally known -- draped in brightly colored wraps, animal hides and beads.

Ngwenya has recruited the sangomas -- sometimes called witchdoctors -- as foot soldiers in the fight against HIV, which has infected about one in three adults in this deeply traditional corner of rural South Africa.

She is teaching them basic AIDS awareness and prevention.

Many of the healers once believed HIV was a curse from the spirit world and patients had been bewitched. Some claimed they could cure AIDS -- and many who have not been trained continue to claim this.

But while they still prescribe roots and herbs for ailments and mutter incantations to dispel evil spirits, these sangomas now also issue condoms, refer patients to clinics for HIV tests and urge them to take life-prolonging anti-retroviral drugs.

"Before, I didn't even know what this HIV animal was, but the training has brought sophistication to my work," said Miriam Tembe, who has been consulting the spirits for tips on treating patients for 25 years.

The training helped her with the practice of scarring a patient then rubbing herbs or powder into the wound: "I used to use one razor for five people -- I used to kill people," she added. "Now I teach them how to protect themselves."

BEWITCHED

The project linking traditional practioners with modern health systems is being run by African Medical and Research Foundation (AMREF), which says more than two-thirds of people in rural Africa consult sangomas before attending a clinic.

Sangomas are revered and trusted in rural communities and play multiple roles as spiritual guide, healer and counselor. Mostly but not always woman, they might offer tips to a young couple on their sex life, advise on proper burial rites, or concoct a treatment for toothache -- all in a day.

AMREF wants sangomas to keep providing spiritual succor and basic healthcare, and also to use their influence and authority to promote HIV-testing and modern medicine in areas where many people are distrustful of hospitals, clinics and ARV drugs.

"Traditional healers are so important in these communities. People trust them more than they trust us nurses," said Ivy Mdletshe, a nurse who works in AMREF's HIV testing centre.

Zandile Bukhosini has benefited from the system. When her feet swelled up and she developed a hacking cough she assumed she had been bewitched and went straight to see Tembe -- her local sangoma.

Fortunately, Tembe knew how to spot the symptoms of tuberculosis, which often accompanies HIV infection. She consulted the spirit world as usual, then sent Bukhosini for an HIV test. The results were positive.

"When Miriam sent me for a test I was skeptical, but her medicine had helped me before so I decided to trust her," said the 25-year-old, hunched inside a mud and straw hut, the bitter aroma of burning incense wafting from the corner.

Now, with Tembe's support, Bukhosini is taking anti-retroviral drugs and looks happy and healthy.

"Miriam encouraged me to take the medicine the doctors gave me," she said. "But she also gives me her own treatment and tells me if I need to slaughter a chicken to appease the ancestors."

TOXIC DRUGS

The AMREF project has particular resonance in South Africa, where Health Minister Manto Tshabalala-Msimang has angered AIDS activists by appearing to question accepted science and emphasizing treatments such as lemon, garlic and the African potato.

Ngwenya insists the two approaches are not mutually exclusive, and argues sangomas can help treat some of the side effects of HIV -- such as skin problems or coughs and colds -- and break down the stigma attached to it.

"Obviously there is not a traditional healer who can cure AIDS but they can help treat the symptoms and help support patients by giving them what they want to believe," she said.

But she also says much more must be done. An estimated 200,000 traditional healers are practicing in South Africa -- there are almost 900 in this small district of some 200,000 people -- and organizations like AMREF have trained just a handful.

Many healers still tell patients anti-retroviral drugs are toxic, condoms are infested with disease-carrying worms and killing a goat will appease ancestral spirits and cure the sick.

And while a few weeks of basic training can halt dangerous practices like razor-sharing, healers may continue to promote traditional methods over modern medicine.

But most sangomas see little conflict between the two approaches, and say learning about orthodox healthcare has helped improve their traditional practice.

"How can the ancestors be angry with me?" said sangoma Philile Gumbi when asked what the spirits thought when she encouraged patients to turn to modern medicine: "Both me and the hospitals are doing the same thing -- we are saving lives."

(Additional reporting by Spokes Mashiyane)

HIV/AIDS
HIV AIDS is a serious problem. It is becoming more and more prevalent in the Muslim community. In light of the serious threat that it poses the lives of all South Africans including Muslims, the Jamiatul Ulama, together with the Islamic Careline (the Jamiatul Ulama, Islamic Careline and the IMA are founder members of MAP – Muslim Aids Awareness Program) are focusing on HIV/AIDS in the Online Newsletter.

Names in the case histories are not actual names (to protect the identity of the persons), but permission to print the case histories has been obtained from the respective persons.

Muslim AIDS Programme / Islamic Careline
We have provided personal testimonies of people living with AIDS (PLWAs) for the last few weeks in order to highlight the realities around this devastating pandemic. As Muslims, we are not immune to HIV and AIDS as many infected and affected people will know.

In conclusion, it is apparent that HIV and AIDS is a major problem in the community at large. The solution is therefore to treat the root of the problem i.e. sexual promiscuity and drug abuse which are the two primary modes of transmission. Prevention should include discouraging sex outside of the marriage, chastity should be vigorously promoted and fidelity within marriage should be upheld at all costs. It is the Muslim AIDS Programmes firm belief,
that this is the only solution to stem if not eradicate the onslaught of the HIV/AIDS pandemic.

As far as drug abuse is concerned, young people should remember to have clean fun with friends, not with destructive substances like drugs and alcohol. Sporting activities are a great way to socialize and enjoy yourself. You cannot get away from your problems but you can learn to deal with them and succeed – so get help if you are in need of it. Your future is too valuable to lose.

We at MAP are confident that we are making a positive contribution to the Faith Based Initiative in the partnership with the National Government in the fight against a disease that is destroying our community and our nation.

MAP: 011 373 8083/5 ~ ISLAMIC CARELINE: 011 373 8080
FAX: 011 373 8089 ~ E-MAIL: careline@islamsa.org.za