Tuberculosis (TB) is responsible for 60 percent of the deaths among persons living with HIV/AIDS.
Given this relationship, the World Health Organization (WHO) recommends that care services are integrated between the two conditions. Uganda has registered some progress but the technocrats want the success rate at 100 percent. Kakaire Ayub Kirunda spoke to Dr Anna Nakanwagi Mukwaya, the Chief of Party in Uganda for the International Union against Tuberculosis and Lung Disease (The Union) to put things into perspective.
Why is the integration of TB-HIV care such a big deal these days?
HIV is the leading risk factor for the development of tuberculosis disease. At the same time, tuberculosis is the leading cause of death among people living with HIV. In a country like Uganda where the TB burden is so huge (the community has with TB germs in the air) and HIV/AIDS that is depressing the immunity of persons with HIV, then chances of picking TB are high.
That is why you see this one AIDS patient with TB but usually the TB came because of the condition of HIV which affected their immunity. We can no longer have a situation where a patient comes into a clinic, gets treatment, and we do not look out for TB. It is going to kill them. Whenever health workers see HIV/AIDS patients, they have to look out for TB as well.
And the day you confirm someone has TB, let them be advised to take an HIV test and if positive, start them on antiretroviral treatment because they will heal much faster than someone being treated for TB alone. If only one condition is treated, the patient may die along the way. If you somehow manage to treat the TB, they will get it again because the underlying problem is not being taken care of. The two diseases are no longer separable.
The latest annual health sector performance report (AHSPR) shows that integration has improved tremendously but there are some academic works that paint a contrary picture. Why the discrepancy?
You have to look at the statistics well. If I were at zero and I have moved to 10 or 20 percent of the performance, I have improved. But it doesn't mean I have reached the optimum that is required. All TB patients are expected to be tested for HIV. So when we say integrate a service, we expect that every TB patient found in this country will receive an HIV test.
So when you look at the AHSPR and last year they tell you they were at 60 percent but this year they are at 70 percent they will say they have improved but we want it at 100 percent.
So why are we not integrating?
Many health workers did not understand this linkage initially. They needed training. It has taken time to have them trained to understand the close linkage between the two diseases. Also if you look at the structure of our services, if you have HIV, you are sent to a particular clinic and if you have TB you are sent to a particular clinic.
So the way our services are organised does not easily facilitate the process of integration. If somebody is in the TB clinic and that clinic does not offer HIV testing, they will refer the patient to the site that offers HIV testing. That alone affects the uptake of services. Probably they have been waiting for long and will promise to come back another day.
But they may not due to several factors because many may not have transport, we don't give them lunch. The vertical HIV and TB programmes are problematic. So what is the teaching now? At the primary healthcare facility we should try to integrate these services as much as possible. Where there is a TB service we should try and put an HIV service and vice versa. This will reduce the inconvenience to the patient.
Now that the need for integration is well understood why are we still wasting time as country?
In countries where TB and HIV services are under the same roof things are much better. For example in Zimbabwe these services are given under the same roof. Patients are not referred. If you go to Benin, it is the same thing. In Uganda, because our services have been structured separately, it takes time. When it comes to health workers, very few in HIV know how to give TB care and in TB it is the same situation.
Uganda needs to get resources and ensure that all health workers in HIV care know how to diagnose TB, treat it and follow up the patient. It should be the same thing on the TB side. Traditionally, the training has been separate. Joint planning by the national TB and AIDS control programmes is also still weak.
But your organisation has been working with Government for some time now. Why don't we have the TB and HIV care clinics merged?
When you are a partner in a country, you do not work in isolation of the government system. Uganda is stuck with the old system structure of vertical programming. So however good your intervention may be, it will be so difficult to integrate services like TB and HIV.
You can only tell them (TB and AIDS control programmes) to talk to each other, collaborate more often, and do what they can. But still where the Union has worked, there has been improvement in the uptake of TB-HIV services in these districts.