30 November 2013

Kenya: Why Conquering TB Is the Next Frontier in Fight Against Aids


On the November 27, the Daily Nation, reported that "A man who has twice defaulted on tuberculosis treatment will now take his daily dose for eight months under the supervision of a court in Nyahururu...resident magistrate, Alice Mukenga, yesterday turned down recommendation by a probation officer and an application by a medical official to have Mr Paul Koech Kosgey locked up in Rumuruti prison for eight months to take his full treatment under supervision."

As the international community marks World Aids Day on December 1, this report should come as good news to all those who care about the progress made in Kenya in the fight against Aids. It confirms that there is indeed a coherent policy - supported by legislation - aimed at limiting the spread of TB.

For although it is HIV/Aids we all dread, it is not being HIV positive that kills you. What HIV does is to weakening your immune system, thus paving the way for a variety of "opportunistic infections" which you would normally have been able to fight off with ease.

And of all the opportunistic infections, none is more devastating than TB. Indeed, TB kills more HIV postive people than just about any other infection.

But maybe it is worthwhile to first explain in some detail what TB actually is. As one authoritative online source (WebMD) explains, "Tuberculosis - a serious disease which spreads through the air - usually affects the lungs...

About 10-15 million Americans, for example, are infected with tuberculosis. For most people with healthy immune systems, this is not a problem. Nine out of 10 of them won't develop active disease with symptoms." So why am I telling you so much about TB, when it is World Aids Day?

Well, the two diseases have a very close link indeed. According to one of the world's premier medical research organisations, the Mayo Clinic, "Since the 1980s, the number of cases of tuberculosis has increased dramatically because of the spread of HIV, the virus that causes Aids.

Tuberculosis and HIV have a deadly relationship -- each drives the progress of the other. Infection with HIV suppresses the immune system, making it difficult for the body to control TB bacteria.

As a result, people with HIV are many times more likely to get TB and to progress from latent to active disease than are people who aren't HIV positive." I think it is a reasonable assumption to say that very few Kenyans are aware of this inimical relationship between the two infections.

Maybe it is because it is in Asia where the greater burden of TB infection is borne, globally, while HIV/AIDS has been far more devastating in Africa than anywhere else.

In any event, we have certainly made greater strides in coming up with ways to halt the ravages of HIV/Aids (for which there is as yet no cure) than in limiting the devastation of TB (for which there actually is a cure - though we now have strains of TB known as MDR-TB or "multi-drug-resistant-TB"; but that is a story for another day.)

So if TB is likely to both bring on more HIV infections, as well as prove deadly in afflicting all those who are already HIV postitive, why is there no national panic about it?

Well, back to the Mayo Clinic website, we find that: "Although tuberculosis is contagious, it's not easy to catch. You're much more likely to get tuberculosis from someone you live with or work with than from a stranger.

Most people with active TB who've had appropriate drug treatment for at least two weeks are no longer contagious." WebMD adds: "You are likely to get tuberculosis in places with poor ventilation or crowded conditions...places like a hospital or clinic; or a jail or prison."

This mention of prison brings us back to Mr Koech, who was so reluctant to take his eight-month-regimen of TB drugs, that the medical officer proposed that he be imprisoned for the duration, as the law permits.

For what place is there, better defined as having "poor ventilation and crowded conditions" than a Kenyan prison? And as such, what better place is there for contracting TB from someone already infected?

Well, in late October, I attended a conference in Paris, organised by the International Union against Tuberculosis and Lung Disease, and was surprised at how much Kenya could learn from the Asian countries where managing TB infections is a truly monstrous public health challenge.

For example, in Indonesia where an estimated 30 per cent of all prisoners were found to be infected with TB, a 'cough officer' is appointed from among the inmates in each section of a prison.

This is the person who reports to the medical staff if there is anyone in his section who seems to have a persistent cough. If found to be infected, this inmate is then isolated from the general prison population until they are no longer likely to spread infection.

Kenya has been at the centre of many breakthroughs in the fight against Aids, most notably in the voluntary male circumcision (which reportedly reduces the likelihood of HIV infection by 60 per cent).

Going forward, we should perhaps give more attention to seeking equally dramatic breakthroughs in the fight against TB. And especially in seeking those solutions which do not require vast sums of money, but nevertheless have an enormous effect on precisely those populations most likely to be most at risk of TB infection.

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