As the number of people with COVID-19 grows daily, Eswatini is now battling yet another health crisis on top of existing epidemics of HIV and tuberculosis (TB)
In Eswatini - which reported its first confirmed case of COVID-19 on March 14 - nearly one-third of adults are HIV-positive, the highest rate in the world. The country is also severely affected by a TB epidemic, with around 70 percent of all TB patients being co-infected with HIV.
While it remains unclear how COVID-19, the disease caused by the novel coronavirus, will impact people living with HIV, it is known that people with existing chronic illnesses and weakened immune systems are more at risk. TB is a disease that attacks the lungs, like COVID-19, and it is therefore likely that people living with TB will suffer more severe symptoms and worse complications if they become infected.
Doctors Without Borders/Médecins Sans Frontières (MSF) has been responding to the dual HIV and TB epidemics in the country--formerly known as Swaziland--since 2007.
Here, Dr. Bernhard Kerschberger, MSF's head of mission in Eswatini, describes the challenges his team is facing while responding to COVID-19 in a setting with high rates of HIV and TB, and how adapting care is critical to reducing the risk of exposure for the people most vulnerable to COVID-19.
Are people living with HIV and TB more at risk of suffering severe forms of COVID-19?
Our understanding of the virus and the disease is still evolving. At the moment, there is not enough evidence to determine if COVID-19 will affect stable HIV patients with weakened immune systems differently than the general population.
However, people living with advanced HIV who have low levels of CD4 - infection-fighting cells - and high levels of HIV in their blood, or those who are not on antiretroviral treatment (ARVs) to fight HIV, are likely more at risk for infections like COVID-19 in general and need to exercise caution.
We don't yet have much experience in treating COVID-19 infections in people with TB, but it is very likely that people with both TB and COVID-19 are more at risk and may have poorer treatment outcomes. This is primarily due to lung damage caused by TB, which likely leaves people more at risk of severe cases of COVID-19 since that disease also targets the lungs.
It is important that people with TB, high viral load levels of HIV, or other coinfections do all they can to avoid getting COVID-19. We are working to reduce the exposure of vulnerable patients by changing the way we treat them, what we call our "models of care."
How will MSF adapt care for HIV and TB patients to reduce the risk of exposure to COVID-19 while receiving treatment?
In Eswatini, MSF has been working for years with community-based models of care to best reach people in rural areas. Now, to reduce the risk of contact for them, we are bringing care even closer to their homes, which will limit visits to health centers and unnecessary journeys by public transport.
Among people most at-risk are those suffering from multi-drug-resistant TB (MDR-TB). To protect them, we have started using "video observed therapy" (VOT). This means that people who have to be supervised in person by a community member or health worker when taking their medication (as per the treatment protocol) now film themselves taking their medicine with a smartphone so they don't have to come into a health facility.
We provide them with a smartphone that is equipped with a secure application through which they can send the video to a nurse. The nurse checks the video and follows up with the patient if there is a problem or if the video does not arrive. We are currently treating 40 people with MDR-TB, the majority of whom will be using VOT.
We have also put into place a small mobile TB clinic for MDR-TB patients comprising a driver and a nurse that visits patients at their homes to carry out medical check-ups and bring them food and refills of their medicines. Before, they had to pick up their food and drugs at the health centers.
Most of our stable HIV patients with suppressed viral loads now receive enough ARVs for six months, so they don't have to go to the health center every month. For people with TB and other chronic conditions, we provide medication for one to three months, depending on their health condition and the availability of drugs. Additionally, MSF now provides counseling and treatment support sessions for them and medical consultations with doctors for those who need it by telephone.
The countrywide partial lockdown put in place by the government has forced us to pause our preventive activities, such as mobile HIV testing points at events, workplaces, and community gatherings. We are instead focusing on distributing and educating people on how to use HIV self-tests.
Are you concerned about shortages of HIV or TB drugs in the country?
HIV and TB patients need to have longer refills to avoid treatment interruptions, as this would further expose them to COVID-19. Health authorities and providers here are working hard to estimate the needs to avoid running out of stock. Ultimately, it is a question of balancing the needs against the availability of drugs and identifying any gaps or ruptures where these drugs are not available. MSF is filling some of these gaps, providing drugs for MDR-TB treatment and other opportunistic infections.
However, if the lockdown continues and international restrictions on the movement of goods remain in place, this could affect the supply of medication from abroad. Many generic drugs come from India, for example, so it would be extremely worrisome if we no longer have access to the medicines they produce. This scenario must be avoided.
How could COVID-19 impact the epidemics of HIV and TB?
At this stage in the outbreak, it is too early to tell, but we are certainly anxious that any reduction in health care delivery and/or in access to care could lead to more illness and deaths among people with HIV, TB, or other chronic diseases.
It could potentially also affect HIV and TB epidemics in the long run. It has been a long battle for Eswatini to break the HIV transmission curve and surpass the international United Nations 90-90-90 target--where at least 90 percent of people know their HIV status, 90 percent of people who are HIV-positive are on ARVs, and 90 percent have a suppressed viral load. If the medical strategies that allowed this to happen are not maintained, it is a sad possibility that those gains might be reversed. Therefore, it is important that basic prevention, testing, and treatment services are maintained to ensure people who need to test for HIV and access the appropriate care can do so.
The number of people who started HIV treatment in MSF-supported health care clinics fell by 64 percent (from 44 to 16) in April, compared to the same month last year. This is the lowest recorded monthly number in the past four years. As we had to reduce our activities in the community because of the lockdown measures, we distributed 46 percent fewer HIV self-testing kits in April (from 298 to 162) compared to last year.
In the short-term, we don't know what impact this will have. But in the long-term, it could prose a real and worrying problem.
What are your main concerns about COVID-19 and the response in Eswatini?
The potential impact of COVID-19 on the Eswatini health system is a major concern here, just like it is elsewhere in the world. We see many countries with advanced health systems struggling to cope, and they don't have HIV and TB epidemics to manage at the same time.
Another worry is the indirect impacts of COVID-19, particularly the socioeconomic consequences. Most people here are quite poor and live in rural areas. This is one reason why the rate of TB is so high, as it disproportionately affects poorer people forced to live in crowded households with poor ventilation. Managing diseases like HIV and TB on a daily basis is already difficult and now the restrictions in place to reduce the spread of COVID-19 will make patients' lives even harder. For many people, COVID-19 is causing further hardship. Some are already telling us they don't have enough food or money to pay for electricity or water--which makes it nearly impossible to follow guidelines like handwashing to prevent the spread of the coronavirus.
What are the main challenges?
It is definitely a challenge to find a COVID-19 response strategy that does not impact the health system in the long-term. It is not always possible to copy and paste strategies put in place by many Western or Asian countries. The situation for Eswatini is different, with many vulnerable people relying on daily wages, meaning social distancing measures and movement restrictions make people's lives more difficult.
It will also be a challenge to maintain access to health care. Both chronic and emergency care have already been affected by the response. Hospital bed capacity is being stretched as the number of new patients with COVID-19 rises each day.
Stigma and fear are also making the response difficult. In some cases, health workers reportedly did not attend to people with COVID-19 for fear of contracting the virus. It is understandable that health workers are afraid if they don't have sufficient personal protective equipment and the necessary material and resources to care for people safely. These shortages are the same all over the world, but if it is a race to get what is needed, the least fortunate--the most vulnerable people--may be left behind.
What would you like to see happen?
The Eswatini health authorities moved quickly to put in place measures to reduce the risk of infection for vulnerable people and to prepare hospitals, health staff, and other logistics needed to be able to receive patients with suspected COVID-19 who are coming to health facilities. There is a lot of willingness from different health providers to support the COVID-19 response, and if the response is well-coordinated, any gaps can be quickly identified and filled.
It is important to consider the particular needs of the people here to ensure there is as little negative impact on their health as possible and the ability to provide healthcare so the country can maintain the gains it has made in responding to the dual HIV and TB epidemics.