Treating HIV/AIDS co-infection: MSF's project in Homa Bay, Kenya
By the end of March 2006, how many co-infected patients were being treated by MSF? "More than 5,000 patients are currently being treated in our Homa Bay programme, of whom nearly 3,000 are currently taking anti-retroviral tri-therapy. In addition, 2,000 patients have been diagnosed with TB and are being followed-up by our team. Some 1,200 of these are being treated in the hospital and about 800 in the surrounding area."
What is the current situation in terms of co-infection? "Among the patients diagnosed with TB in our Homa Bay clinic, nearly 85% accept to under-go an HIV test. From these, more than 70% turn out to be HIV positive. On the other hand, detection of TB is much harder for those who are already being followed-up in our HIV/AIDS clinic.
"Co-infected patients tend to have a severely weakened immune systems and for about 70% of them, it is extremely difficult to detect pulmonary TB. A high proportion of co-infected patients develop what we call extra-pulmonary TB, which is hard to detect due to the lack of adapted diagnostic tools."
What is the largest constraint when caring for co-infected patients? "The largest constraint is primarily the diagnosis of TB. There are two diagnostic tools available to us: the most important is the examination of sputum under the microscope, which unfortunately only detects the 30% of the HIV/AIDS cases who have contracted pulmonary TB.
"The second method is to X-ray the patient, but this is not available everywhere. Even if this exists in district hospitals in Africa, it is rarely available in peripheral facilities.
"There is also a third possibility which is clinical examination, but in most of the situations we face, this is only based on empirical evidence. This means that the doctor has to take a decision based on the symptoms to decide whether or not the patient has TB, but without having the option to confirm it."
Does the simultaneous treatment of the pathologies pose any problems? "TB programmes are generally pretty out-dated and have been developed in a vertical manner - meaning that they treat TB and TB alone. On the other hand, anti-retroviral tri-therapy programmes are newer. The problem rests in the fact that up until now, few actors have managed to integrate the two programmes.
"This sometimes causes a great deal of confusion for patients: it means having to first go to the AIDS clinic, then to the TB clinic, and not getting clear information from either of them. This leaves some patients totally misunderstanding the medicines necessary for one or the other illness.
"Therefore, we have decided to treat all the co-infected patients in one and the same place. Like this, the Homa Bay TB clinic is the place in which co-infected patients are treated for both infections. Once the TB treatment is completed - and therefore they are no longer co-infected - the patients are transferred to the AIDS clinic. But this hasn't been simple.
"The solution might seems obvious, but the method of treating separately was so ingrained, that it has taken us two years to manage to convince all the others actors involved."
What should we expect from this new approach? "It's a question of treating all the patients under one roof, so one clinician can treat both illnesses. This will allow us to be much more coherent in terms of treatment and follow-up. This approach helps to give the patients a much easier time at the hospital, giving them more coherent appointments in the same diary and above all giving them the necessary information about treatment adherence.
"For the co-infected patient, the integrated approach also allows us to implement a more efficient six- rather than eight-month treatment programme."
What future evolutions will be indispensable? "For us, the most important thing will be to have a quicker diagnostic test, which is easier to use for carers, and which allows us to save time against the advance of the TB and helps to avoid the potentially fatal interaction with anti-retroviral tri-therapy treatment.
"Because, without having the means to confirm, it seems that certain HIV/AIDS patients at an advanced stage of the disease die because their reaction to the anti-retroviral tri-therapy is amplified by undetected TB."