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TB Thrives Among South Africa’s HIV-Positive Population

March 24, 2009 at 12:00 AM EST
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Tuberculosis is the No. 1 killer of patients with immune systems weakened by HIV/AIDS. In the second of three reports from South Africa, Ray Suarez looks at the deadly partnership between the diseases in the rural KwaZulu-Natal province.
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JIM LEHRER: Next tonight, the second story in our series from South Africa, this one about the resurgence of tuberculosis.

A study released today by the World Health Organization found that 1 out of every 4 tuberculosis deaths is HIV-related, twice as many previously recognized. Ray Suarez has our report on how that very problem is playing out in South Africa.

RAY SUAREZ: Every morning, the scene is the same. Patients get into a long line to wait hours for tuberculosis screening at this specially designed clinic in Durban, South Africa.

Seven hundred patients will pass through these doors on an average day. The Prince Cyril Zulu Centre handles four times as many patients today as it did 10 years ago.

Tuberculosis, or TB, is now a leading cause of death in South Africa. In fact, estimates are that, every hour, 13 South Africans will die from TB.

And the patient profile has changed, too. Tuberculosis, once a disease of older men, has a new face. The reason: the HIV virus.

DR. SALIM KARIM, AIDS-TB expert: HIV has created a new dynamic in the TB epidemic. To start with, the patients who have both T.B. and HIV are younger, they tend to be more female than previously, and they tend to be sicker.

RAY SUAREZ: HIV has created a population of immune-depressed host bodies. More than 7 million South Africans are HIV-positive, a perfect lab of sorts for the TB bacteria to flourish. TB is an old killer given new life by the onslaught of the HIV virus.

Professor Salim Karim is director of CAPRISA, the Centre for the AIDS Programme of Research in South Africa.

DR. SALIM KARIM: HIV is potentiating the TB epidemic, so that we have these terrible twins of HIV and TB tracking together. And TB is the single most common presenting illness in AIDS, so this means in South Africa somewhere around 70 percent or so of patients who are presenting with tuberculosis have HIV infection.

Old technology hinders treatment

RAY SUAREZ: Those that come to Prince Cyril are asked to cough into a cup. The specimen, or sputum, is brought to the lab, but the lab, even at this state-of-the-art T.B. clinic, exposes a big problem with the TB resurgence: old technologies.

Most of the diagnostic methods for tuberculosis were developed over 100 years ago and only catch about half the cases. New testing tools are in use, but not widely available.

And in the rural areas, like iLembe district in KwaZulu-Natal, diagnosis is even more problematic. At rural clinics like this, a patient's T.B. test is sent to a city lab and the patient is told to go home and come back days later, but often the patient is on foot and they never make it back.

Dr. Refiloe Matji is an expert in tuberculosis and rural treatment of the disease.

DR. REFILOE MATJI, TB expert: Imagine, this is a patient who'll walk the distance to the clinic. He is ill. What is the patient told? "Take these three bottles. Go back home." Would you be happy?

You are ill. You are in pain. All you are given are three bottles. You then bring back the sputum, come back after three days. Hence, patients end up not coming back and dying.

RAY SUAREZ: Without question, the biggest challenge of the tuberculosis epidemic is treatment. The standard treatment for T.B. is an arduous six months of daily medication. If medication is not finished, deadly drug-resistant strains of the tuberculosis bacteria can develop.

That's why, at the Prince Cyril Zulu Centre, hundreds of patients show up every day before work, show their card and swallow their medication in front of a health worker. It's called DOT, or directly observed therapy. It's promoted by the World Health Organization as the gold standard for care.

JEANNE LIEBETRAU, Prince Cyril Zulu Communicable Diseases Centre: The biggest problem is, after the first two months they have been on T.B. treatment, the first -- after two weeks, they start to feel really, really good, and then after two months they're actually feeling so much better. And I think after the two months review is quite often where we have the most people dropping out. And it's really worrying. At the moment, I think we're losing about 23 percent of our patients.

Treating rural populations

RAY SUAREZ: Following a TB patient through six months of treatment in rural areas is even trickier.

We're about seven miles from the clinic -- not that far, really -- but, remember, when you're talking about patients who are among the poorest of the poor, a $1.50 for a round trip and a taxi service is far beyond reach.

And remember, also, that we're talking about patients who are still often quite ill, so walking any distance is out of the question, as well. The answer? Bring the clinic on the road where the patients are.

On a February day, late in South Africa's summer, the temperature tops 100 degrees. Jabu Makhathini, a social worker, heads out on foot to observe tuberculosis patients taking their medication. The program is partially funded by the U.S. Agency for International Development.

Most residents in this rural area are poor. Many are hungry and, taken without food, TB drugs can make you sick to your stomach.

DR. REFILOE MATJI: The major problem in TB is compliance. Are we saying people who have TB are different than us? They are not. But the circumstances they live in, unfortunately, make them at times not to take treatment.

RAY SUAREZ: Very few districts have money for programs like this one in iLembe. Dr. Matji says tuberculosis funding has been overlooked by the international health community, leaving the treatment unchanged for decades.

DR. REFILOE MATJI: It takes six months to cure a patient, which is a long time. Imagine if tomorrow we'll be told there's a drug that can cure tuberculosis in five days. Is that impossible? It's not. Therefore, we need also to tell the international world that it's time to invest in developing new drugs.

RAY SUAREZ: As it stands, only about 70 percent of all patients in the KwaZulu-Natal province will finish their treatment.

DR. SALIM KARIM: That is what creates the problem, because then what we've got is we've got incompletely treated TB, and that lays the foundation for getting a resistant TB.

The organism has an opportunity to interact with the drug and then develop a resistance to the drug, which means that our two major drugs that we use in the treatment of TB, the mainstay, the backbone our treatment, are not available. That's a huge challenge.

Drug-resistant strains

RAY SUAREZ: It's a challenge now seen in two dangerous strains: multiple-drug resistance TB, or MDR-TB, and extensively drug resistance TB, called XDR-TB.

DR. SALIM KARIM: So most patients with MDR will die within two years. We have very low cure rate of MDR-TB. We have drugs available. We can use combinations of drugs that are effective, but the efficacy is quite low and they have quite severe side effects.

RAY SUAREZ: The prognosis for extensive drug resistance is even worse.

DR. SALIM KARIM: You can't diagnose it easily, so it takes six to eight weeks to get a result. These patients are dead by then. Average survival is something like about two to three weeks. So you are only making the -- you only know who's got XDR-T.B. long after they're dead.

RAY SUAREZ: In fact, the concern is that someone with XDR-TB could get on an international flight and spread the disease even before they're diagnosed.

King George Hospital in Durban has some of the highest numbers of drug-resistant TB patients in the world. Nesri Padayatchi is the former medical director of the facility.

DR. NESRI PADAYATCHI, TB expert: About 10 years ago, we started up an out-patient facility to follow-up patients with MDR-T.B. And that facility was a room of about 16 square meters, and we used to see maybe 20 patients a week. Now that same facility sees over 400 patients a week.

RAY SUAREZ: Patients like Innocent Hilengwa, who has multiple-drug resistant TB, like most TB patients, Hilengwa found he was HIV-positive when he went in for TB symptoms. And like most TB patients, he was treated for his TB before he was given HIV drugs, because the combination of drugs is considered too dangerous and TB is the faster killer.

INNOCENT HILENGWA: I was always thinking that I am dying.

RAY SUAREZ: But when Hilengwa's HIV progressed to a deadly point, doctors started him on both HIV and TB treatments.

INNOCENT HILENGWA: Yes, I was taking 22 tablets every morning and an injection. Of course, I wasn't even eating. I was eating one spoon of porridge in the morning, one spoon porridge in the day, and one spoon of porridge at night.

Debate over treatments

RAY SUAREZ: Hilengwa survived, although he still has TB, and the debate over how to treat co-infection continues. Dr. Karim recently conducted a trial in which patients were treated for HIV and TB at the same time.

DR. SALIM KARIM: Two years into the study, the study had to be stopped halfway through, because we found that patients who were getting integrated care had 56 percent lower mortality. They had less than half the mortality than the patients where we were waiting to first treat their T.B. and then start the antiretrovirals.

So the message is clear. We should integrate care. We should provide T.B. patients with both antiretrovirals and TB treatment. It will save lives.

RAY SUAREZ: While South Africa's numbers for tuberculosis are grim, one promising note to the epidemic is unfolding an hour outside of the country's legislative capital, Cape Town.

In the town of Worcester, where TB infection rates are arguably the highest in the world, testing continues on new tuberculosis vaccines. And this month, human trials move into a critical stage of development.

Vaccines are considered the holy grail of disease prevention, and the current vaccine for TB was developed in 1921 and is largely ineffective. The site director for South Africa's TB Vaccine Initiative, Hassan Mahomed, says South Africa is the place for trials.

DR. HASSAN MAHOMED, South African TB Vaccine Initiative: If you want to find a place where you want to see if a vaccine works, this is the place to do it. This is a place where you'll be able to show whether the vaccine actually makes a difference or not.

RAY SUAREZ: By 2015, scientists will know whether these babies have been protected long term against TB, and a lifesaving drug can then head out from this sun-drenched South African valley to a country and a world waiting for new weapons against an old killer.