TB: Lesotho in a state of emergency

By Tsitsi Matope

MASERU — Lesotho will tomorrow belatedly commemorate World Tuberculosis Day in Nazareth amid a disturbingly high incidence of the disease.

Globally, the commemorations take place every year on March 24 as a way of building public awareness about the global epidemic and efforts to eliminate the disease.

The national theme for this year is: “Reaching every Mosotho with TB Test, Treatment and Cure”, which is relevant to the Ministry of Health’s efforts to decentralise and revitalise its primary healthcare services.

The Global theme, on the other hand, is: “Reach the three million — A TB Test, Treatment and Cure for all”, which highlights that TB is curable although in the case of Africa, efforts to combat the disease are inadequate.

Out of the nine million people who get sick with TB globally every year, a third of them do not get the services they need, and many of these three million patients live in the most vulnerable communities in developing countries.

Lesotho is not spared from this epidemic, which continues to claim lives and has reached crisis levels. The Lesotho Times (LT) met with the National TB Programme Manager, Dr Llang Bridget Maama this week to discuss the TB situation in Lesotho, why Lesotho is failing to combat TB and efforts currently underway to manage, control and reduce incidences.

LT: Could you start from the very beginning by reminding us what causes TB?
Dr Maama: TB is an airborne disease caused by mycobacterium tuberculosis.
It is inhaled through droplet nuclei in the air when someone with TB coughs, sneezes, talks or sings without covering his or her mouth and nose.

LT: What is the current TB status in Lesotho?
Dr Maama: Lesotho has a very high burden of TB with high notification rates.
To really emphasise where we are, we are in a state of emergency.
The World Health Organisation (WHO) states incidences above 230/100 000 people is an emergency. Lesotho is way above that at 630/100 000 people.

LT: So what is fuelling TB in this country?
Dr Maama: There are a couple of factors but the major cause is the high HIV prevalence rate, which is 23 percent, followed by poverty which can even extend to poor housing and overcrowding.

LT: But is TB treatment free of charge in Lesotho?
Dr Maama: TB treatment is absolutely free in this country, whether it is the Initial TB or Multi Drug Resistant TB.
The Initial TB may take at least six months of treatment. In new patients, treatment can stretch to eight months. It takes between 18 to 24 months to get treated and cured of MDR-TB.

LT: Are there any shorter treatment regimens available in the country?
Dr Maama: It is still premature to even think about shorter courses for the Initial TB since research is at an early stage and no conclusive evidence has been reported.
The shorter treatment regimens for MDR-TB are being tried in some countries in order to gather adequate evidence of their effectiveness. As a result, Lesotho will wait for guidance from the WHO as to the outcome of the trials.

LT: Can you explain how far you have gone with the TB fight? Are you doing well in terms of reducing stigma and ensuring every patient adheres to treatment?
Dr Maama: Sadly, stigma still exists mainly in some families of patients suffering from Multi-Drug Resistant TB and also some local communities and healthcare workers.
We have not defeated this war on stigma.
However, despite the gloom, there is also light at the end of the tunnel because we are seeing improvements in the treatment outcomes and steady increase of HIV Co-infected TB patients on Anti-Retroviral Treatment.
We are optimistic that we might just surprise the world next year when countries present how they fared in achieving the Millennium Development Goals.

LT: Is adhering to treatment a problem in Lesotho?
Dr Maama: Yes, it’s a major challenge. In 2012, at least 13 percent of our TB patients were lost during the follow-up process (defaulted treatment).
This has a direct bearing on the persistently low treatment success rate, which we expect to be at 85 percent by next year from the current 76.2 percent.
What worries us is this is potentially a group of patients who are likely to come back with MDR-TB.
Patients default for different reasons.
Those we found blamed hunger and inability to take their medication on empty stomachs, some migrate internally or externally for economic reasons or just to be nursed by one member of family as they take turns to contribute to the care of the patient.

LT: Is there something that can be done to reduce non-adherence to treatment?
Dr Maama: To curb poor adherence, the Ministry of Health engaged psychosocial officers through the Global Fund support in order to closely support patients to adhere to treatment.
We have also increased the frequency of visits to facilities by patients where they would continue receiving counselling on the importance of adherence.
I would also like to challenge individuals, the private sector which includes public transport owners and all ministries to make an effort to support TB patients in various ways. As we commemorate World TB Day on Friday, it would be a noble thing for all people to participate by bringing to the nearest health facility, someone for TB screening and treatment.
Importantly, we all need to support TB patients to make it easy for them to adhere to treatment. Employers should also find ways to accommodate employees who are on treatment in the workplace.

LT: So what interventions do we need to effectively combat TB?
Dr Maama: All interventions should start with a strong political commitment. We can see this through commensurate financing of the programmes.
These would enable access to quality diagnostics and Anti-TB medicines, as well as other health system pillars such as human resources.
At community level, we require more knowledge through Advocacy, Communication and Social Mobilisation (ACSM).
This would help improve the health-seeking behaviour, involve all potential stakeholders in finding all the TB patients in the community and support of them through daily Direct Observation of Treatment (DOT).
A good diet is also an integral part of treatment in order to enhance treatment adherence and ensure positive outcomes.
In fact, adherence and psycho-social support of all TB patients would go a long way in effectively managing the disease.

LT: How is Lesotho managing the TB crisis?
Dr Maama: The government of Lesotho fully funds the procurement of first-line Anti TB Medicines.
However, there are also several partners on the ground such as Partners in Health supporting the Programmatic Management of Drug Resistant TB (PMDT), International Centre for AIDS care and Treatment Programmes (ICAP) and Elizabeth Glazier Paediatric and AIDS Foundation (EGPAF) who support TB and TB/HIV collaborative activities.
Additionally, partners like Doctors Without Borders, Solidarmed support both TB and HIV activities.
The Ministry of Health is also a sub-recipient to the Global Fund Against AIDS, TB and Malaria (GFATM) grants — now implementing round eight of the TB grant in order to support the scale-up of MDR-TB services.

LT: You mentioned Multi-Drug Resistant TB as being targeted in one of your current programmes. Why has it become a major problem?
Dr Maama: Yes; MDR-TB remains a major concern. Sadly, it will remain a problem for as long as we continue to see patients who get lost during our follow-up from initial TB treatment.
We have patients who get, for the first time, an already resistant strain of TB.
The number increases gradually every month and so far, we have enrolled 1 020 cases since the inception of the programme in 2007 to the end of February this year.
Currently there are 213 patients actively on treatment.

Dr Llang Bridget Maama
Dr Llang Bridget Maama

LT: What are the challenges when it comes to dealing with MDR-TB?
Dr Maama: This is a resource-intense programme and unfortunately, resources are often limited.
Human resource shortage is also one key component we are struggling with, which results in the heavy dependence on our implementing partners.
One other challenge is that stigma still prevails.
We have seen some cases where families rejected patients once they knew they had MDR-TB.
High rates of HIV co-infection and high death rates among these patients, also worries us.

LT: Tell us about the link between TB and HIV
Dr Maama: TB accelerates the replication of HIV and this leads to AIDS within a short period of time.
On the other hand, HIV also promotes high transmission rates in the general population because there is very minimal containment of the mycobacterium in the lungs of an HIV co-infected TB patient.
So basically, the two fuel each other.
It is imperative for every person to know his or her HIV status.

LT: Would you say because of much attention on HIV, we lost a lot of ground for some time in our efforts to combat TB?
Dr Maama: Yes. I think because TB is a global concern and if not managed effectively, can recur and even have more patients suffering from MDR-TB.
Unfortunately, there were years when not enough resources were allocated for the comprehensive combating of the disease — despite it being a curable.
We have seen a trend that sort of directed more resources to HIV and AIDS and rightly so, but then TB, which was the one killing people living with HIV, was under-resourced.
This reminds me of the significance of a statement made by one great leader that, “It is futile to give very expensive ARVs to people living with HIV but let them later die from TB which is curable and at very low cost.”

LT: Let’s talk about the management of TB in pregnant mothers. Are such cases manageable?
Dr Maama: Well, the management of TB is the same in pregnant mothers although we avoid giving them some types of medication to avoid complications onto the unborn baby.
It is also important for people to know that we are able to manage pregnancy in any woman who is diagnosed with TB.
There are also medicines that are safe for the mothers to use even during breast feeding.

LT: Recently there has been the signing of an important declaration on TB in the mining sector in South Africa. How is this important to the Basotho miners who are vulnerable to TB?
Dr Maama: This declaration aims to provide mineworkers, their families and mining communities access to treatment in the sub-region, through their physicians who will prescribe the same interventions and also follow the same set of guidelines for disease management signed by the four Ministers of Health on March 25.
As you know, there are a significant number of miners from Lesotho, Swaziland and Mozambique working in South Africa.
As a result, the four countries have requested support from the World Bank and other partners such as the World Health Organisation, the Stop TB Partnership and others to begin implementing the Declaration’s provisions, starting with the
harmonisation of management of TB among mineworkers.
Currently and locally, there are numerous efforts on the ground following the signing of the Declaration.
We have an ongoing TB Reach Project, which is a tripartite collaboration between the Ministry of Health, The Employment Bureau of Africa (TEBA) and the Columbia University’s International Centre for AIDS Care and Treatment Programmes (ICAP) Lesotho.
The objective is to improve the accessibility of services for the mineworkers through on-site TB screening, diagnosis and treatment.

LT: Does the declaration talk about other forms of financial support to the affected families?
Dr Maama: It actually contains aspects of how to assist the affected mineworkers to make their claims to an established fund.
There are also other several plans underway in South Africa to improve access to this funding. Individually, the affected countries have shown interest to establish One-Stop-Shop facilities that would provide the required services nearer to the eligible mineworkers. There is one such
centre in South Africa and it is functioning well.

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