In the dusty streets of Bulawayo’s densely populated townships, Susan Nkiwane is making house calls today. She is one of a group of twelve women who form a fragile web of support for TB sufferers in her community.
The conditions in the Nkulumane neighbourhood where Nkiwane works are ripe for the spread of tuberculosis. The disease thrives in densely-populated areas and enclosed spaces that faciliate airborne transmission of the disease.
This is made worse by widespread fear and stigma of TB – which is closely associated with AIDS here.
As a home-based caregiver, Nkiwane has witnessed silent suffering in many houses where she sees visibly-ailing people who resist her advice to get tested. It is common for people to hide their sick relatives.
“People are still afraid,” Nkiwane says. “Many still believe getting tested for TB and being found with the disease also means you are living with HIV and AIDS.”
The World Health Organization (WHO) says that because of their weakened immune system, people living with HIV are less able to fight infection and are more likely to develop active TB. In the streets of Bulawayo, this well-known connection is slowing the fight against both diseases.
The two diseases are like evil twins. Co-infection rapidly increases the mortality rate and untreated sufferers of both HIV and TB are the most infectious, posing the greatest risk to those around them.
Both diseases can also be treated successfully – but the first step in treatment is testing and diagnosis.
“We get some patients who stay home after being told they need to take these TB tests because they have conditioned to associate TB with HIV and vice versa,” said Feluna Nxumalo, a senior nurse at the Bulawayo City Council’s Thorngrove Tuberculosis Clinic.
WHO recommends a “three I’s” approach to control HIV and TB: Isoniazid Preventive Therapy, Intensified TB screening and Infection Control for TB. The strategy is to screen people living with HIV who show signs of TB for the disease; this will enable them to be put on appropriate treatment both for their own health and to prevent them infecting others.
It is also recommended that all children and adults living with HIV be routinely given isoniazid, a cheap anti-TB drug, as a preventative measure for six to 36 months – or longer in a setting with a high prevalence of TB and HIV.
Nkiwane and her colleagues work with the local clinic in Nkulumane, which provides them with latex gloves and face masks to protect the care-givers’ own health as they make their rounds of the neighbourhood.
“We tell members of the family to avoid unnecessary contact with the patient as TB is highly contagious in closed spaces and especially for children,” Nkiwane said.
Others have advised total quarantine of TB patients but this is controversial with both patients and relatives who say it only serves to increase stigma against TB patients. Support and care from family can be an important part of successful treatment.
The Bulawayo municipal health services department has city-wide campaigns to help raise TB awareness and reverse perceptions that hinder control of the disease.
This has included awareness programmes at local clinics where TB patients are educated about how to avoid spreading infection – wearing masks and ensuring rooms are as well-ventilated as possible reduces the risk.