TUBERCULOSIS: KENYA: TB patients with HIV miss out on ARVs

20 August 2010 Only a third of Kenyans infected with tuberculosis and HIV are receiving treatment for both conditions, despite the latest World Health Organization (WHO) guidelines [http://www.who.int/hiv/pub/arv/rapid_advice_art.pdf] recommending that anti-retrovirals be taken soon after TB treatment begins.Kenya has achieved good results [http://www.who.int/tb/publications/global_report/2009/pdf/full_report.pdf] with its national TB programme, becoming one of the first sub-Saharan African countries to meet WHO targets for detecting new cases as well as treatment success. However, a lack of proper coordination between TB treatment centres and those providing anti-retroviral treatment (ART) has led to only a small number of the 40 percent of HIV patients co-infected with TB being treated for both."We have more TB treatment sites than sites that offer ART and this means one accesses TB treatment at one site and might be forced to [travel] kilometres to access ART," said Joseph Sitienei, head of the Tuberculosis and Lung Disease Programme at the National AIDS and Sexually Transmitted Infections Control Programme.There are 2,228 tuberculosis treatment sites across the country compared with 700 that offer ART.When medication for both HIV and TB is available at a single site, the government's policy is to initiate treatment for HIV two months into TB treatment."As a standard, we start with treating TB in co-infected patients before we start them on anti-retroviral therapy," Sitienei said. "It is TB that will kill an HIV-infected patient, so we deal with that [first]."He added that for patients seriously ill with TB, starting two different combinations of powerful drugs could be more than their bodies can handle. "You therefore improve one situation first and deal with the other when the condition improves."The WHO updated its guidelines in 2009 to recommend starting ART as soon as possible in HIV-infected patients with TB following a study [http://www.sciencedaily.com/releases/2010/02/100225091340.htm] that showed a link between early initiation of ART and improved TB outcomes.Another study [http://www.niaid.nih.gov/news/QA/Pages/CAMELIAqa.aspx], conducted in Cambodia and released at the International AIDS Conference in July 2010, found that starting ART two weeks rather than two months after beginning TB treatment improved the chances of survival for co-infected patients with severely damaged immune systems.Pilot programmeFollowing the new WHO guidance, the Kenyan government is piloting combined TB and HIV treatment in three provinces.According to Lillian Otieno, a nurse at the Mbagathi District Hospital, one of the pilot sites in the capital, Nairobi, most patients have benefited from combination treatment.Sylvan Mbori, one of the patients receiving combination treatment, said while his overall health had improved, he was worried about the drugs' side-effects."As you can see, my legs are swollen and the nurse told me these drugs I am taking are causing it," he told IRIN/PlusNews. "But I am happy because... my body feels better these days... they tell me this swelling will disappear."Mbori also said the large number of pills he had to swallow every day was a challenge."When you combine these drugs for TB and for HIV, some people will experience side-effects and especially those still using Stavudine [an antiretroviral drug], but the government is phasing out Stavudine," said Otieno. "The drugs used for treating TB also have side-effects, but we try to give medication that can reduce the swelling."Resource challengeSitienei noted that rolling out combination treatment nationally would be challenging for the government, which is strapped for cash and lacking health workers.While nurses can administer TB treatment, ART has to be administered by clinical officers who are not available at all facilities and laboratory facilities are needed to diagnose TB."It means training health personnel to administer drugs for these two," Sitienei said. "I don't think we have resources to say we can do that immediately... That is the challenge."