Cutting in on the AIDS-TB death dance
ITEACH seeks to raise treatment standards, awareness
On a hill in South Africa's KwaZulu Natal province, near the hall where Nelson Mandela delivered his last speech before prison and the station where Mahatma Gandhi was tossed off a train to begin his life's work, stands Edendale Hospital.
Once one of South Africa's best medical centers, its glory days are long gone. Today, after more than a decade in the center of South Africa's raging AIDS epidemic, Edendale appears exhausted. From the dingy tile floors to the balky elevator doors to the casual disregard for infection control, the 900-bed hospital seems used, worn, and a half-step behind the diseases it exists to fight.
Those who work there acknowledge the risks they take to care for their patients. Tuberculosis bacteria are everywhere, floating in the air of the wards and halls. The staff accept that hazard but hedge their bets, taking the stairs to avoid sharing an elevator's confines with a coughing patient. After months of lobbying by the medical staff, the hospital just recently began distributing respirator masks to use on the tuberculosis wards, where bed after bed of thin, coughing patients lie.
The AIDS epidemic has gotten far ahead of the health care system in this poor part of one of Africa's richest countries. Health care workers move as fast as they can just to keep from falling further behind an epidemic that has already infected 5.5 million and orphaned 1.2 million South Africans, according to the Joint United Nations Programme on HIV/AIDS (UNAIDS). The situation is even more dire in KwaZulu-Natal, one of South Africa's nine provinces. At Edendale, 60 percent of pregnant women at antenatal clinics test positive for HIV, the virus that causes AIDS. Each day in KwaZulu-Natal, 200 babies are born HIV positive, the same number born in the United States in an entire year.
While the hospital's grim reality may keep some people away, Edendale's struggles are what drew Krista Dong, lecturer in medicine at Harvard Medical School, infectious disease physician, and assistant in medicine at Harvard-affiliated Massachusetts General Hospital (MGH) and the Partners AIDS Research Center. The center is headed by Professor of Medicine Bruce Walker, who runs several prominent AIDS-related programs in the same part of South Africa and has encouraged and fostered Dong's efforts.
Two years ago, Dong established a nonprofit called ITEACH, which stands for "Integration of TB in Education and Care for HIV/AIDS." The name recognizes the deadly interplay between HIV and TB. When HIV infects a person's body, it attacks the immune system. As the immune system weakens, the patient is vulnerable to ailments, called "opportunistic infections," that he or she might fight off if healthy. Tuberculosis has emerged as the most deadly of these opportunistic infections and today is the number one killer of HIV-positive patients in sub-Saharan Africa.
South Africa has one of the world's worst tuberculosis programs, from the standpoint of the percentage of patients who complete their six-month treatment course and are cured. In 2007, TB treatment completion rates in KwaZulu-Natal were as low as 32 percent. Before ITEACH started its work at Edendale, Dong said, doctors there ordered sputum tests to diagnose tuberculosis in just 13 percent of suspected cases. The attitude was fatalistic, she said. Almost everyone had tuberculosis, so why bother testing for it, especially if the patient was going to die anyway.
"If the doctor ordered [the test], nobody brought a cup to the patient. If there was a cup, no one told the patient to cough into the cup. If the patient coughed into the cup, the cup didn't make it to the lab," Dong said.
ITEACH established what it dubbed the "TB Warrior" program, assigning two staffers to sit in on the physicians' daily case meetings and ensure that suspected tuberculosis cases get the testing and follow-up they need. The TB warriors' work is relatively simple, but crucial: Make sure cups are available for testing, make sure sputum samples make it to the lab, and make sure lab tests make it to the doctors so they can order medication.
Today, Dong said, between 80 percent and 90 percent of suspected TB cases get a sputum test and results come back within 24 to 48 hours, a vast improvement over the situation before ITEACH began its work.
"There is a huge impact from little things," Dong said.
Dong's work is just one example of an enormous and diverse body of global health research, education, and training across Harvard. Researchers toil away to understand everything from the genetic code of the malaria parasite to the impact of air quality on human health, instructors impart the latest in medical knowledge to top students, and colleagues at Harvard's many affiliated institutions not only teach and conduct research of their own, they also put that knowledge into action to improve people's lives — in Boston and around the globe.
A second ITEACH program is modeled after the TB Warriors, but aimed at another procedural flaw that was costing patients their lives. In South Africa, Dong said, antiretroviral drugs are offered only on an outpatient basis and only to those who complete a three-module training course. Those conditions left severely ill AIDS patients who were admitted to the hospital without a way to get antiretroviral drugs, even if they were dying from opportunistic infections, Dong said. ITEACH established a fast-track program where patients admitted to the hospital who were severely ill with AIDS would be identified, an ITEACH staffer would teach one module of the training program to a family member, and the patient would be started on antiretroviral drugs in as little as a day. The patient would complete the full training course after becoming more stable.
Those are just two of the several ways ITEACH is working to combat South Africa's twin HIV/TB epidemics at Edendale Hospital. They also work in 23 satellite clinics that feed the hospital and in the surrounding community. Dong and her ITEACH team, mostly made up of native South Africans, have worked to link community resources, creating and distributing a guide of programs and services. They are beginning HIV educational campaigns at elementary schools and have launched research programs to inform government and hospital policies.
One such research project is examining whether additional patient-support for those taking antiretroviral drugs can improve drug adherence and clinical outcomes. Thandekile Phahla, the study's coordinator, said the project will follow 450 people who are taking antiretroviral drugs for one year. Ninety of the participants will receive extra support, in the form of regular visits by a counselor, referrals to community services, and other forms of nonfinancial help. The rest will receive just the current standard care of monthly antiretroviral drug distribution. After a year, Phahla said, they will compare drug adherence from each group, as well as how many patients have been hospitalized, what their viral load is, and what their CD4 counts are, measuring immune system function and the disease's progression.
If the study shows that home visits improve outcomes, they can recommend the government begin a new cost-effective support program to enhance its antiretroviral distribution campaign, which began in 2004, Phahla said.
Phahla said the study was created because of the additional burden that poverty puts on the region's AIDS patients. Not being able to afford regular meals interferes with antiretroviral therapy, she said, because it is difficult to take medications on an empty stomach. Counselors who visit patients at home can refer those who can't afford regular meals to soup kitchens and other social welfare organizations.
"Patients have a pill burden. They have no food. Most of them are unemployed, so it's difficult for them to take those two kinds of treatments at the same two times every day. Some of them default. Some of them don't come at all; we are the ones that have to chase them," Phahla said. "Our aim is to get 95 percent adherence."
Dong credits her energetic team for many of the organization's advances. Led by Deputy Director Zinhle Thabethe, the 16 staffers came to ITEACH from a variety of walks of life. What they all share is a recognition of the threat that AIDS and TB present to their communities and a commitment to do something about it.
The program is also helping educate a new generation of physicians about conditions at the pandemic's epicenter. Students from Harvard Medical School and residents from Massachusetts General Hospital visit Edendale regularly, conducting research and assisting the hospital staff.
Peter Hammerman, a resident at Massachusetts General Hospital, was one of two residents visiting Edendale in February 2008. Hammerman said there are significant differences between his experience at MGH and at Edendale. For one, he said, patients at Edendale come into the hospital much sicker than they would in the United States. There are also fewer resources to treat them, he said, with the consequence that more patients die.
"You see things you would never see in the U.S., the ravages of untreated illnesses," Hammerman said.
Alex Herrera, a student at Harvard Medical School and Doris Duke Research Fellow at Edendale, said he's getting valuable exposure to the situation in South Africa.
"The main thing I've gained is a true personal experience and understanding of [the AIDS epidemic]. You hear about it back in the States, but you have to come here to really understand the burden of it," Herrera said.
Despite the advances of the past two years, Dong acknowledged that Edendale's situation remains grim. Patients still come to the hospital too late, filling the wards with the sickest of the sick and presenting doctors with patient after patient on death's doorstep. Hospital procedures are still too slow to adequately respond to health crises. Further, although hospital and Ministry of Health officials are enthusiastic about the reforms that Dong and her ITEACH team suggest, policy changes can be very slow in the public health sector. Tuberculosis treatment remains a problem area, Dong said, with patients still being released into the community too soon — still infectious and having completed just part of their TB treatment program, a practice that fosters the growth of drug-resistant strains.
"If we don't do a better job of meeting the TB demand, we will be systematically machine-gunning MDR-TB [multi-drug-resistant tuberculosis] across the province," Dong said.
Current and former staffers at the hospital echo Dong's assessment of the problem. Siabongire Shezi, chief nurse on the hospital's medical ward for 23 years, said she remembers when people came to Edendale with a variety of illnesses. Today, she said, most people come in with AIDS and AIDS-related opportunistic illnesses, such as tuberculosis and meningitis.
Joy Vanderplank, who ran Edendale's female ward for three years before joining ITEACH recently, said it is easy for hospital staff to get discouraged because they're asked to treat patients with too little equipment, supplies, and manpower. Patients are often sent home before they are well. Back home, the support is often inadequate, and they wind up coming back.
"It was quite challenging to work here," Vanderplank said. "It became draining personally. You didn't see patients recovering, just in and out."
Poverty is an inextricable part of the area's health problem, Vanderplank said. Sick people who have jobs are reluctant to miss work to get treatment, while those who don't have jobs are eligible for government grants as long as they stay sick. Vanderplank said that policy has resulted in AIDS and TB patients purposely defaulting on their medicines and engaging in activities such as selling infected sputum so healthy people can qualify for aid.
"It is hunger and poverty," Vanderplank said. "Poverty is the biggest problem."