LUSAKA, ZAMBIA – Justina Banda, 44, says that because she is HIV-positive, it makes her extra prone to tuberculosis, TB. She has had TB three times, most recently last year.
Though she has completed her TB treatment, she says she stills feels sick often. She is scared that she might have another relapse. She is going for a TB review in a few days.
Banda rents a one-room apartment in the heart of Kanyama, the most densely populated area west of Lusaka, the capital. She says crime, poverty and unemployment plague the area. Its residents live in tiny houses that are linked together and have poor infrastructure. They lack proper ventilation and access to clean water.
She shares the one room with her husband and their six children, some who are in their late teens. The room is their bedroom, kitchen and living room. It is tiny, and, with just one small window, ventilation is poor.
Banda, who learned she had HIV two years ago, says her struggle with TB began in 1996. She underwent treatment but got it again in 1999 and 2010.
“I was told to eat a balanced diet, but hunger is part of our life and it’s a challenge for us,” she says.
Banda’s face is dehydrated, and her body is fragile. She says she is weak because she can’t afford to eat three meals a day, which makes it hard to take the free TB and HIV drugs she receives from the government.
“Sometimes it’s a challenge to take both TB and HIV drugs on an empty stomach,” Banda says. “I struggle to eat required food for a TB patient because I don’t have any source of income, and it has really been difficult for me to take my drugs.”
With a faded chitenge – an African garment similar to a sarong – wrapped around her waist, she knits plastic threads into a handbag, which she aims to sell to raise a few kwachas, the currency here. She used to crush stone and sell charcoal, but her doctors advised her to stop.
“I struggle to work, as I feel weak and my back pains severely,” Banda says. “My children cannot go to school because we cannot [afford] to take them to school.”
Banda says she doesn’t just worry about her own illness, but also about the possibility of infecting her family with TB. Her second youngest child, the only one who is HIV-positive, was diagnosed with TB last year but has recovered. She says it’s a miracle that more of her children haven’t had it considering their close living quarters, but she still worries about their health.
She says her anxiety also grows each day regarding her responsibility to put food on the table. She says her husband, 58, who is HIV-negative, is unemployed and too old to find work.
“My husband is very supportive and reminds me to take my HIV drugs,” she says. “None of us knows how I acquired the virus, but I remember washing other people’s clothes, which had blood.”
Banda washes other people’s clothes as a source of income. She says she hopes she doesn’t have another TB relapse because she is her family’s breadwinner.
“I get tired of taking the TB drugs,” she says. “It paralyzes my duties. I wish there was a way I can avoid getting infected.”
In addition to the health risks created by poverty and malnutrition, doctors say that people living with HIV are extra prone to TB because of their weakened immune systems. Women living with HIV say they are especially susceptible because it is their job to care for the sick, leading to increased exposure to TB. The government, nongovernmental organizations, NGOs, and support groups are working to prevent new TB cases and relapses.
TB is a leading cause of death among people living with HIV here, according to Justin O’Brien, policy, advocacy and communications manager for The Zambia AIDS Related Tuberculosis Project, ZAMBART, an NGO that collaborates with the government and various academic institutions in its aim to improve the quality of life of people affected by the dual epidemic of HIV and TB. About 70 percent of Zambian TB patients are infected with HIV, according to the World Health Organization, WHO.
Zambia has the ninth highest TB incidence worldwide, and the most affected are people living with HIV, pregnant women, children and prisoners, O’Brien wrote in an e-mail. Lusaka continues to fuel the TB epidemic, with the HIV prevalence rate at 22 percent in the capital compared with 14.3 percent nationwide, he wrote. He estimates the TB prevalence at 500 per 100,000 people here, with about 45,551 total TB cases reported in 2009.
TB levels are high in HIV patients mainly because of their weakened immune systems, according to Dr. Nathan Kapata, National TB/Leprosy Program manager for the Ministry of Health, in the Times of Zambia, a newspaper here. TB, caused by a germ in the lungs that can be spread when an infected person coughs or sneezes, is easily passed among people living closely together, according to Kapata in the Zambia Daily Mail, another newspaper here.
Dr. Peter Chungulo of ZAMBART says that poverty and malnutrition, or undernutrition, also contribute to the transmission of all forms of TB – new cases and relapses.
“Poverty leads to poor sanitation and ventilation – poor infection control and overcrowding – which are the drivers of TB,” he says. “Undernutrition reduces immunity and hence promotes TB infection. TB patients who are undernourished may not have a good outcome of their treatment. Recovery from any illness needs good nutrition.”
Chungulo says relapse means that a patient improves while on treatment but becomes ill again after stopping treatment. He says this occurs usually six months after treatment to patients who are not taking drugs regularly and according to instructions.
Stella Maliwa, secretary for Langa, a local HIV support group, says TB is especially a problem for women living with HIV.
“We are at high risk,” says Maliwa, who is HIV-positive. “HIV-positive women here take up the responsibility of caring for the sick.”
She says women are the caregivers who look after chronically ill TB patients, but that most of their houses have just a little window or no window at all. She says the women also lack protective garments against TB, and, as a result, many acquire TB from the patients.
“Most HIV/TB positive women are not empowered, yet they have to look at their families and care for the sick,” she says.
The Strengthening TB, AIDS and Malaria Prevention Programme, STAMPP, aims to strengthen the existing prevention, treatment and care strategies at the community level. STAMPP is funded by the European Union and implemented by three NGOs – ZAMBART, CARE Zambia and Kara Counseling and Training Trust.
Chungulo says his organization, ZAMBART, has been implementing isoniazid prevention therapy, IPT, for STAMPP. He says the purpose of the program is to prevent the reactivation of TB in people who are living with HIV. He says people living with HIV are first screened for TB and only those found to have no TB are put on IPT for six months.
The government is also working on the STAMPP project. According to Kapata, the National TB Control Programme has also been successfully implemented, thanks to the government, which has ensured the availability of drugs and diagnostic equipment recommended by WHO.
TB drugs are free, but there is a minimum laboratory free to test one’s sputum – the mucus and other matter brought up from the lungs, bronchi and trachea.
Zambia has attained its target of 85 percent for its TB treatment success rate in recent years, according to a 2010 progress report by the United Nations. But the report cautioned that adequate resources are necessary to sustain progress and tackle the root causes of HIV/AIDS, TB and malaria in order to meet goal six of the Millennium Development Goals, a global anti-poverty initiative, to reduce these diseases by 2015.
The Sixth National Development Plan 2011-2015 emphasizes TB research and aims to expand access to appropriate care, support and treatment for people living with HIV/AIDS, their caregivers and their families – including services for TB.
Chungulo says TB can be reduced here with a special focus on vulnerable groups. He says there is a need to implement the three I’s: Intensified case finding, Isoniazid prevention therapy and Infection control. O’Brien wrote that Zambia-South Africa TB and AIDS Reduction, a seven-year study funded by the Bill & Melinda Gates Foundation, aimed to operationalize the three I’s, the WHO-recommended strategy, in 16 sites across Zambia. ZAMBART aims to partner with the Ministry of Health to implement them and other TB-HIV initiatives nationwide, he wrote.
In addition to the efforts by the government and NGOs, there are also support groups that aim to empower women with HIV and TB here. Maliwa of the Langa support group says that empowering women with prevention tools and HIV/TB support groups with financial funding are key to TB reduction.
Banda says she joined the Langa support group to gain knowledge about TB prevention.
“I am a member of a support group where [I] am learning on how to prevent myself from TB, and I hope in [the] future our group will be funded to support us financially,” Banda says.
She says she also hopes to learn how to earn a better living from the support group in order to improve her and her family’s health.
“I hope to find a source of income and live in an environment where I will be free from TB relapse,” Banda says.
