Africa's TB Crisis May Spur AIDS Treatment

Cape Town Plan Promotes Test, 'Twins' Approach

KHAYELITSHA, South Africa -- Soon after Andile Madondile, 27, got the double diagnosis of tuberculosis and AIDS last year, his boss fired him and his girlfriend moved out, leaving him with both their leaky shack and their young daughter.

As coughs shook his body during sweaty, miserable nights, Madondile said he fantasized about walking down to the tracks that run through this gritty township, waiting for the morning express train to approach and then leaping into oblivion.

A year later, though, he has come to see those terrible coughing fits as his first step toward recovery. Long before Madondile could accept that he had AIDS, with its heavy stigma of sin and death, he began seeking relief from tuberculosis. Treating one disease became the gateway to confronting -- and ultimately controlling -- the other.

The World Health Organization last month declared a tuberculosis emergency for Africa, where the rate of infections has quadrupled in many countries since 1990. The epidemic, which is especially severe in Khayelitsha, kills more than 500,000 Africans each year, although with proper treatment TB can be cured within six months.

The crisis has been caused by the growing levels of AIDS, which weakens resistance to such infections. The two diseases occur together so frequently that doctors call them "the terrible twins."

But, as with Madondile, tuberculosis can also speed treatment of AIDS by prompting patients to seek medical help early enough for life-saving antiretroviral drugs to work. At a time when the vast majority of those dying from AIDS do not even know they have the disease, TB can serve as a vital early warning sign. In Cape Town, a glitzy seaside city whose boundaries include Khayelitsha 20 miles inland, TB patients now are the largest source of referrals for antiretroviral programs, officials say.

Though such programs still reach only a small minority of those with AIDS in South Africa, they are expanding rapidly in its biggest cities. Cape Town's health plan envisions treating tuberculosis and AIDS increasingly in tandem and having every TB patient take an HIV test.

"It works," said Ivan Toms, city health director, "but it's because the rest of the system isn't working."

A combination of political pressure and increased production of generic drugs has led to a dramatic decrease in the price of antiretrovirals. But treating AIDS on a mass scale in South Africa, where estimates of HIV infections exceed 5 million, has proven far more complicated than just providing medicine.

There are not nearly enough doctors, nurses or pharmacists to prescribe and distribute the drugs. Most public health facilities are poorly equipped and managed. And the disease's stigma remains so powerful that many choose to die at home rather than seek treatment. But here in Khayelitsha, where most of the 400,000 residents live in tiny shacks, one survey showed that 41 percent of adults said they had been tested for HIV at least once -- many times higher than the national average.

Part of the reason is Khayelitsha's stratospheric rates of tuberculosis, and the determination of health officials to offer those with that disease an HIV test as well. In Europe and the Americas, an average of 46.5 out of every 100,000 people contract TB each year, according to WHO statistics. The rate in Khayelitsha is many times higher.

Doctors have found that patients infected with TB are more likely, because of its less-severe stigma, to seek medical help than those with AIDS alone, providing a ready pool of patients to be tested for HIV.