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TB in Zimbabwe: A silent explosion propelled by HIV
Southern Africa AIDS Information Dissemination Service (SAfAIDS)
November 07, 2007

Tuberculosis (TB) is out of control in Zimbabwe. With years of health system neglect, one of the most severe HIV epidemics in the world, and the stark social and economic conditions many of its people have to contend with, prevention and control of TB is increasingly desperate.

As one of the world's highest burden countries, Zimbabwe already has some shocking TB challenges to address. In absolute numbers, the country is the 20th most TB-affected nation in the world. Factor in overall population size and that position rockets to seventh on global rankings.

Adding to the complexity, a significant proportion of TB in Zimbabwe may not be easy to identify. WHO estimates that just under half of its TB disease can be detected using the established TB diagnostic test: the 'sputum smear'. But with limited testing services available - including only one laboratory able to carry out key bacterial culture and drug sensitivity tests - many cases of TB either go undiagnosed or are treated without an accurate diagnosis. As a result, TB treatment in Zimbabwe often relies on a doctor's ability to recognise the disease, or on guesswork.

And yet, just a couple of decades ago, the country won acclaim for its successful TB programme. That was before HIV changed the TB control equation.

"Since 1954 we have had a very successful fight against TB, to the point where the association declared that the war on TB had been won," remarked Ellen Ndimande of the Zimbabwe Association for the Rehabilitation and Prevention of Tuberculosis (RAPT). "But the past few years have shown us that the disease has re-emerged to become the number one killer of people with HIV."

HIV weakens the immune system, making people living with HIV (PLHIV) up to 50 times more susceptible to TB infection and disease. Even the potential benefit of antiretroviral (ARV) treatment is in doubt, because PLHIV with TB often seek treatment before ARVs are prescribed, or go undiagnosed.

In 2002, the Government of Zimbabwe declared HIV a national emergency but, at the epicentre of the HIV epidemic, Zimbabwe now has six times the number of TB cases that it did 20 years ago.

HIV is also be undermining the government's response to TB in other ways. According to Zimbabwe's Minister of Health and Child Welfare, David Parirenyatwa, not enough has been done to tackle the growing threat.

"I have to admit, as a government, we have not done enough to address the issue of tuberculosis, and this is something that I have stated publicly," he said in an interview with Partners Zimbabwe. "The focus on HIV has largely driven our attention from TB, and this is something we have to redress as a matter of urgency."

"We recently launched the fixed-dose combination for TB treatment, which will make it easier for the uptake of drugs and adherence," he added. "But much more work needs to be done to integrate TB and HIV. My ministry needs to push up the management systems in order to have appropriate advocacy on TB."

Little is known about how big a problem drug-resistant TB is in Zimbabwe, although conditions appear to be ideal for multi-drug resistant (MDR) forms to flourish. MDR can emerge as a result of incomplete or inadequate TB treatment, such as when antibiotics are taken for too short a time. According to latest WHO data, Zimbabwe already has the lowest treatment success rate among all the TB high-burden countries, with only just over half of all cases successfully treated. Without a complete course of antibiotics, the remainder stand a good chance of TB recurring in a drug resistant form. And this can only get worse, as current fuel shortages dramatically cut transport options, making trips to clinics - and as a result, TB drugs adherence - even more difficult.

Paradoxically, sky-rocketing inflation has also made migration to neighbouring countries for work even more frenetic. And porous borders between Zimbabwe and South Africa provide a convenient gateway for drug resistant TB to take the same path.

"We are sure that we are seeing multi-drug resistant TB, but because there is no laboratory that can do the culture or sensitivity tests we don't have the evidence to prove it," commented Lynde Francis, Director of The Centre, a community-based care facility in Harare. "The government is saying that because we do not have any drugs for TB patients there is no point in testing for multi-drug-resistant TB."

"One result of this lack of support and information is that people with TB are starting to face almost the same social stigma as people with HIV," Francis added. "Many now believe that a positive TB test automatically means you are HIV positive as well, and so they are avoiding even getting tested."

Diagnosis, management and treatment of TB in Zimbabwe, particularly among PLHIV, cannot be improved without significant increases and acceleration of investments in services, as well as in patient literacy about TB.

In June 2005, a proposal to strengthen the national TB control programme was submitted to the fifth round of the Global Fund to Fight AIDS, Tuberculosis and Malaria. A year-and-a-half later, the grant agreement was signed (December 2006), and today about one-third of the US$ 12 million funds has reached the country and implementation is just commencing.

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