Miss Margaret Akinjide, a 24-year-old student of Ogun State University, Ago-Iwoye tested positive to HIV last October. She was very sick, weak and had cough suspected to be tuberculosis. Owing to the state of her health, especially the cough, she left school temporarily.

In search for solution, she was taken to the clinic at the Nigerian Institute of Medical Research (NIMR), Yaba, Lagos, where, fortunately, there is collaborative treatment for HIV and tuberculosis.

Margaret, who is yet to start anti-retroviral treatment, was first treated for tuberculosis because of the severity of the cough.
“I had sleepless nights, I cough all through the night,” she told Daily Sun.

Barely a month after starting the TB drugs, Margaret regained her health. The coughing stopped. She was no longer weak and sick. She regained her weight and is back in school.
She said: “Since I started the TB drug, there has been tremendous improvement. Before now, I was having frequent malaria, almost every other week, sometimes at intervals of two days. It was just regular. But since I started taking the TB drugs, it has been different.

“I’ve not been the lazy type. Whatever the sickness, I try to move on. Before I started on the TB drugs, I could not stand. All I could do was to lie down. If I tried to stand up, it was as I would fall down. But since I started on the TB drugs, I am very strong. I go about my normal activities.”
Margaret is not the only person living with HIV, who has had this experience. Thelma Elegbede, a 26-year-old hairdresser, had malaria and typhoid. In the course of investigation and treatment, test result in January 2007 revealed she had HIV. She was coughing excessively.

According to her, “I was coughing terribly, I was very weak. They used to carry me about, bathe me, take me to toilet, I lost much weight, I couldn’t talk, I could not do anything. I was very weak. I was brought to the clinic at NIMR. Doctors directed that I should be placed on TB drugs because I was coughing. I started taking the drugs few months ago, now I thank God I am fine and okay. I have regained my weight. I have returned to my business.”

Speaking on HIV-TB collaborative treatment, Dr. Dan Onwujekwe, Principal Research Officer, Nigerian Institute of Medical Research, said: “We saw a lot of TB cases here, which were difficult to diagnose. If you follow the strict TB approach, you will not be able to put your finger on TB in many people with HIV. Perhaps, you will need to do microscopy.

“We are using all kinds of approaches to improve case finding. We begin from the first port of call of any patient diagnosed of HIV, and we ask questions to screen whether the person has symptoms of TB. We do that to see if we can identify the patient early, do test and put the person on TB treatment.
“If the person is coughing, we do this more quickly as a way of reducing the transmission of TB infection among people living with HIV who are in the same waiting areas.” Similarly in the TB clinic, when somebody comes without a known HIV status, after seeing the person, they also refer the person for voluntary HIV counselling and testing.

“So, that is the kind of collaboration we are doing, and we believe that has helped in detecting HIV and TB cases and decide how best to manage them from beginning.”
On approaches to detect TB, he said: “We have many approaches to detect TB first of all, we are using symptoms-based questionnaire to screen people for symptoms of TB. We use questionnaires, because there are three to five questions when answered can reveral symptoms of TB. We use them as the first step in screening. Also for those who are coughing, we use the sputum-smear method or direct smear for diagnosing TB. We also use x-ray. Everybody with HIV infection is sent for x-ray of the chest, as a matter of screening for TB. Those are the three methods we are using.

On how to approach patient with dual infection of HIV and TB, Onwujekwe said: “If we see somebody who has been confirmed to have TB-HIV co-infection, we would want to initiate TB treatment first because we are sure it is TB that may kill that person and may make the person sick if not diagnosed and treated. There is a cure for TB.

“TB and HIV collaborate within the cell of the individual, and both of them amplify the effect of the other. So, we believe that by initiating TB treatment first, watching out to see how the person responds to it, the person will respond to anti-retroviral treatment better. And this approach was borne out of practice.

“The first thing we will do is to diagnose TB, with anybody with HIV. If he has TB, we begin treatment. We watch out within two weeks to one month if he is doing well. We then commence anti-retroviral therapy. In commencing anti-retroviral therapy, we want to avoid drug that will interact negatively with the anti-TB.

“Any anti-TB treatment that does not have Rivampfucine as part of the back-bone will not work. It’s not likely to work. We value preserving Rivampfucine, using as much as possible in managing TB. We will not give the person Nevitapine, if we are starting anti-retroviral therapy. We will prefer to give the person Efaverance because of the interaction between Rivampfucine and Efaverance. Both of them will be effective in managing both the HIV and TB.

Any health worker who manages HIV-TB co-infection must bear in mind that you cannot give the person Rivampfucine as well as Nevitepine and expect the person to be cured of TB. And also expect the person to do well on anti-retroviral treatment, because you are killing the two backbones.”
Speaking on why they are encouraged by this method, he explained: “At the beginning, when we started this clinic in 2002, we saw many of people who got worse when anti-retroviral was started. Some of them came here and cried that since they started taking the anti-retroviral, their illness became worse
“We were challenged.

That challenge made us to educate ourselves, read more books, go to internet, look for help, so that we would understand what was going on in our patients. We had much awareness about TB. Lucky enough, Harvard PEPFAR came in, and encouraged us to screen everybody. We said x-ray are not part of the national programme. We don’t want to be accused of doing things that are not acceptable in developing countries. But we had to make a case.

We monitored the number of TB cases we were seeing.
“We were seeing that atimes 60 per cent of the patients had TB. TB disease, not TB infection, sometimes, we saw that 45 per cent of the patients had TB. That made a case for making screening for TB part of the protocol for managing HIV. You must screen them for TB, and you must screen them again every year. That was what encouraged us and we saw ourselves succeeding.

“We take their address, telephone numbers, because of follow-up. It is becoming intractable now because we are busy. At the beginning, we had all these details so, that we could follow up. We also give then our phone numbers to call us if they had a problem. We were coping, but now it is too much. There is a new home-based care treatment that we are trying to implement. So that if we can’t visit them, we get people to visit them, find out what is happening. In all these things we found out again that most of the people we were not seeing again had died. When you check their records, you see they had TB. Some of them were placed on TB treatment. Those of them who were really very bad.

Onwujekwe disclosed that they have management protocol that ensure that people treated for TB do not come down with TB again in future. His words: “INS prophylaxis, which is the prevention treatment for TB, using one of the drugs for TB is known to be very beneficial in preventing TB re-infection. But the National TB Control programme is very uncomfortable with the universal application of INS prophylaxis. The reason is that it is one of the key drugs for treating TB disease. Giving anybody who is infected with TB INS prophylaxis, you are likely to bring resistance. And we say we don’t have second line drug yet.

“So, prophylaxis is not yet admitted in the country as a management approach for preventing TB in people with HIV. But on our own, we are giving what we call secondary prophylaxis. You can call it a renegade approach. People who have been treated for TB and have been cured, are given what we call secondary INS prophylaxis for six months after stopping their TB treatment, so that we can push away the possibility of re-infection within a short time.

“And we are also trying to use administrative approaches to reduce the rate of re-infection. By this I mean, we are trying to reduce waiting time for people with cough in the waiting room, where the patients are waiting. People who are having cough, we try to identify them when they are registering, and make sure a doctor sees them quickly.