The TB patients who must sneak into hospital

Faith Kwamboka lives an isolated life. The first time we meet, at her mother’s in-law home in Manga, Nyamira County, she is vivacious with life.

Her smile sits well in her chiselled face, cheekbones prominent like a model’s. She laughs occasionally, laughter stopped immediately by a relentless cough.

That cough is the symptom of a serious kind of tuberculosis, which cannot be treated by the drugs usually used against the disease. Multi drug resistant TB is caused when TB bacteria develop resistance to the powerful first line anti-TB drugs Isoniazid and Rifampicin.

Her condition is difficult to treat, both medically and because of the stigma she faces daily. Data reviewed by Nation Newsplex shows the number of infected people has increased 157 per cent from 2010 to 2014.

The following day, I ask to meet her at the Kiangoso Health Centre, where she has been receiving 14 and a half tablets under strict supervision and a painful injection at 11 o’clock, every day, for the last eight months.

The health centre is about three kilometres from Kwamboka’s home, a beautiful area surrounded by hills and shambas boasting healthy tea plantations. Arriving before Kwamboka, we naturally train our eyes to the gate where patients, mostly women and children, trickle in.

A few minutes after 11 o’clock, Nurse Imelda Kwamboka announces that Faith Kwamboka has arrived, and shocked, we wonder how we missed her. As the nurse takes us through the waiting room to the back of the health centre, she points at a small opening in the fence.

“That has been Kwamboka’s route,” she explains, giving us two reasons. “One, as she is suffering from Multiple Drug Resistant TB which is highly infectious, she is not allowed to mix with other people. She cannot even ride on a motorbike, or shop; she cannot work.”

Kwamboka is accused of defaulting on her TB drugs. That, or taking medicine incorrectly, results in MDR TB, for which treatment takes two years and is more expensive.

It costs about Sh1.5 million to diagnose and treat MDR patients and about Sh4,000 to treat standard TB, says Evaline Kibuchi, the Chief National Coordinator of Stop TB Partnership-Kenya.

SURGICAL MASKS ALWAYS

Ordinary TB is treated in six months, with the World Health Organisation (WHO) recommending that patients should be strictly supported and supervised.

The nurse explains the second reason for Kwamboka’s stealthy entries. “We have to supervise Kwamboka’s intake of the TB drugs, and she has been coming here every day for the last eight months. She has 16 more months to go. This heightens stigma, and she has to use back roads to avoid community scrutiny.”

While saying this, Kwamboka is fidgeting shyly, a shadow of the lively woman we met just yesterday. Each journey she makes to the health centre, using back roads like a criminal, heightens her sense of isolation.

At home, she has been alone with her three children, with whom she is not allowed to have close contact lest she infect them. They’re supposed to wear surgical masks at all times, but Kwamboka says she was told the masks were out of stock at the health centre.                                                                              

But the nurse opens up a new box of surgical masks in our presence, handing each of us one. 

Kisii County, the TB and Leprosy Co-ordinator, Omondi John, says care should be directly observed therapy, he says. If care fails, the patient could default on treatment, leaving him or her at risk of an even more dangerous resistant strain, extensively drug resistant TB (XDR).

NAIROBI AND GARISSA LEAD

According to Kibuchi, there are four extensively drug-resistant TB (XDR TB) patients in Kenya and it costs three million shillings to diagnose and treat a patient, over a period of 36 months.

Treatment for drug resistant TB is supported by the Global Fund. It used to be that patients could only receive treatment for multi-drug resistant TB at Kenyatta National Hospital in Nairobi and the Moi Teaching and Referral Hospital in Eldoret, but devolution of health services has improved things.

Kwamboka is one of two people with MDR TB in Nyamira’s Manga Sub- County. Nyamira in total has 15 cases, while Kisii County has had 20 MDR cases diagnosed since 2012.

That same year, the National Tuberculosis, Leprosy and Lung Disease Program (NTLP) started using software called Tibu Initiative, which records real-time data on TB cases.

Data from the health ministry indicates that new drug resistant TB cases increased from 112 cases in 2010 to 288 cases in 2014, an increase of 157 per cent, with children accounting for five per cent of the cases. Nairobi and Garissa Counties accounted for a quarter of the cases.

The current TB prevalence in Kenya is not known because there has been no national TB survey since 1958. So the country relies on the number of people diagnosed to keep track of the disease. To fill this gap, in 2015, Kenya embarked on a massive survey, with the results yet to be announced.

TB STIGMA

Kisii and Nyamira currently have some of the highest prevalence of HIV among Kenya’s counties.

When a patient is infected with both HIV and TB, a serious condition results. Statistics from the Ministry of Health indicate a gradual decline in the TB HIV co-infection rate among notified TB cases from 45 per cent in 2008 to 35 per cent in 2014.

In these two counties, stigma, which fuels the silent spread of TB and to a larger extent, HIV, is high due to cultural beliefs, according to Felisters Muma, Nyamira County TB and Leprosy Co-ordinator

This is because, according to the Kenya AIDS Indicators Survey, 2012, HIV infected adults and adolescents with a TB diagnosis were more likely to know their HIV status than persons without a TB diagnosis. So people with TB are automatically labelled HIV-positive by the community.

Co-infection is high in both counties. Of the people diagnosed with TB in Nyamira in 2013, 37 percent had HIV in 2015. In Kisii, 35 per cent of those diagnosed with TB were HIV positive in 2015.

Kwamboka is co-infected with HIV and TB.  So in addition to dodging her neighbours to get TB drugs, she takes antiretroviral drugs in the privacy of her home. Their intense side-effects make her feel drunk and lazy, and she sleeps for the greater part of the day.

TB AND MALNUTRITION

MDR-TB patients are not expected to work, and get a monthly Sh6,000 stipend from the government, in partnership with Amref Health Africa.

Kwamboka, who started treatment on November 30, 2015 claims that by June 2016, she had never received a single cent. Muma explains that this is due to transition from the previous donor, Centre for Health Solutions, to Amref.

Without a balanced diet, treatment for MDR TB patients is like torture.  According to the NTLD programme, in 2014, 33 per cent (23,268) of all new TB patients had severe and moderate malnutrition. Among severely malnourished patients, 61 per cent received nutrition therapeutic support.

About one in three people worldwide has latent TB or dormant TB and can fall ill with TB if their immune systems are comprised by say, malnutrition, diabetes or HIV ,according to the WHO.

Earlier, Kwamboka used to take the 14 and a half tablets with water, which would immediately get her nauseated. Today, she took the drugs with maize porridge, which, though not very nutritious, helps somewhat.

DRUNKEN DEFAULTERS

Money is also a bane. In Kisii County, Mr Omondi says most clients with MDR TB are alcoholics.

“They receive the money in bulk for several months, say six, directly to their M-Pesa, and most immediately run with the ‘windfall’ to changaa dens.”

“Though we have 90 per cent of people with TB completing treatment, we have a default rate of four to two per cent, with death rates of people on treatment standing at six per cent,” says Omondi. It is worse in Nyamira, with a 20 per cent default rate, and a nine per cent death rate in 2015.

According to the WHO’s Global Tuberculosis Report, in 2014, there were 246 cases of TB per 100,000 people in Kenya, and an estimated 110,000 cases in total. Of this number, 17,500 people died from the disease.

About half of those who died were co-infected with HIV.

In 2014, Kenya was ranked 14out of 22 highest TB burden countries in the world according to the WHO. The previous year, Kenya recorded a treatment success rate among ulti-grug resistAMT TB cases at 86 per cent per cent, higher than the WHO target of 75 per cent.  However six per cent were lost to follow-up and five per cent died.