The Story of Jui
Tuberculosis and HIV/AIDS in Thailand
Von Mieke Ponnet / Caritas Schweiz
Camillian Social Centre and Médecins sans Frontières-Belgium care for people living with HIV and AIDS. Although none of us runs a TB-project, we are daily confronted with this disease. Of the 19 HIV-positive children living in Camillian Social Centre, three children had or have TB. To illustrate which problems we face related to TB, we tell you the story of Jui.
Camillian Social Centre is a relief centre for people living with HIV and AIDS. It is located in Rayong, about 2 hours driving from Bangkok, the capital of Thailand. Father Giovanni Contarin from the Camillus Congregation is responsible for the centre. It is home to about 50 adults living with HIV and AIDS and 23 children, of whom 19 are HIV-positive. Mdecins sans Frontires-Belgium has close links with the centre: An MSF-B nurse comes two days a week to the centre for the medical follow-up, and an MSF-B doctor comes twice a month and looks after the children in the centre.
People living with HIV and AIDS have a lower immunity, this means they have difficulties defending themselves from infections. One of the most common infections is tuberculosis (TB). The Mycobacterium tuberculosis is spread from human beings to other human beings only. If a TB-patient has a so called cavern in his lungs and he coughs, he spreads the pathogen in the air. Via small particles in the air the pathogens can be transferred to another person. If this other person has a normal immunity, probably nothing will happen. If this other person has a low immunity, for instance because of AIDS, the person is more likely to develop tuberculosis.
Jui is a 10 years old girl. She is HIV-positive as all the other people living in Camillian Social Centre. As her immunity was very low, she started receiving anti-retroviral treatment: 3 drugs that can lower the number of viruses in the blood. One month later she developed a large swelling of the left side of the neck. As it was getting bigger she was sent to the regional hospital for further investigations. The girl stayed in the hospital for two weeks but no investigations were done, although she received antibiotics. The MSF-B nurse went to see Jui and the doctors of the hospital. The nurse discussed the possible diagnoses with the doctors and finally the investigations were done. Not surprisingly the diagnosis was TB. Jui was put on anti-TB treatment by the hospital. But, instead of the usual 4-drugs-regimen, she was only put on 2 drugs. As this is not standard of care, and not according the Thai national guidelines, two more drugs were added by the MSF-B nurse working in Camillian Social Centre.
The case of Jui is a good example of the problems we face in our daily work. Because we believe it is important to work with the local health system, we send people to the nearest hospital for investigations. People living with HIV and AIDS should be treated in the normal health care system. But people in general, even health care professionals, fear HIV. They are scared of people living with HIV and AIDS. This is the reason why necessary investigations are not done or delayed. If one of our nurses goes to the hospital and talks with the doctor, it is often possible to get the investigations done. We do not blame the doctor in that particular hospital, but we believe that the attitude of the treating doctor is a crucial factor in the decision if investigations will be done.
From our experience we know that children - and adults - living with HIV often do not receive anti-TB treatment or receive sub-optimal anti-TB treatment. In Thailand there are very clear national guidelines providing the necessary medical information. These guidelines are known by the medical profession. But again the attitude is important. If the doctor believes it is not useful to treat people living with HIV and AIDS because they are going to die anyway, then it is difficult for them to get treated. Not everybody has the chance to get anti-retroviral therapy as the child in the given example, but people living with HIV and AIDS still have the right to be treated for their tuberculosis.
In Thailand there is a National TB Control Policy (consistent with DOTS therapy): the implementation is expanding rapidly. Although this is positive news, it does not address the mentioned problems. In Thailand some NGOs provide an attitude training for health professionals, but it is impossible to give such a training to all health care professionals. So a nurse asking for information about the treatment of a client can be a first step. Ideally the patient should be empowered and ask that information, but in the case of a child it is not feasible.
Especially in countries with a high TB-incidence it is important that the health care providers have a good attitude towards people living with HIV and AIDS. It is the only way they can get the correct treatment in case they are diagnosed with TB. This statement is independent from the fact of a good national TB control policy is on place or not.
*Mieke Ponnet, MD, Medecins sans frontieres-Belgium, Thailand, firstname.lastname@example.org . The Camillian Social Centre in Rayong has been supported by Caritas Switzerland since 1996.