The challenges of treating TB in Uganda

Tuberculosis (TB) is one of the world's deadliest infections and a growing concern in Uganda. Each day, close to 240 people contract TB and approximately 30 lose their lives to it.  More than half of TB-related deaths are among people living with HIV, yet it is preventable and curable.

Uganda is one of the world's high-burden countries for TB and each year, approximately 91,000 people get infected. Fifteen percent of these are children below the age of 14 years. Also, two out of every 100 people with TB have drug-resistant TB that cannot be cured by first-line drugs. 

Although Uganda’s target is to end TB by 2030, during the Covid-19 pandemic, there was a 32 percent increase in the number of TB cases in the country, according to Dr Stavia Turyahabwe, the assistant commissioner health services for Tuberculosis and Leprosy Control at the Ministry of Health.

Dealing with latent TB
According to the Ministry of Health, more than 30 percent of Ugandans (12 million people) have latent (inactive) Tuberculosis. This means they have the TB bacteria, which does not make them sick, but they can spread it to other people.

This number, according to the World Health Organisation (WHO), is above the global estimate, which is supposed to be a quarter of a country's population (about 10 million people). 

Although latent TB does not show signs, Dr Turyahabwe warns it can spread to other people through the air when someone who has TB coughs, speaks, laughs, sings, or sneezes. It can also be activated by an infection or a weakened immune system. 

Since ending TB by 2030 is a priority for the government of Uganda, there is need to scale up efforts in the fight against the disease.

“For example, as a way of curbing the disease, the Ministry of Health adopted the preventive treatment strategy for people with latent TB. However, preventive treatment prioritises vulnerable and high risk populations such as people living with HIV, children and adults who live with TB patients (contacts), those in prison and health workers,” she says.

Treatment
Rahma Nakazibwe, a nurse at the TB clinic at Kayunga Regional Referral Hospital, says: “TB preventive treatment is usually given in combination with antiretroviral therapy and lowers the risk of TB disease.

It also helps HIV positive patients live longer, healthier lives. It is given for a period of three months for people living with HIV and six months for those who are negative.” 

She adds that this treatment also protects the risky populations for two years, although their risk may increase thereafter.

Challenges in TB care
Although TB has existed for a long period of time, Joseph Ggita, a population scientist at World Alliance for Lung and Intensive Care Medicine in Uganda (Walimu), says there is limited awareness and so, many people still have misconceptions about the disease. 

“Many still think TB only affects people with HIV, which is not true. Because of this, many face stigma and fear to come out and seek treatment or even tell other people they are sick. This greatly hinders their adherence to treatment,” Ggita says, adding that although patients get free TB treatment, sometimes, the drugs meant to treat some side effects are out of stock, forcing the patients to look for money in order to buy the needed medicines. 

Dr Turyahabwe says a study done in 2018 by the Ministry of Health revealed that 53 percent of people with TB spent about 20 percent of their annual income on seeking TB services as a result of the distance involved in accessing TB management and care.

Some patients have to walk a distance of about five kilometres in order to get the services because they remain centralised at the health centres. 

This becomes very expensive, especially for those with multi-drug resistant TB and hinders their adherence to the drugs.

“TB treatment has to be as accessible as possible through the support of village Health Teams, health centre IIs, clinics and pharmacies closer to patient residences. It is urgent that we rethink how we are offering the services. We need to take TB care closer to the people using the already existing systems,” she says.

Ggita adds that there is a need to transform when, where and how TB services are accessed and delivered.

“Most TB facilities are also very congested, which forces health workers (for their protection) to carry out screening and other services outside the small rooms. This compromises the privacy and confidentiality of patients,” he says.

“Many TB patients do not receive counselling on what the treatment is, how to take the drugs and what side effects they are likely to face, so that they do not get discouraged.  However, they require counselling and continuity of psychosocial support throughout the treatment process since six months is quite a long time,” he adds.

“I call upon stakeholders to ‘close the dent’ in reducing the burden of TB and close critical funding gaps to ensure universal access to TB prevention and care as well as for research, more investments towards supporting the rollout of WHO recommended TB preventive treatment options and shorter TB treatment regimens,’ said minister of Health Dr Jane Ruth Aceng while responding to the report of the review team. 

She noted the lack of awareness of the TB challenge and called for domestic funding and strengthening private not-for-profit facilities by piggybacking on other programmes such as immunisation to enhance community engagement.

Strides
In 2022, the Ministry of Health conducted a door-to-door campaign offering Tuberclosis services and were able to identify 94,000 cases, which surpassed the estimated number of cases recorded by the World Health Organisation. 

“The disease exists in our communities but our surveillance has not been adequate. The way we have been doing contact tracing needs to be strengthened to be able to reach out to more people. We need to benchmark on Ebola and Covid-19 surveillance and contact tracing. We need to strengthen awareness. It may be expensive, but it can be achieved by improving community strategy,” says Dr Stavia Turyahabwe, the assistant commissioner health services for Tuberculosis and Leprosy Control at the Ministry of Health in Uganda.