Liberia Records Progress In HIV, TB Response….But Challenges Remain Enormous

By: Reuben Sei Waylaun

Fellow, AAMIN Health and Human Rights Journalism Fellowship

As part of effort in responding to the spread of HIV and Tuberculosis (TB) in Liberia since the World Health Organization (WHO) declared the country as one of the high burden countries, the National Tuberculosis and Leprosy Control Program (NTLCP) and the National AIDS and STIs Control Program (NACP) of the Ministry of Health say significant gains have been made in providing treatment for Tuberculosis patients (TB) and persons living with HIV respectively.

Tuberculosis (TB) is a variable communicable disease of humans and some other vertebrates that is caused by the tubercule bacillus. It affects especially the lungs, but may spread to other parts such as the kidney or spinal column, and is characterized by fever, cough, difficulty in breathing, formation of tubercules, caseation, pleural effusion and fibrosis, while HIV (Human Immunodeficiency Virus) is a virus that attacks the body’s immune system. If HIV is not treated, it leads to AIDS (Acquired Immune Deficiency Syndrome).

According to the World Health Organization (WHO) report of 2017; TB incidence in Liberia for the year 2016 was 308/100,000 population compared to 242/100,000 in 2000 [2]. Liberia is among the high TB burden countries in Sub-Saharan Africa

Reporting progress about TB, the Program Manager of the National Tuberculosis and Leprosy Control Program (NTLCP), Ernest Choloplay said the number of notified TB cases reduced from 8,733 in 2012 to 6,000 prior to the outbreak of Ebola epidemic in 2014.

The National Tuberculosis and Leprosy Control Program (NTLCP) has increased the number of treatment facilities to 333 across the country.

However, Mr.  Cholopray was quick to point out that the program has suffered at the hands of Ebola in 2014 and currently with COVID 19. According to him, every activity of the TB Program got stalled in 2014 due to the Ebola virus Disease (EVD) outbreak derailing all of their gains made, noting that while the Program was picking up, then came COVID-19 pandemic eruption that increased set-back to TB control in Liberia

“COVID-19 and TB signs and Symptoms are common but every focus was placed on mainly COVID-19. Due to this, no medication, or help from international partners, and we actually ran out of supplies. All of our efforts reversed completely and TB incidence has risen to 314 per every 100, 000 persons of our population,” Cholopray said in an interview with Anti-AIDS Media Network specialized health and human rights reporters at his Congo Town office.

Currently, the National Tuberculosis and Leprosy Control Program (NTLCP) Program Manager said HIV and TB incidence is 44 per every 100, 00 population and Multi Drugs Resistance (MDR) is 7.5 per every 100,000 of the country’s population.

He said mortality rate stands at 56 per every 100,000 persons; while HIV positive stands 46 per every 100,000. According to Mr. Cholopray, multidrug resistance (MDR) is antimicrobial resistance shown by a species of microorganism to at least one antimicrobial drug in three or more antimicrobial categories.

Speaking further, Choloplay said new cases of MDR stands at 2.5% due to no treatment or patients just starting drugs, and that most often MDR cases last up to two years for full completion or full recovery.

“Normal treatment takes eight-to-nine months. Currently, our treatment coverage is 48% and globally we need to be 90% according to WHO. According to WHO National Statistics, we were progressing, but the COVID-19 outbreak has made us to regress.  However, we have been making tremendous progress in creating the necessary awareness. We are in partnership with others on this,” Mr. Cholopray said.

The NTLCP Program Manager cited specimen transportation after screening, lack of fees for patients to treatment centers, food among others as some of the major challenges confronting the institution.

Mr. Cholopray: “We have initiated specimen transportation where we are engage into specimen collection, suspected patients are asked to produce sputum and treatment should be without default and we ask  a family to provide care and after full completion. We provide certificate, lack of follow up interrupts treatment and current rate of this situation is 29%.

He indicated that “every TB patient is screened for HIV because we presume them to be positive due to vulnerability. This is because HIV weakens the immune system. The Liberia National Leprosy and Tuberculosis Control Program has worked to expand access to the international standard of care for tuberculosis, DOTS (Directly Observed Treatment) Short courses”.

For her part, the Program Manager of the National AIDS and STIs Control Program (NACP), Dr. Julia Toomey-Garbo

Liberia was initially between 74 and 77%, but with improved coordination and collaboration, they are above 90% level in term of those presumptive of TB cases are tested for HIV. She disclosed that test kits are readily available to all facilities for HIV testing.

The National AIDS and STIs Control Program (NACP) and the National Tuberculosis and Leprosy Control Program (NTLCP) are charged with the separate responsibilities to drive the National HIV and TB response. Both institutions collaborate on TB and HIV co-infection related issues.

“From the HIV Program perspective, all of the patients that come to the facilities for HIV treatment are screened for TB on a regular basis, so, if you were to come on a monthly basis for your refill, when you come to the facility you are assessed for TB using the World Health Organization (WHO) symptomatic approach (four symptoms that include: Cough, night sweat, weight loss, and fever)”.

She said “these four symptoms are used and once the person responds to yes to one or two of those symptoms, the person is referred for TB diagnosis, but most time those people are immune compromised. The TB is also immune compromised disease, if you do sputum, sometime they don’t produce it, and if they produced it, sometime it is negative. So, the WHO is pushing for G-Experts, which is a molecular test and diagnostic tools to be used in screening for TB among people living with HIV (PLHIV).”

Molecular testing is a laboratory method that uses a sample of tissue, blood, or other body fluid to check for certain genes, proteins, or other molecules that may be a sign of a disease or condition. Molecular testing can also be used to check for certain changes in a gene or chromosome that may increase a person’s risk of developing cancer or other diseases, according to WHO Facts Sheet 2021.

Regarding TB, Dr. Toomey-Garbo NACP has introduced what she calls isle-nasals preventive therapy or TB preventive therapy.

According to her, if the person is screened for TB and such person doesn’t present with any sign and symptom of TB, the person is placed on preventive therapy and if the person is TB positive, the person is initiated on TB and HIV treatment. She said the timing varies because if the person was just coming and tested for TB and positive and also tested for HIV and positive.

“The person will be initiated on the TB medication and tolerate it between two to four weeks, the person will be initiated on ARV drugs interaction,” Dr. Toomey-Garbo said.

However, the NACP Program Manager said continuous discrimination and stigmatization against persons living with HIV and tuberculosis in the country are serious storming block toward Liberia meeting reducing the spread of the diseases.

 “There is still issue of stigma and discrimination. There is stigma ranging from community, family, friends and even health facilities. So we designed strategies where peer-HIV educators who have accepted their status and disclosed to family members and other people go into the community and carry out de-stigmatization campaign that people should know that HIV is not a death sentence, if you have HIV you can live normal life like somebody who doesn’t have. HIV is just a chronic disease like diabetes, hypertension among others,” the NACP boss said. 

“People living with TB are also experiencing stigma and discrimination as well. During those days people living with tuberculosis were thrown into the evil forest because people believe that it was evil that befell them. So, it is the same thing in the communities. Everyone is exposed to TB, but because we are healthy the bacterium is suppressed….once we have immune compromised situation like malnutrition conditions, the bacterium begins to multiply, and we begin to develop active TB,” she said.

Dr. Toomey-Garbo, who spoke to a team of Ant-AIDS Media Network Specialized Health Reporters, said the Program has over the years partnered with the National Leprosy and TB Control Program to ensure that patients who are tested for TB are also tested for HIV.

Dr. Toomey-Garbo further highlighted as challenges, financial and human resources for health, infrastructure and supply chain   confronting the national HIV response.

 “We have numerous challenges ranging from resources, [financial and human resources], infrastructure and supply chain, that is getting the commodities from the manufacturers to the end users and it takes about six to eight months to be distributed from warehouse to counties and facilities and it has been an issue. By right, we should have four distributions per year, but we doing at most three distributions per year, some of the commodities can expire in the warehouse and county levels,” she said

This story was made possible through the professional intervention of Anti-AIDS Media Network (AAMIN), with funding from the American Jewish World Service (AJWS).