Dr. Grania is a key member of our team working on the development of and clinical trial for a new (faster – cheaper) diagnostic method for TB. She was back in Kampala last month and has posted this update on her Blog.
A key aspect of our plan for the TB project has been to work with the resources available. Doctors and other highly-skilled professionals are a scarce and expensive resource in Uganda, and so for our project to be affordable (and sustainable) we had to use as few doctors as possible.
One of the biggest problems with TB detection and treatment in Uganda is the lack of knowledge about the symptoms and how the treatment works. In particular, patients with TB are usually unaware they need to complete the full course of tablets for the treatment to be successful. CATTS (Community ARV TB Treatment Supporters) are a vital part of addressing this.
CATTS are volunteers from the local community who are given basic training in TB detection and treatment. They are then sent out into the community to visit patients with TB who are on ARV medication. This proactive approach – visiting patients in their own homes, providing advice and guidance and answering the questions they have – helps to ensure they take their treatment correctly.
I had seen CATTS in action in my old job at ReachOut Mbuya, but they were mainly used to assist patients with HIV-AIDS to take their ARV medication. This is an established part of HIV treatment, but despite the “TB” in the acronym I had not seen CATTS provide much TB treatment.
My VSO successor at IHK, Dr Richard, had already delivered TB training sessions for the Touch Namuwongo CATTS – signs and symptoms, treatment, common myths and prevention. I was now going to spend the day with Rose, one of the CATTS, to see how she was incorporating this training into her work.
Rose is a very friendly lady who has been working with Touch Namuwongo for four years. She has 8-10 patients, who she sees at least once a week. Her patients are either on ARV medication, TB medication, or both. Today we were going to see two patients on ARV drugs.
We met at the hospital and set off into the Namuwongo slum that surrounds the hospital. Quickly I lost my bearings in the rabbit-warren of dirt roads and winding shortcuts… this was a world away from the manicured lawns of the hospital grounds. Thankfully, Rose knew where she was going, and soon we found ourselves at the home of her first patient.
Florence was a widow with AIDS who was on ARVs. She lives in a room she shares with her four children. Rose checked that she had access to clean water (to take her tablets), gave her some advice on hygiene and ensured that the mosquito net provided by the Touch Namuwongo project was being used correctly. As we sat down to count her tablets (to check that she is taking them correctly), Rose suddenly launched into a series of questions about how often Florence had sex.
Florence did not appear as shocked by this line of questioning as I was, and mentioned that she was a widow of five years and did not have sex. Not put off by this answer, Rose then asked, “But what about your sexual needs?”
Again Florence answered with a negative reply. Then Rose followed up with “what if you took a man to fulfil you?” My British prudishness was by now in overdrive…
It transpired that Rose was trying to find out if Florence knew how to use condoms if/when she was having sex. After a thorough grilling, Rose was satisfied that Florence was taking her treatment correctly and was doing well. Concerning TB, Rose spoke to her about the symptoms associated with TB and made sure she knew that if she developed a cough, or began to have night sweats or unexplained weight loss, she should let the doctor know at her next clinic visit. Regarding testing her children, Rose said that she had spoken at length to Florence about this in the past. The issue was complicated by the fact that Florence hadn’t actually told her children she has AIDS (because she didn’t want to scare them as they have already lost their father to the disease) but this was something as a CATTS she could continue to advise and support Florence with.
We had some time before our next appointment, so Rose decided it was time for some community education – CATTS are encouraged to educate the wider community on health matters while they are out and about. We entered a small compound where a group of ladies were washing clothes. After introducing ourselves Rose launched straight into finding out what they knew about HIV-AIDS, how it was spread, what to do if your husband is unfaithful, etc.
(I have noticed here that there is almost an expectation amongst Ugandan women that their husbands will have other women. Although Uganda claims to be a mainly Christian country, polygamy is widespread, and the practise of inheriting a brother’s wife if he dies is common. This is one of the reasons why it has been so difficult to control HIV-AIDS.)
Again Rose’s line of questioning quickly became very personal and I was impressed that these ladies didn’t seem to mind us walking unannounced into their compound, interrupting their work, interrogating them about their sex life and questioning their husbands’ faithfulness!
After chatting to these ladies for half an hour or so, we continued on to our next patient, stopping at a local shop for a soda. Rose takes her job as community educator very seriously, so even the shopkeeper was not spared from a grilling. After buying our sodas, Rose launched into the next round of personal questions, this time asking him if he knew how to put on a condom and could he please demonstrate on a pen. Thankfully for the shopkeeper, he passed the test.
Next she enquired if he was circumcised. (Can you imagine the response if you walked into your local newsagent, asked the person behind the counter for a Coke and then enquired about their sexual practises?) Wishing I was somewhere else, the shopkeeper informed us that he wasn’t circumcised but was looking into it. There is actually a reason behind asking about circumcision, as recent evidence has shown that circumcised men are less likely to transmit as well as contract HIV, so advising safe medical circumcision is now part of the HIV prevention message.
The next patient we saw was a refugee from the Democratic Republic of Congo (DRC) with HIV. According to Rose he was “stubborn”, which in Ugandan terms means he has been a challenge to treat. Rose has been working with him for six months, stressing the importance of taking his treatment correctly as well as how to prevent the spread of HIV. His current wife (it is unclear how many wives he may have in the DRC) is not infected, but unfortunately he is not keen to use condoms to prevent her becoming infected.
In the short time I had been with Rose, I sensed that she had a passion for her job and would be a force to reckon with if you didn’t do what she said. She did mention that after a number of forceful meetings with this patient she had improved his compliance with treatment and he was now asking for access to the free condoms provided through the Touch Namuwongo scheme.
My day with Rose provided me with many insights into how the CATTS operate. I was very impressed with her knowledge of various health matters (including TB) and the passion she has to help her community prevent illness and improve their wellbeing. I am glad, though, that I never knew entirely where I was, and that I’m unlikely to bump into the people we met – I am not used to knowing the sexual habits and circumcision status of the local shopkeepers!