As coronavirus rapidly spreads through the developed world, exposing gaps in otherwise well-functioning health systems and devastating relatively healthy populations, doctors in the developing world are bracing ourselves.
As COVID-19 makes its way into communities in the developing world, many more issues will arise for the already vulnerable, highly disadvantaged populations we treat.
Cough, fever, shortness of breath. These are, as we know, symptoms of COVID-19. But they are also symptoms of other infections prevalent in the developing world, such as tuberculosis (TB). For patients in places where TB is common, it must always be considered in the list of potential causes.
TB – considered a chronic respiratory condition – reduces the lungs’ capacity for normal breathing and therefore increases the risk that a patient may develop a severe strain of COVID-19. This is because the virus can have the worst effect on those with existing respiratory issues, as well as people in immunocompromised states, those with cardiac disease, diabetes, or aged above 65.
Human immunodeficiency virus (commonly called HIV) – another disease more prevalent among patients in the developing world – also weakens the immune system, reducing the body’s ability to fight off infections and mount a proper immune response. Like TB, it will also allow COVID-19 to cause a more severe infection in the patient’s body.
The burden of diseases like TB and AIDS (caused by HIV) falls mostly in Africa and Asia, regions with poorer socioeconomic conditions than those that have so far seen the majority of COVID-19 cases.
Because of the under-resourced health systems in these countries, very little research has thus far been done regarding the coronavirus infection among AIDS and TB patients – and whether or not they are at a greater risk of developing severe disease.
Already, multiple factors add to the prevalence of HIV infections in such environments – including poverty, which may force women to resort to unsafe sex work; a male-dominated culture in which there may be gender-based violence, and even when there is no explicit violence, a woman’s freedom to demand that protection be used may be limited.
Stigma surrounding HIV in many communities also means people do not want to test for the disease. This lack of knowledge about people’s own health causes untested and untreated individuals to spread the disease.
The prevalence of TB is also exacerbated by poverty, such as in places where people live tightly packed or in very close proximity to one another, allowing for the easy spread of the airborne disease in their community.
TB and HIV are also usually linked in these contexts. An HIV infection that is not virally suppressed (or well-controlled) increases a person’s risk of contracting TB, and very often we see patients suffering from both.
Although these continue to be challenging conditions, great strides have been made in the treatment of both TB and HIV. It is thought that when a person living with HIV is virally suppressed (or the disease is well controlled), they are not at a higher risk of contracting the coronavirus or developing severe complications from COVID-19 than the general population.
This, however, is not the case for those whose HIV infection is uncontrolled.
If people with TB or uncontrolled HIV contract COVID-19, they can expect to suffer similar symptoms to the general population, such as coughing, sneezing, and a fever. But they will most likely also have shortness of breath, a sign of severe infection, and may require oxygen therapy.
Social distancing and self-isolation have become synonymous with COVID-19 and are aimed at prevention of its transmission. But these recommendations, which are more easily applicable in comparatively affluent communities, are not well-suited to the large proportion of the population in developing countries. The same demographic that carries the highest burden of HIV and TB are those living in informal settlements. They often share small living spaces with multiple people, and it is not possible for them to practise social distancing, let alone self-isolation.
Moreover, hospitals in these contexts are already struggling to cope with many previously healthy patients now requiring admission for COVID-19. This begs the questions: What will happen to those most at risk? Will they fall through the cracks? This remains to be seen as the virus continues to spread in countries with under-resourced health systems.
As with the general public, the recommendations for people living with HIV or infected with TB would not change: hand-washing and self-distancing or isolation would still be recommended, but due to the increased risk of severe disease, patients should not hesitate to go to the hospital to get tested before their condition deteriorates.
To mitigate the dual challenge of the environments where they live combined with the added concern of COVID-19, my advice for people living with HIV and/or infected with TB would be to get tested as soon as possible.
If a TB or HIV-positive patient has symptoms or has been in contact with a person who tested positive for the coronavirus, they should stay home as much as possible, and use a face mask to reduce the chance of infecting others.
One strength of communities in informal settlements, townships or favelas in the Global South is the sense of community between its members. These networks should be utilised.
People should ask neighbours to help them during this difficult time – ask them to go to the shop or to fetch water for them; these small tasks will reduce the need to leave the house. Most importantly, patients should ensure that they have enough chronic HIV and/or TB medication on hand, as defaulting from these regimens could be more detrimental to their long-term health.
We are seeing the coronavirus strain all over the world, with unfathomable numbers of infections in countries that are leaders in healthcare. It would be naive to think that a greater health emergency could not occur in developing nations. With our greater burden of disease in HIV/TB and poor living conditions, it has the potential for even greater impact.
Many governments in Africa have taken the early, proactive step to close their borders and institute isolation measures, including complete lockdowns. Hopefully, this will be enough to flatten the curve and reduce the spread. Time will tell how well these measures will work.
In the COVID-19 crisis, we are all in unchartered waters. While hindsight may be the only way to determine if we followed the right course, we must endeavour to not let the most vulnerable drown along the way.