HIV is known to fuel tuberculosis (TB), but the lesser-known threat of diabetes actually places people at greater risk of getting sick with TB. Screening people with TB for diabetes is advised in the national guidelines, but does not happen routinely in practice.
At the age of 27, Goodman Mkhanda was diagnosed with type 2 diabetes. At 31, he was told he had tuberculosis (TB). A few days later his local clinic in Khayelitsha, outside Cape Town, called him to tell him he had multi-drug-resistant TB (MDR-TB).
“I thought diabetes was for old people but when my mom told me she had it, it made sense because it is passed down in families. But the TB, I was truly shocked,” the energetic man told Health-e News, from the Doctors Without Borders’ (MSF) station on the outskirts of Khayelitsha.
But he shouldn’t have been. Although most people know that living with HIV, because it weakens the immune system, increases your risk for developing TB, most people don’t know that diabetes does the same.
Risk: Diabetes versus HIV
According to a 2014 report in the Lancet Diabetes and Endocrinology medical journal, diabetes is directly responsible for 15 percent of all tuberculosis cases worldwide, because it weakens the immune system.
“Patients with concurrent diabetes suffer worse tuberculosis treatment outcomes, a higher rate of relapse following tuberculosis treatment, and a higher risk of death from tuberculosis than patients with tuberculosis alone,” noted the authors.
The World Health Organisation (WHO) estimated that in 2015 there were 11 percent of new TB cases who were living with HIV.
MSF’s Dr Jenny Hughes, who works with TB patients in Khayelitsha, said that diabetes, in fact, is a higher risk factor for developing TB than even HIV.
“Having diabetes increases your risk for TB by at least threefold compared to patients without diabetes. Patients with poorly controlled diabetes or those on insulin are at even higher risk of getting sick with TB,” she said.
TB and diabetes are both killers
But, she said, there is very little data on TB and diabetes from Africa specifically, making the true burden of the co-epidemic in South Africa largely unknown.
This month Health-e News reported that diabetes is now the biggest killer of South African women and the second biggest killer overall, according to the 2015 death statistics released recently by Statistics South Africa. And TB was the leading killer in men.
Mkhanda himself thought he must have HIV and was surprised when he tested HIV-negative.
“Only then did I find out that TB is a common disease for diabetics,” he said.
Treating the two conditions is already difficult but in March 2014 things got worse.
Although he had endured with pain the daily treatment for MDR-TB, which consists of daily painful injections and a cocktail of oral drugs, for months, he did not get better.
DR-TB and toxic drugs
He was told he had extensively-drug resistant TB (XDR-TB) and he would have to change medications.
According to the WHO, MDR-TB is resistant to two of the most effective anti-TB drugs and has a cure rate of about 50 percent. XDR-TB is resistant to four of the most effective anti-TB drugs but only about a quarter of patients are cured.
Both involve around two years of treatment with toxic drugs with serious side-effects including deafness.
Diabetes develops when the level of sugar (glucose) in a person’s blood is abnormally high. Over time, the high level of glucose in a person’s bloodstream damages the blood vessels, causing strokes, heart attacks, blindness, kidney failure and nerve damage that can lead to amputations.
Although Mkhanda was offered access to one of few new anti-TB drugs on the market, bedaquiline, he still did not get better.
Three years later, he has been offered another new anti-TB drug, has had an operation on his lung and is still on treatment.
“I am finally feeling better but I have to take my medication for about one more year and then I can say that I have been cured,” he said.
Controlling sugar on TB meds
I want to be a living, walking example that having TB doesn’t mean you have HIV too. When you have diabetes your immune system can be weak too, and that is when TB strikes.” – Goodman Mkhanda.
According to Hughes, who treated Mkhanda, it was “extremely difficult” controlling his sugar levels throughout most of his TB treatment and he needed constant monitoring.
“The TB bacterium can also affect glucose homeostasis,” she said.
Patients can develop hyperglycemia – extremely high blood sugar – which can cause complications. This is possibly why we couldn’t get Goodman’s glucose under control while his TB disease persisted,” she said.
It was only after he had surgery on his left lung, and started taking the new drugs offered to him by MSF, that the bacteria started to decline “and then his sugars started coming under control”.
Mkhanda said, “It’s been a long journey and it hasn’t been easy but I am happy to have been able to take bedaquiline and linezolid through MSF.
“But the stigma associated with these diseases must stop. I want to be a living, walking example that having TB doesn’t mean you have HIV too. When you have diabetes your immune system can be weak too, and that is when TB strikes.”
Mkhanda also wanted to draw attention to the stigma patients with drug-resistant strains of the disease face.
Stigma is a stumbling block
“People automatically think you defaulted on treatment, that you had normal TB and stopped taking your tablets. But this XDR-TB, this is the first time I have ever had TB, which means I contracted it from someone else,” he explained.
Just last Friday, on World TB Day, the Lancet medical journal published a report detailing the phenomenon of “incurable TB” which is spreading in South African communities.
Mkhanda said stigma fuels the spread of TB, drug-resistant or not, and needs attention to tackle the epidemic.
“You can get exposed to TB anywhere, at a taxi rank or in any public space; you need to be aware of your risk – especially if you are also diabetic,” he said.
Hughes said national guidelines stipulate that all TB patients should be screened for diabetes but this is not happening routinely across the country.
“If we don’t control our diabetes we could go blind, have amputations or die. Having TB brings the risk of these complications closer. You need to be very careful,” said Mkhanda.
Although he’s down from 35 tablets a day to 11, he will only celebrate the end of years of treatment in February 2018, at the age of 35.
He jogs and goes to gym in his spare time and urges others to lead a healthy life.
“I want to send the message to take care of yourself. And if you suspect anything, go immediately to your clinic to get tested. TB can affect anyone, especially people with diabetes – and it can kill.”
An edited version of this story was published on the Daily Maverick.