Introduction
Malawi is gripped by a twin epidemic of AIDS and tuberculosis (TB). In 1999, the country had an estimated 800,000 people living with HIV/AIDS1, and 24,396 registered cases of TB (source = National Tuberculosis Programme). Health workers have little hesitation in considering TB as a possible diagnosis, but the same cannot be said of AIDS. AIDS is still a highly stigmatised disease, and there seems to be reluctance by health workers to label patients with this diagnosis or refer patients for voluntary counselling and HIV testing (VCT). We carried out a countrywide cross-sectional survey to document i) the principal working diagnoses in medical in-patients, ii) the frequency with which TB was considered in the differential diagnosis and investigated by sputum smear examination and iii) how often AIDS or a synonym of AIDS was written in the case file or a referral made for VCT.
Methods
All 44 district, mission and central hospitals in Malawi where TB registration and treatment takes place were visited between April and June 2001. In each hospital, all adult non-fee paying medical in-patients aged 15 years and above who were in general or medical wards were seen. Case notes and treatment cards were inspected, and data related to the study objectives were collected into structured proformas. Patients who were already registered and receiving treatment for TB were not included. Data were analyzed using EPI-INFO 6.04 software. Proportions were compared using X2 test, differences at the 5% level being regarded as significant.
Results
There were 1536 patients, 695 men and 841 women, whose mean age (SD) was 37 (14) years. The top 10 working diagnoses in men, women, and all patients, are shown in the Table.
Table.
Top ten working diagnoses in medical inpatients in Malawi hospitals
| Male Diagnosis |
No. | (%) | Female Diagnosis |
No. | (%) | Total Diagnosis |
No. | (%) |
| Tuberculosis* | 127 | (18.3) | Tuberculosis** | 180 | (21.4) | Tuberculosis*** | 307 | (20.0) |
| Pneumonia | 116 | (16.7) | Pneumonia | 168 | (20.0) | Pneumonia | 284 | (18.5) |
| Malaria | 72 | (10.4) | Malaria | 109 | (13.0) | Malaria | 181 | (11.8) |
| AIDS | 39 | (5.6) | AIDS | 38 | (4.5) | AIDS | 77 | (5.0) |
| Anaemia | 25 | (3.6) | Anaemia | 38 | (4.5) | Anaemia | 63 | (4.1) |
| Heart failure | 25 | (3.6) | Gastro-enteritis | 32 | (3.8) | Heart failure | 50 | (3.3) |
| Meningitis | 24 | (3.5) | PID | 25 | (3.0) | Gastro-enteritis | 49 | (3.2) |
| Stroke | 19 | (2.7) | Heart failure | 25 | (3.0) | Meningitis | 45 | (2.9) |
| Ascites | 19 | (2.7) | Meningitis | 21 | (2.5) | Ascites | 40 | (2.6) |
| Bacteraemia | 17 | (2.4) | Ascites | 21 | (2.5) | Bacteraemia | 37 | (2.4) |
| Total | 483 | (69.5) | 657 | (78.2) | 1133 | (73.8) |
No. PTB 113
No. EPTB 14
No. PTB 164
No. EPTB 16
No. PTB 277
No. EPTB 30
Legend: PID = Pelvic Inflammatory Disease PTB = Pulmonary TB EPTB = Extrapulmonary TB
TB was the most common principal working diagnosis, while AIDS was fourth. In 614 (40%) patients, TB was considered either as the principal diagnosis or in the differential diagnosis, and in 572 (37%) patients sputum specimens had been requested for AFB examination: there were no differences between men and women.
In 223 (15%) patients, AIDS or one of its synonyms was mentioned in the case files (this included patients with a principal diagnosis of AIDS), and in 138 (9%) VCT had been requested: there were no differences between men and women. Fifty six patients had a principal working diagnosis of Kaposi's Sarcoma, chronic enteropathy, cryptococcal meningitis, Pneumocystis carinii pneumonia, or oesophageal candidiasis: AIDS was mentioned in 24 (43%) and VCT requested in 20 (36%) of these patients. Three hundred and seven patients had a principal working diagnosis of TB: AIDS was mentioned in 43 (14%) and VCT requested in 26 (9%). AIDS was mentioned in the case files more frequently in mission (21%) and central (17%) hospitals compared with district (11%) hospitals [p < 0.05]. Referrals for VCT were low in each type of hospital (mission - 11%; central 11%; and district - 8%).
Discussion
This cross-sectional study highlights the enormous burden imposed on hospitals by the TB epidemic. Many patients are considered for possible TB, and in over one-third sputum specimens are being requested for laboratory AFB examination. Seventy seven percent of TB patients in Malawi are HIV-seropositive2. In Queen Elizabeth Central Hospital, over 70% of all medical in-patients are HIV-seropositive (Zijlstra, personal communication), in keeping with findings from other African countries3. Despite this, AIDS is infrequently written in case files, even when diseases which are almost always associated with HIV, such as Kaposi's Sarcoma or cryptococcal meningitis, are diagnosed. There are few referrals for VCT, even in patients with suspected TB or a classical HIV-related disease.
Stigma and the absence of anything to offer a patient labeled with a diagnosis of AIDS are the likely explanations for not mentioning the diagnosis of AIDS in case notes or referring patients for VCT. However, changes have to take place if Malawi is start winning the battle against HIV /AIDS. Modeling studies in East Africa have demonstrated the cost-effectiveness of VCT in averting further HIV infections4. Cotrimoxazole prophylaxis, recommended by UNAIDS as part of a minimum package of care for people living with AIDS in Africa5, should be considered for HIV-seropositive patients, and this may provide individual benefit. Antiretroviral therapy may become accessible to the population in the future. Health workers must take a lead in this difficult area, and can begin by “breaking the silence”.
Acknowledgements
We thank the Department for International Development (DFID), UK, the Norwegian Agency for Development Cooperation (NORAD) and the Royal Dutch Tuberculosis Association (KNCV) for financial support as part of their aid contribution to Operational Research of the Malawi National Tuberculosis Control Programme. The study received the approval of the National Health Science Research Committee.
This article has previously been published in Tropical Doctor in 2002.
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