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In South Africa, the province of KwaZulu-Natal has become the epicenter of the country's HIV epidemic. South Africa already has more people infected with HIV than any other country in the world. But parts of KwaZulu-Natal have HIV rates more than twice the national average. Now in addition to that, the province is dealing with a tuberculosis epidemic.
NPR's Jason Beaubien sent this story on the challenges of trying to control HIV, AIDS and TB.
(SOUNDBITE OF A COW)
JASON BEAUBIEN, BYLINE: In the northeastern part of KwaZulu-Natal, dusty dirt tracks wind through pastures and fields of sugar cane. The hillsides are dotted with small huts made of cinder blocks and field stones.
Fifty-one-year-old Bongiwe Buthelezi is sitting on a straw mat on the floor of her two-room house, getting tested for HIV.
LINDANI MNGOMEZULU: (Foreign language spoken)
BONGIWE BUTHELEZI: (Foreign language spoken)
BEAUBIEN: A counselor from Doctors without Borders, Lindani Mngomezulu, has just pricked Buthelezi's finger and put a few drops of blood on an HIV test strip. The team from Doctors Without Borders is going door to door through the area offering free HIV tests.
Buthelezi says she's getting tested because her husband works hundreds of miles away, doing construction and she suspects he sleeps with other women.
BUTHELEZI: (Through Translator) She says not staying with the husband. The husband is working at Mzmkula. She think that maybe he has a partner somewhere.
BEAUBIEN: Buthelezi has asked her husband to get checked for HIV, but she says this suggestion always makes him angry and he refuses to get tested. She lightheartedly adds that his stubbornness is one more sign that he's guilty.
Fifteen minutes after they start the test, Mngomezulu and Buthelezi peer down at the paper test strip.
BEAUBIEN: The test has come back negative.
The epidemic in KwaZulu-Natal is driven by social, political and economic factors. And the HIV rate in some impoverished parts of the province tops 40 percent.
Dr. Yunus Moosa says HIV has overwhelmed the local health care facilities. Moosa is a doctor at the King Edward's Hospital in Durban and the head of infectious diseases at the University of KwaZulu-Natal.
DR. YUNUS MOOSA: If you were to walk through a ward with me now, you would be hard-pressed to find a patient that's HIV negative. In fact, when we see a patient who is HIV negative we all are surprised. You know, what is this patient doing in hospital?
BEAUBIEN: Last year, South Africa broadened the criteria for free HIV drug therapy, in an effort to get more people onto treatment earlier in the course of the disease. But Moosa says many patients, even though they know they're HIV positive, avoid the country's overcrowded public clinics until they're extremely sick.
MOOSA: There's only so much medication can do. And you need a patient to come to you with a reasonable state of health, so our medicines can make a difference. But they come to us in a severe condition and it's so difficult to reverse all of that. So the mortality is very high.
BEAUBIEN: Showing up for appointments is extremely important for TB treatment, which takes at least six months and can require numerous trips to a clinic. If patients don't follow their regimens, drug-resistant TB can develop. KwaZulu-Natal has now seeing thousands of cases of multi-drug-resistant TB each year.
Dr. Moosa says the TB epidemic is getting worse because the health clinic staff aren't handling it properly - for instance, misdiagnosing drug-resistant TB as regular TB.
MOOSA: So you will have a patient that has multi-drug-resistant TB, again on treatment for standard TB and sent back into the community. So he's on inappropriate treatment, getting sicker but at the same time, disseminating his bacteria to people around him. So the epidemic is gradually growing simply because we cannot deal with the numbers that we have seen.
BEAUBIEN: The clinic in KwaZulu-Natal that sees the most TB patients is the Prince Zulu Communicable Disease Center in Durban, the provincial capital. The clinic sits right next to the city's main public transportation hub, the central taxi stand. Each month the Prince Zulu Center has about 5,000 patients on TB treatment.
DR. SURIE CHINAPPA: Just to show you our X rays, that is his X-ray.
BEAUBIEN: Surie Chinappa is a doctor and an administrator at the Center.
CHINAPPA: This is the same patient who has got TB and that is not normal. There's this big cavities in his lung, that's all infection.
BEAUBIEN: Chinappa peers at a chest X-ray on her computer of a patient who just arrived, severely wasted from TB. Wispy white clouds extend across the X-ray image of his chest.
CHINAPPA: In a normal X-ray all this will look black because you have air, it just penetrates your air. But this patient, you can see that he's got a big cavity and infiltration in both the lungs actually. So he's quite weak. He's coming for admission. He's going to be admitted into hospital today.
BEAUBIEN: Chinappa says many patients come to this center in downtown Durban, because they don't want to be seen getting treatment for TB or HIV at their local clinics. She says this pushes an increasing burden on public facilities such as hers. For instance, last year, the center's HIV drug treatment clinic had more than 2,000 patients on drug therapy, yet only one full time doctor.
One concern among many clinicians in South Africa is that the number of patients needing HIV and TB treatment continues to rise, at the same time that international assistance to combat these problems is going down.
The U.S. government, through the President's Emergency Plan for AIDS Relief, or PEPFAR, has been providing about a half a billion dollars a year to help South Africa confront HIV, but that allocation has started to shrink. And U.S. officials have made it clear that, over the coming years, they plan to get out of the business of funding long-term HIV care in South Africa.
Jason Beaubien, NPR News, Durban.