Manguzi hospital serves a population with an extremely high incidence of TB and HIV and these two diseases account for a large amount of the work load of the health services.

At present (2007), the HIV positivity rate amongst our Antenatal Clinic attendees runs between 24%-28% every month. (Compare to RSA -29%, KwaZulu-Natal - 39% and Umkhanyakude District _36%). The rate of HIV amongst the general population (all age groups) is estimated to be at 10%, whilst in population >15yrs it is estimated to be 18%. Approximately 70% of all in-patient deaths are HIV-related. Nevirapine is used in the PMTCT program with disappointing results - 24% of the babies that were tested, are still HIV positive - we have started a dual regimen in August 2007, which should (hopefully) reduce it to 5%. The ARV program was started in 2004 - currently there are 2,600 patients on treatment - approximately 70% of the total estimated eligible patients. The ARV program has been rolled out to all PHC clinics, which necessitated more frequent visits by doctors. The burden that AIDS patients places on the hospital is significant both in quantity, cost and also in the type of care they require. Many patients require full time 100% nursing care (bathing, feeding, turning) in the terminal stages. They often have prolonged hospital stays (prolonging our average length of stay) and also require longer courses of antibiotics /more expensive treatments.

ARV PROGRAMME
The ARV programme was started in July 2004. As of October 2007 over 2600 adults and children have been started on these life saving medications. This programme has been fully decentralized to the Primary Health Care level with al l 10 clinics initiating and managing patients on ARVs. There is much opportunity for doctors to be involved in this programme and training and support is readily available. ARV patients constitute 10% of total outpatients and the medicine cost is 50% of the total hospital medicine budget.

We have a Home Based Care (HBC) unit in the hospital, but the lack of a hospice for those patients that fall "in the gap" (not needing acute hospital admission but not well enough to be cared for at home) mean that they are often admitted for "HBC"/hospice care. This situation is changing now with more patients on ARV.

TB PROGRAMME

Tuberculosis is an important cause of morbidity and mortality amongst adults and children. The TB programme currently registers over 1000 new TB patients each month. More chilling besides the sheer numbers of TB patients (250 in 1993, 800 in 2002 and 1052 in 2006), are the epidemics within the epidemic. The cure rate of sputum positive individuals is 77% as at June to August 2007. Patients receive 6 to 8 months supervised treatment in the community by trained DOTS supporters.

MULTI-DRUG RESISTANT TB
Multi drug resistant TB (MDR) is on the rapid increase, currently (2007), we have 146 MDR TB cases on treatment (6%). We register approximately 12 new patients each month. A small MDR unit (16beds) was established in late 2006. Patients are admitted for 6 months at hospital for daily injections or receive these at home if they live near a clinic. The hospital has participated with the MRC in a research trial in assessing the usefulness of a rapid diagnostic test for MDR. The hospital has been identified to become a district referral centre for MDR TB and will receive a dedicated 40 bed unit.

TB RETREATMENT
Retreatment cases are also concerning, constituting approximately 10% of all TB patients. Extra-pulmonary TB is often causing difficulty in diagnosis. Approximately 70% of TB patients are co-infected with HIV. The TB Control Program is getting good results with a 77% cure rate in 2006 (RSA 59%, KZN 50%), and a defaulter rate of 1%. The death rate of 18% is mainly due to HIV co-infection. DOTS is followed, 2 tracer teams are in place and all close contacts less than 5 years are screened. All patients eligible for ARV treatment are also screened for active TB, before ARV treatment is started. PHC clinics are diagnosing and treating sputum positive PTB.