JUST-MEN: Fighting Tuberculosis among men in Kenya
Nelson Mandela once said, “It always seems impossible until it’s done”. The “JUSTMEN ” only forum organized by Stop TB Partnership-Kenya and WACI Health captured part of our dream of making the impossible possible by bringing men together, as we strive to fight and end Tuberculosis (TB) among men in Kenya.
TB remains a major public health threat as it is the leading cause of mortality in Kenya. The burden for TB, TB/HIV and Drug-Resistant TB, over the years, has remained high in Kenya. In 2020, the incidence was estimated to be 140,000 people while that of DR TB to be 2,500. Further, 33,000 people died of TB while the Program diagnosed and started on treatment 72,943 people with drug-susceptible tuberculosis (DSTB) and an additional 961 with DRTB respectively.
Men remain the most affected population by TB with 66% of all cases notified with TB in 2020 being men. In terms of age group, people between the ages of 20 and 44 years carried the majority of the TB burden. The country, however, continues to miss approximately 40% of incident TB cases with the highest burden of the disease being twice as high in men compared to women and among the most economically productive age group.
In many settings, men have a higher prevalence of TB. They remain infectious in the community for a longer period than women. They, therefore, generate a greater number of secondary infections than women. In addition, social mixing patterns suggest that men are responsible for the majority of infections in men, women and children. They also are likely to have higher rates of exposure to TB, because on average, they have more contact with other adult men than they do with children who tend to have less infectious TB disease. The higher prevalence of TB in men is not due to under-diagnosis in women but it seems to be more related to late presentation, thus delayed diagnosis of TB in men.
Whereas the targets for the End TB Strategy are ambitious, they are still achievable, but they will only come to pass if we improve diagnosis and treatment among men. While addressing TB and gender-related issues, we should not continue to insist on addressing the needs of women and girls whilst ignoring the inequity faced by men and boys. They carry a higher burden of the disease and often have less access to timely diagnosis and treatment. Addressing men’s burden of disease and disadvantage in TB care is not only an issue for men’s health but for broader TB prevention and care. Both national and global TB discourse and policies on key populations need to include a focus on men.
The World Health Organization’s End TB Strategy emphasizes the importance of equity in access to diagnosis and treatment. It calls for the prioritization of systematic screening of high-risk groups to ensure early diagnosis of individuals with TB. Our 2019-2023 National Strategy considers men as a high-risk group for TB.
Why are men disadvantaged in the TB care pathway? Why do male TB patients often delay care-seeking longer than female TB patients? Is it that our screening procedures in community and facility-based active case finding are less effective in identifying TB disease in men than women? Is it that men refuse to report symptoms or are the sub-clinical phase of the disease longer for men? Are we addressing the wrong barriers related to visiting of healthcare facilities?
Evidence has shown that factors such as loss of income and financial barriers, as well as stigma, affect men’s healthcare decisions. Care-seeking decisions are further influenced by perceptions of masculinity that discourage admission of illness, and systems of care that might take away men’s sense of control and leave feelings of inadequacy. While the prevalence of HIV is slightly higher among women than men, the prevalence of TB is higher among men, even in countries with generalized HIV epidemics. Men face a relative disadvantage in accessing and remaining in HIV care and so men’s risk of TB is likely to be further increased as a result of undiagnosed and untreated HIV co-infection and missed opportunities for TB screening within HIV care.
Interventions to improve case detection among men, therefore, must recognize and address the aforementioned barriers. In addition, case detection efforts, whilst not ignoring women and children, should be greatly strengthened for men. This will require concerted efforts to address the barriers that men face in accessing care.
Our healthcare system should be cognizant of and sensitive to men’s needs. We should consider offering dedicated clinic times and outreach services that are men targeted. Comparable opportunities for TB strategies offering convenient access to TB care while maintaining men’s sense of control should be explored as well. Also, the effectiveness of TB diagnostic services that incorporate men’s peer networks or workplaces to promote wellness and reduce stigma cannot be understated.
The Ministry of Health through the National TB, Leprosy and Lung Diseases Program (NTLD-P) has made significant progress towards achieving the objectives set to end Tuberculosis (TB) in Kenya. In the current implementation plan, we have placed greater emphasis on the high burden of disease in men and the need to invest in male-friendly diagnostic and screening services to reduce undiagnosed TB. This is in line with our vision as projected in NSP geared towards a Kenya free from TB and Leprosy, and reduced burden of Lung Disease.
As a country, we are committed to diagnose and cure at least 597,000 people with TB by the year 2023, including 55,000 children, 542,000 adults and 4,500 people with Multiple Drug Resistant (MDR) TB in addition to providing TB Preventive Therapy to all Kenyans at risk who also include men.
We all have a role to play in the fight against TB in Kenya particularly among men. We must come up with collaborative measures to promote and undertake TB care and control activities. We need, therefore, to leverage the untapped potential of manpower among men to roll out awareness, detection and treatment programs that are male-centered. The National TB Program cannot win this war alone. With togetherness, we will progress and succeed as one nation.