HIV/AIDS has become the
greatest public health threat in the last
500 years. To combat it, effective global
strategies must be tightly linked to TB
control strategies. The WHO recommended
DOTS TB control strategy must be made available
to all, and so must comprehensive HIV prevention,
care and support programmes. Moreover, these
must include advanced treatment paradigms,
such as Highly Active Anti-Retroviral Therapy
(HAART), both in order to prolong lives
and to help prevent the rates of new TB
infections from increasing catastrophically,
conceivably beyond all hope of control.
Infants with HIV can die if they're given a standard tuberculosis vaccine, according to a three-year study conducted in South Africa.
The World Health Organization said the study found that babies born with HIV were more likely to contract a deadly form of TB if they were given the BCG, or bacille Calmette-Guerin, vaccine, the Associated Press reported.
Infants with HIV should not receive the vaccine, and vaccination should be delayed if a baby's HIV status is unknown, the researchers said.
The study appears in the Bulletin of the World Health Organization.
Tuberculosis and tuberculosis/HIV co-infection in pregnancy.
Both tuberculosis (TB) and human immunodeficiency virus (HIV) affect women aged 15-29 years. This is the prime childbearing age group with an increasing mortality due to HIV. The key to the prevention of neonatal TB among these women is early recognition of TB, based primarily on maternal history and relevant investigations of the mother and newborn. There are World Health Organization (WHO) guidelines for maternal prophylaxis and therapy and prophylaxis to the newborn on the stage of the maternal disease. In HIV-infected women, CD4 counts should be monitored urgently as a guide to antiretroviral (ARV) prophylaxis. When the CD4 count is <200cells/mm(3), WHO recommends that the mother should be treated with combination antiretroviral therapy (cART). In resource-rich settings most guidelines recommend treatment with cART when the CD4 count is <350cells/mm(3). The combination of ARVs and anti-TB therapy poses difficulties which can be resolved by combination of different drugs. In both conditions, evidence suggests that in resource-limited settings exclusive breastfeeding is recommended, with the addition of flash heating of the mothers' milk for HIV-infected women.
Latest Approaches To HIV Infection Management A Focus On HIV/TB And HIV/hepatitis Co-infections
Fondation Mérieux organizes its 15th Cent Gardes Symposium in New Delhi - India on March 3-6, 2009.
The conference will be opened by Alain Mérieux, chairman of Fondation Mérieux and Professor Albert Osterhaus (Erasmus Hospital - Rotterdam). Keynote addresses will be given by Professor Françoise Barré-Sinoussi, 2008 Nobel Prize in Medicine.
This conference aims at reviewing the HIV situation in India and other Asian countries in light of the strong prevalence of viral hepatitis and tuberculosis.
As co-infection with HIV and hepatitis viruses or TB strongly affects the epidemiology, diagnosis, patho-biology, and treatment of each disease, the objective of this meeting is to understand the impact of the co-infection on the prevention, detection and management of the three diseases.
More than 100 scientists, clinicians, public health actors in the fields of HIV, hepatitis and tuberculosis, from all the continents - will share their knowledge and experience in order to define the most adapted strategies to mitigate the spread and the impact of the co-infections in the Indian and Asian continent.
The following major issues will be addressed:
The epidemiological situation in Asia,
The immunopathology and natural history of dual infections,
Immunization (strategies of TB and HBV vaccination in HIV infected patients),
Disease diagnosis and patient monitoring,
Therapeutic strategies in case of co-infections.
This conference aims at promoting comprehensive care and treatment for co-infected patients, by decompartmentalizing the different diseases approaches and considering the impact of various social, economic and public health organizational factors.
This symposium falls within the framework of « The Cent Gardes » international conferences created by Dr. Charles Mérieux in 1986, during the period when the HIV infection was surfacing. Past symposiums have allowed the foremost specialists throughout the world to present their work to the international scientific community, in particular in the field of vaccine approaches for this pathology. After Beijing in 2005, this is the second time for Fondation Mérieux to organize « The Cent Gardes » international conference outside France, which shows its commitment in promoting scientific exchange and collaboration between developed and emerging countries in the fight against HIV/AIDS
Tuberculosis and HIV: a global menace exacerbated via sex trafficking
2009 Jan 17
Brigham & Women's Hospital, FXB Building, 7th Floor, 651 Huntington Avenue, Boston, MA 02115, USA
OBJECTIVE: Global tuberculosis (TB) elimination requires recognition and management of TB/HIV co-infected individuals, including those in marginalized and/or understudied populations. We sought to examine the prevalence of TB among repatriated sex trafficked Nepalese girls and women in whom a high HIV prevalence was previously reported.
METHODS: We reviewed case records for cases of TB among 287 sex trafficked girls and women repatriated to a single, rehabilitation non-governmental organization in Kathmandu, Nepal between 1997 and 2005. TB case detection was based on sputum smear results for acid-fast bacilli, radiographs, or histories, as reported in medical tests and/or case records.
RESULTS: There were 17 cases of TB that developed after rescue within the sample of girls and women who were aged 7-32 years when they were trafficked. The majority of cases (70%) were likely pulmonary TB. Nearly 9 in 10 individuals who developed TB were HIV co-infected.
CONCLUSIONS: Although preliminary in nature, our findings highlight the need for more comprehensive exploration of TB prevalence within sex trafficked populations, particularly in light of the large numbers of individuals who are sex trafficked in South Asia, the high prevalence of HIV documented in this group, and the risk of transmission of TB from and to others.
TB/HIV FACTS 2008
- The number of new TB cases has tripled in high HIV prevalent countries in the last two decades
The number of new TB cases has tripled in high HIV prevalent countries in the last
two decades.
Targeted action on HIV and tuberculosis needed to reach drug users
4 AUGUST 2008 -- MEXICO CITY -- Health and criminal justice authorities need to provide targeted services to drug users, especially those who inject drugs, to prevent and treat tuberculosis (TB) and HIV. TB is a major cause of death for people living with HIV, but drug users who are HIV-positive face stigma, discrimination and barriers to accessing life-saving treatments.
New guidelines issued today aim to reduce these preventable deaths by, for example, improving access to antiretroviral drugs and to isoniazid for drug users living with HIV. Isoniazid preventive therapy (IPT) significantly reduces the risk of TB disease in people living with HIV, but is not widely used.
These are the first recommendations to actively include TB and HIV care within the context of support to drug users. They form part of the Evidence for Action series and build on policy guidance on both TB/HIV and injecting drug use.
Even where IPT is available, health care and outreach workers face major challenges in delivering full care to drug users who are often marginalized by homelessness, poverty, imprisonment, and by public and political hostility. These factors contribute to the transmission of both HIV and TB, and at the same time are barriers to TB, HIV and drug dependence treatment.
To ensure all drug users, including those in prison, can benefit from TB and HIV prevention, treatment support and care, WHO, UNAIDS and the UN Office on Drugs and Crime have developed Policy Guidelines for Collaborative TB and HIV services for Injecting and Other Drug Users - An Integrated Approach. The measures1 aim to break down the barriers that stand in the way of better health, outline key interventions, and promote ways to improve coordination and planning across all those who interact with injecting and other drug users.
HIV weakens a person's immune system. Because of this, people living with HIV are up to 50 times more likely to develop TB in their lifetimes than people who are HIV-negative. Without proper treatment, the majority of people living with HIV die within two to three months of becoming sick with TB. In 2006, 231 000 people died with HIV and TB. Many of these deaths were preventable.
Unsafe injecting drug use is now a major route of transmission for HIV. Excluding Africa, nearly one in three of all new HIV infections are attributable to unsafe injecting drug use. In areas of eastern Europe and central Asia, that figure rises to two out three new infections. In some areas of eastern Europe a significant association between HIV and multidrug-resistant TB has been observed by researchers.
Addressing TB/HIV is a key theme of the 2008 International AIDS Society conference and comes two months after world leaders issued a call to drastically cut the number of TB/HIV deaths by 2015 at the landmark Global Leaders' Forum on the co-epidemic, held at the UN headquarters in New York.
Summary of the 13 recommendations in the Policy Guidelines for Collaborative TB and HIV services for Injecting and Other Drug Users:
Joint Planning:
Multisectoral coordination on TB and HIV activities for drug users
National plans with roles and responsibilities of service providers
Staff training to build effective teams
Operational research on TB/HIV services for drug users
Key Interventions:
TB infection control in congregate settings including prisons
Case-finding protocol for TB and HIV for services dealing with drug users
Access to appropriate treatments for drug users
Isoniazid preventive therapy for drug users living with HIV
Health workers to assess and provide HIV prevention methods
Overcoming Barriers:
Universal access to TB and HIV prevention, treatment and care as well as drug treatment services to drug users
Quality medical services available to prisoners
Treatment adherence support measures for drug users
Other infections (e.g. hepatitis) and factors should not prevent drug users accessing HIV and TB treatments
For more information contact:
Saira Stewart
WHO HIV/AIDS Department
Mobile: +41 79 467 2013
E-mail: stewarts@who.int
Glenn Thomas
WHO TB Department
Mobile: +41 79 509 0677
E-mail: thomasg@who.int
FACTS ON HIV/TB
“We cannot fight AIDS unless we do much more to fight TB.”
Nelson Mandela
The Challenges
TB is the leading cause of death among people living with HIV in Africa and a major cause of death elsewhere. It is also the most common illness among people living with HIV within the first three months of starting antiretroviral therapy worldwide.
Almost a quarter of a million people died with HIV associated TB in 2006.
During the past 15 years the number of new tuberculosis cases has tripled in countries with high HIV prevalence.
HIV/TB is a threat to global health security, particularly because of the emergence of virtually untreatable TB strains (multidrug-resistant and extensively drug-resistant TB - MDR/XDR-TB), with case fatality rates over 90% among people living with HIV and XDR-TB.
A recent World Bank and WHO analysis estimated that investment in TB control efforts can reap benefits that equal 10 times the costs.
Health care workers are particularly vulnerable to TB infection and ultimately TB disease owing to workplace exposure, and this further compromises weak health systems.
An estimated 85% of TB cases in people living with HIV occur in sub-Saharan Africa, but large numbers also occur in Eastern Europe and Asia.
At least one-third of the 33.2 million people living with HIV worldwide are also latently infected with TB and have a greater risk of developing TB disease i.e. a 5-10% risk of developing TB every year compared to non-HIV infected persons who have up to 10% risk over their lifetime.
It is estimated that up to 10% of all new HIV infections are attributable to injecting drug use (30% if Africa is excluded), and that approximately 3 million past and current injecting drug users are living with HIV. Drug users living with HIV have a 1 in 10 chance of getting TB disease per year. Countries where the HIV epidemic is mainly drug use driven also have the highest rates of multidrug-resistant tuberculosis (MDR-TB).
Individuals with HIV and TB disease are more likely to face increased stigma and discrimination than those suffering from HIV or TB alone.
Annually, over three million women develop TB disease, and about three- quarters of a million women die of TB. Tuberculosis affects women mainly in their economically and reproductively active years, the impact of the disease is also strongly felt by their children and families. In some parts of the world, the stigma associated with TB is greatest for women and when accompanied by HIV, the social effects of disease can be severe.
There is also the problem of archaic diagnostics and old drugs for TB. There have been no new TB drugs recently and the current diagnostic test is over 120 years old.
There are huge unmet research needs for TB. Current funding levels for research and development for TB drugs, diagnostics and vaccines is inadequate to meet current targets and needs. Investment needs to increase from about $400 million each year worldwide, to about $2 billion per year.
The Stop TB Partnership Global Plan 2006-2015 calls for US$ 6.7 billion in funding for HIV/TB control in affected countries. An estimated US $ 536 million is need to address HIV/TB in 2008. There is an estimated gap per year of approximately 40-50%.
Introducing ‘TB Advocacy Week' in Uganda
To engage TB and TB-HIV stakeholders at the community, district and national levels, the Ministry of Health and the Uganda Stop TB Partnership (USTP) will start marking a "TB Advocacy Week" as a build-up to the World TB Day activities in March every year.
The National Tuberculosis and Leprosy (NTLP) Programme Manager, Dr. Francis Adatu, during the USTP Quarterly meeting at the World Health Organization offices in Kampala, said: “We need to strengthen advocacy activities for TB and TB/HIV, targeting policy makers, health workers, TB patients, people living with HIV/AIDS, schools and communities.” Dr. Adatu’s remarks come one month after the successful organisation of World TB Day 2008 in which communities in Mbale (Eastern Uganda) participated in several TB advocacy activities. “Advocacy will help keep TB on the agenda of policy makers and decision makers and will increase awareness about the symptoms, causes and prevention of TB among the general population.” Before 2009 World TB day, the Ministry of Health, in collaboration with partners and with support from the Global Fund, has planned a series of advocacy activities to build on the success of 2008 World TB day. According to Dr. Adatu, these activities will address existing information gaps, misconceptions and negative attitudes on TB and TB-HIV.Some of these activities will include:
Advocacy meetings targeting district leaders and health teams in districts with low case detection and treatment success rate, such as Kampala, Mbarara, Ntungamo, Kaabong, Yumbe, Maracha, Amuria, Bukedea, Koboko and Kaliro, among others
A series of school health talks on TB and TB-HIV using already existing drama groups within primary and secondary schools nationwide
Community drama groups and sensitization meetings at sub-county levels,
Print materials including posters and brochures and radio messages on TB causes, symptoms and treatment.
These activities will be spread over a two-year period and Dr. Adatu says will help take the TB and TB-HIV message to the communities using a community-based approach, where communities themselves, through drama, debates and mass media spread the message to others. The NTLP Manager therefore appeals to all partners to support the above activities and play their part in stopping TB.
CDC HIV/AIDS Facts - January 2008
TB control is an exercise in vigilance. The goal of controlling and eventually eliminating TB worldwide requires a focused, continual effort to address the prevention and treatment needs of persons most at risk, including those who are infected with HIV. Efforts to eliminate TB are therefore essential to reducing the global toll of HIV infection.
The seven Working Groups of the Stop TB Partnership have each prepared a working group strategic plan for 2006-2015. The combined Working Group Strategic Plans now form the basis of the Second Global Plan to Stop TB (2006-2015), which will lead us towards achieving the Millenium Development Goals.
An
HIV/TB strategy for the Eastern Mediterranean Region
(2006–2010)
The human immunodeficiency virus (HIV) pandemic
presents a massive challenge to the control
of tuberculosis (TB). Tuberculosis is one
of the most common causes of morbidity and
the leading cause of mortality in people
living with HIV/AIDS (PLWHA). Although the
state of the HIV epidemic in many countries
in the Eastern Mediterranean Region is currently
at a low level, it is increasing and in
some countries is in a generalized state.
Furthermore, there are a significant number
of countries that have a high burden of
tuberculosis in the Region. The challenge
presented by the double burde of HIV/TB
is therefore one which the Region should
address in order to prevent the problem
from escalating and reversing the successes
so far achieved against tuberculosis.
There is a need for enhanced
collaboration between existing HIV/AIDS
programmes and tuberculosis programmes,
in order to coordinate the response to HIV/TB,
ensure a continuum of care for people with
tuberculosis and HIV/AIDS, build on respective
programme strengths and exploit synergies.
Project
to focus TB control programme in special groups
Sep 2005
Mumbai : The Central government has chalked
out a project to improve the quality and
reach of its Revised National TB Control
Programme (RNTCP) in special groups like
slum-dwellers, migrants and HIV-infected
tuberculosis patients in urban areas.
A task force comprising stakeholders like
the state TB offices, NGO representatives,
private medical practitioners, MDACS (Mumbai
District Aids Control Society) and research
institutes will assist in the planning and
implementation of the 'Urban TB Control
Project'.
Yatin Dholakia, a member of TB Control
Society of India, told UNI that the government
has envisaged the project to effectively
combat the disease, which was a major health
problem in the country.
The project has been set up in four major
cities - Mumbai, Hyderbad, Varanasi and
Indore - and is targetted at special groups
like slum-dwellers, migrants, HIV-infected
TB patients, street children and substance
abusers and others.
In the metropolis, Inter-Aid Development
India has been appointed as the nodal NGO
to implement the project in collaboration
with the Mumbai District TB Control Society.
Dr Dholakia said 15 wards have been selected
in Mumbai for project implementation on
the basis of density of slum population
and poor access to public health services.
These will be covered in a phased manner,
he said.
The major goal of RNTCP is to achieve at
least 85 per cent treatment success and
at least 70 per cent detection of new cases
in order to reduce morbidity, mortality
and disability due to TB, thereby cutting
the chain of transmission so that tuberculosis
ceases to be a major public health problem
in India.
Authorities
in Andhra Pradesh grapple with deadly duo as District
sees rise in HIV-TB co-infection cases.
May 2005
VIJAYAWADA: Krishna district
is facing fresh challenge on the health
front. A new trend of HIV-TB co-infection
cases pouring in from various pockets has
forced the district tuberculosis control
wing and the district leprosy department
to sit up and take notice of the emerging
danger.
Interestingly, the district
administration was unaware of the new threat
until a group of local voluntary organisations,
jointly working on Krishna Community Health
Intervention Programme (KRISCHIP) -- funded
by the UK-based Community Fund -- took the
matter to the notice of the authorities
concerned. The objective of KRISCHIP is
to reduce the vulnerability of poor rural
and urban communities in Krishna district
to the spread of communicable diseases like
tuberculosis, HIV/AIDS, malaria and leprosy.
"While preparing
separate statistics for HIV/AIDS and tuberculosis,
we found the `co-infection' factor creeping
into several cases, thus creating a lot
of confusion. A large number of persons
affected by HIV-AIDS were found to be suffering
from tuberculosis too," explained a
volunteer from Lepra India, the lead partner
in the KRISCHIP.
Mortality rates
According to latest findings, mortality
rate in TB with HIV positive cases is four
times more than cases of TB with HIV-negative.
TB has been found to be shortening the life
span of HIV positive patients. It kills
half of all HIV-afflicted people in the
world.
The district has eight
Voluntary Counselling and Testing Centers
(VCTCs) and 43 Revised National TB Control
Programme (RNTCP) centers. "This is
the first time the VCTCs and RNTCPs have
been asked to work in coordination to detect
the exact number of HIV-TB co-infection
cases existing in the district," says
the District Tuberculosis Control Officer,
Sashidhar Reddy. He admitted that the rise
in number of `co-infection' cases has prompted
the two departments to focus on making joint
efforts to effectively curb the ailment.
In Andhra Pradesh, one
person dies of tuberculosis every 15 minutes.
If left untreated, a TB-afflicted person
can infect at least 10 to 15 persons in
the span of a year.
Mr. Reddy says early detection
of TB symptoms in HIV positive patients
can reduce the mortality rate in co-infection
victims. He says training is being imparted
to all VCTC and RNTCP counsellors to identify
and treat the `co-infection' cases that
pose a major threat.
In a survey conducted
in 42 of the 135 slum habitations that comprise
Vijayawada urban zone, a total number of
498 TB cases were reported, of which, 212
were confirmed. And, 31 of the 72 cases
referred were found to be HIV positive.
The KRISCHIP volunteers are studying the
incidence of `co-infection' to establish
the exact number of people victimised by
the twin diseases.
India
'must tackle tuberculosis and HIV/AIDS together
Tuberculosis and HIV/AIDS must be tackled
together if India is to meet the UN Millennium
Development Goal of halving deaths from
tuberculosis by 2015, say researchers.
In a paper published yesterday
(5 July) in the Proceedings of the National
Academy of Sciences, Chris Dye of the World
Health Organization and colleagues warned
that unless patients with both tuberculosis
and HIV have access to drugs to treat both
conditions, many could die.
Less than one per cent
of Indian adults have HIV, but the country's
large population size means that its total
number of infected people — five million
— is second only to South Africa.
Some scientists have suggested
that this figure could increase to five
per cent, which, most agree, could greatly
increase the number of people dying from
tuberculosis.
To investigate whether
adequate tuberculosis control could counteract
the threat of increased HIV in India, Dye's
team created computer models for varying
scenarios of HIV infection and tuberculosis
control for the period 1990–2015.
In 1998, India began to
implement its Revised National Tuberculosis
Control Program, which included the WHO-recommended
'DOTS' strategy.
The researchers' models
showed that if the programme had not been
implemented, 33 per cent more HIV-positive
people would die from tuberculosis by 2015.
With the national control programme however,
the models predict that deaths due to tuberculosis
will drop by 39 per cent reduction, a result
the researchers say is "reassuring".
The team calculates that
the total number of Indians with HIV is
unlikely to increase substantially between
now and 2015.
But in areas of India where already more
than one per cent of people are HIV-positive,
deaths from tuberculosis will only fall
by 15 per cent — even with the national
tuberculosis control programme.
Ensuring that India meets
the Millennium Development Goal of cutting
the number of tuberculosis deaths in half
by 2015 will need additional efforts, they
say.
The team says tuberculosis
patients should have access to HIV testing
and to HIV drugs if they test positive.
This will be especially important in regions
of India, such as the area from Mumbai to
Karnataka, where HIV prevalence is high.
Effectively
treating TB will not solve the worldwide AIDS crisis,
but it will significantly reduce its burden
While approximately 70 percent of the TB
and HIV/AIDS population lives in sub-Saharan
Africa, another 17 percent of the world’s
individuals with TB and HIV/AIDS live in
Asia.
Asian countries, with their
large cities, high rates of TB infection
and growing spread of HIV currently account
for two-thirds of all new TB cases. As in
Africa, the increase of tuberculosis is
due to the rapid spread of the HIV/AIDS
epidemic. Inadequate health programs and
lack of drugs exacerbate the problem.
Central Asia is still in
the earliest stages of an HIV/AIDS epidemic.
However, there is cause for concern due
to the steep growth of new HIV cases in
the region; the established related epidemics
of injecting drug use, sexually transmitted
infections and tuberculosis; youth representing
more than 40 percent of the total regional
population; and the low levels of knowledge
about the epidemics.
A
few facts:
TB is the leading killer of people with
AIDS.
TB is the first manifestation of AIDS in
over 50 percent of cases in developing countries.
Patients with immune systems disabled by
HIV/AIDS face a 30 times greater risk than
others of contracting TB.
Escalating tuberculosis
case rates over the past decade in many
countries in sub-Saharan Africa and in parts
of Southeast Asia (places like northern
Thailand) are largely attributable to the
HIV epidemic. Since the mid-1980s, in many
African countries, including those with
well-organized programs, annual rates of
reported TB cases have risen 400 percent.
A total of 12 million people
worldwide are co-infected with both TB and
HIV, with the majority of them living in
Southern Africa.
Because of the increased spread of HIV in
sub-Saharan Africa, the number of TB cases
in that region will double to 4 million
new cases per year shortly after 2005.
Importance
of blood samples for diagnosis and drug sensitivity
testing in HIV positive patients with suspected
tuberculosis
Background:
Diagnosis of tuberculosis is difficult in
HIV positive patients since they often present
with atypical symptoms and are susceptible
to pulmonary infections that mimic tuberculosis.
Sputum collection may not be possible even
in patients with pulmonary involvement since
a productive cough is not always present.
In such patients, blood smear and culture
for AFB apart from serving as a diagnostic
tool can be used for testing drug sensitivity.
Objectives:
This study was undertaken to explore the
value of blood culture for diagnosis in
patients with suspected TB .In addition,
a comparison of drug sensitivity patterns
of blood and sputum isolates in 10 of these
patients was also carried out .
Methods:
Blood and sputum samples were processed,
cultured and isolates tested for their drug
susceptibility and for niacin production,
nitrate reduction as well as catalase activity
at
680 C
Results:
All 214 blood samples were culture positive
although only 6 were smear positive .On
the basis of the biochemical investigations,
22 strains were identified as Mycobaterium
tuberculosis All the 10 sputum samples were
culture positive despite 4 being smear negative.
Comparison of drug sensitivity profiles
from blood and sputum revealed concordance
to five first or second line drugs in 5
of 10 patients. Additionally, 2 patients
demonstrated discordance for only one first
or second line drug.
Conclusion:
The study demonstrates the importance of
blood culture in confirming diagnosis of
blood culture in confirming diagnosis of
tuberculosis and testing for drug sensitivity
in HIV positive patients without productive
cough .The level of discordance in drug
sensitivity profiles between blood and sputum
in the same individual is suggestive of
infection with multiple strains. Testing
for the occurrence of multistrain infections
through individual colony examination of
single isolate is necessary since such infections
would affect treatment of non responder
patients having HIV-TB dual infections
Two
Diseases - One Patient
HIV and TB - one
community, one patient
Participants at the third
meeting of the TB/HIV Working Group in Montreux
in June were struck by the extent of common
ground between TB and HIV communities, embodied
in the opening theme "Two diseases
– one patient". For the first
time, the goal of working together as one
community seemed truly achievable, with
broad representation and contribution from
both the HIV and the TB communities. Programme
collaboration is essential if we aim to
deliver effective, comprehensive care and
prevention at the community level. Care
must be patient focused. People with TB
and/or HIV often have a range of conditions
and should not need to attend health services
separately for each of them. great optimism
that joint action can work. Evidence for
the effectiveness of joint TB/HIV action
is mounting. As participants heard, it has
modified risky sexual behaviour in Malawi,
achieved a sixfold increase in the number
of people getting HIV test results in projects
in southern Africa, impressively accelerated
the development of joint strategies in Asia,
and integrated TB and HIV care in Chiang
Rai, Thailand. One key lesson emerges: it
is joint action that works – not TB
or HIV programmes working in isolation.
Joint action can
bring "3 by 5" nearer
Even more exciting for
the future, it emerged that TB/HIV collaboration
can help in reaching the "3 by 5"
target – 3 million PLWHA on antiretroviral
treatment by 2005. Already, more than 300,000
people with HIV are diagnosed with TB each
year in Africa alone, and an estimated 400,000
more cases are not yet identified or notified
by national programmes. If all these patients
were offered HIV testing and counselling
they would, without doubt, constitute the
largest single group eligible for ART. Furthermore,
the experience that TB programmes have gained
in the provision of care makes them natural
partners for AIDS programmes that have now
added care to their prevention responsibilities.
What now for joint
TB/HIV action?
Demand was high for TB/HIV policy guidance,
and WHO and partners presented the work
in progress. Participants strongly endorsed
the five key components:
Strengthen DOTS and HIV care and prevention
Establish a national-level TB/HIV coordination
committee
Establish HIV surveillance among TB
patients
Offer HIV testing and counselling to
all patients with TB
Screen for TB all people attending
for HIV services.
This is not a new vertical TB/HIV programme
but joint national TB programme/national
AIDS programme action. Financial barriers
are falling fast, with new funding sources,
such as the Global Fund to Fight AIDS, Tuberculosis
and Malaria, but national TB and HIV programme
leaders demanded an immediate increase in
human resources and capacity. All partners
are urged to address this problem. WHO AFRO,
particularly, was charged with alerting
NEPAD (New Partnership for African Development)
and other African partnership organizations
to wake up to joint TB and HIV issues. As
the world begins to focus on "3 by
5", let’s ensure that, at the
very least, all TB patients in high-HIV
areas can access an HIV test as the entry
point to the most appropriate care and prevention.
Think globally – but act locally.
The
rise of "Ebola with wings"
In June 1994, Hawaii's
State Health Department notified the US
Centers for Disease Control and Prevention
(CDC) that a 32-year-old woman from Korea
had died of complications from pulmonary
TB. Prior to her diagnosis, she had flown
from Honolulu to Chicago, from Chicago to
Baltimore, and then back to Honolulu. The
CDC conducted an investigation of her contacts
on those flights and discovered six fellow
passengers whom the woman might have infected.
As of February 1996, all six remained free
of signs and symptoms of active tuberculosis
But what makes this story even more frightening
is that the deceased woman's TB strain was
resistant to five of the strongest antimicrobials
used to cure the disease. Quite possibly,
the six passengers in question acquired
the same strain. Today, drug-resistant strains
of tuberculosis, and even of Multi Drug
Resistant tuberculosis (MDR-TB), are spreading
quietly, insidiously-within families, institutions,
communities and across national borders.
These prospects are so alarming that the
mainstream press has given MDR-TB the singular
epithet, "Ebola with wings". Ebola
is a deadly haemorrhagic fever diagnosed
in the mid-1990s in several hundred people
in a small region of the former Zaïre.
Untreated TB, like ebola, has a high fatality
rate. But unlike Ebola, TB is spread by
sharing the air we breathe. "Once MDR-TB
is unleashed, we may never be able to stop
it," warned the World Health Organization
in 1997. But MDR-TB has already been unleashed.
In one sense, this is a cautionary tale
about our "global village", where
travelers can arrive from anywhere, carrying
microbial hitchhikers. More importantly,
the rise of MDR-TB speaks to dangerous global
disparities in health care services that
affect rich and poor countries alike. For
countries like the Ukraine, economic and
political upheaval has weakened the health
care system and compromised the treatment
of thousands of TB patients. Incomplete
treatment has led to the development of
microbial resistance to the most common
and effective anti-TB drugs. The resulting
MDR-TB is a clear and present danger to
global TB control. Due to poverty, complacency
and neglect, TB remains a paradox at the
very heart of our modern age: in an era
of unprecedented wealth and scientific advancement,
millions are dying each year from a disease
for which there is a proven, cost-effective
treatment and hundreds of thousands are
becoming infected with resistant strains
that are more expensive to treat.
HIV/AIDS
has become the greatest public health threat
in the last 500 years. To combat it, effective
global strategies must be tightly linked
to TB control strategies. Multidrug-resistant
TB is a clear and present danger to global
TB control.
TUBERCULOSIS,
HIV ON COLLISION COURSE IN ASIA
Co-Epidemic
to Multiply Seven-Fold
The number of people in Asia who develop
tuberculosis because they are infected with
both the human immunodeficiency virus (HIV)
and the TB bacillus is expected to multiply
nearly seven fold this decade, according
to the World Health Organization (WHO).
Preliminary figures on
HIV/TB co-infection in the region are remarkably
high, according to a statement issued by
the WHO TB Programme during the 10th International
Conference on AIDS in Yokohama, Japan. In
several studies, between 52 and 70 percent
of AIDS cases in Thailand, India, and Nepal
have developed TB.
"TB and HIV are feeding
off each other at an alarming rate,"
said Dr Arata Kochi, Programme Manager of
the WHO TB Programme. "When they're
together, they multiply each other's impact."
A person with TB/HIV infection
is nearly 30 times more likely, in any given
year, to become sick with TB than a person
infected with just TB. Tuberculosis can
also further suppress the immune system
of an HIV-infected person and accelerate
the occurrence of other opportunistic infections.
With nearly half of all
people in Asia already infected by TB, and
HIV infection increasing, WHO warned that
there is no end in sight to how bad the
dual epidemics might get.
THE
SITUATION IN ASIA
1990 / 1995 / 2000
Illnesses (annually) TB
cases 4,945,000 / 5,544,000 / 6,207,000
TB cases among HIV positive people 85,000
282,000 639,000 Percent of all TB cases
attributable to HIV 1.7% 5.1% 10.3%
Deaths (annually) TB deaths
1,731,000 / 1,940,000 / 2,172,000 TB deaths
among HIV positive people 30,000 / 99,000
/ 224,000 Percent of all TB deaths attributable
to HIV 1.7% 5.1% 10.3%
(Numbers on Asia include
Southeast Asia and Western Pacific)
In Asia, the number of
annual TB deaths in co-infected people is
doubling every three years. Asia will surpass
Africa in the number of annual TB/HIV deaths
by the year 2000.
The unfortunate truth is
that most Asian governments have yet to
respond by putting effective TB programmes
in place to stop the co-epidemic's acceleration."
The situation is also deteriorating
in other parts of the world. WHO estimates
that 5.6 million people worldwide were dually
infected with HIV and TB by mid-1994, and
that this number will increase to nearly
14 million by the year 2000. HIV-infected
people will account for nearly 10 percent
of the 30 million people likely to die from
TB in the next decade.
THE
GLOBAL SITUATION
1990 1995 2000
Illnesses (annually) TB
cases 7,537,000 / 8,768,000 / 10,222,000
TB cases among HIV positive people 317,000
738,000 1,410,000 Percent of all TB cases
attributable to HIV 4.2% 8.4% 13.8%
Deaths (annually) TB deaths
2,530,000 / 2,977,000 / 3,509,000 TB deaths
among HIV positive people 116,000 266,000
500,000 Percent of all TB deaths attributable
to HIV 4.6% 8.9% 14.2%
The TB and HIV epidemics
are each notorious killers in their own
right. We cannot defeat one without attacking
both. While we search for a cure for AIDS,
we need to begin now making more extensive
use of the effective medicine we already
have to cure people who have TB.
Tuberculosis medicines
cost as little as US$ 13 in developing countries
and are almost completely effective. Currently,
one of the most affordable and feasible
ways to extend the lives of people with
HIV is to treat opportunistic infections
such as TB. Likewise, effective HIV/AIDS
prevention will ultimately reduce the number
of new TB cases and deaths.
Although the two epidemics
are fuelling each other, they are still
very distinct health problems. Different
weapons are needed for fighting each of
these diseases. For AIDS, the emphasis is
on changing sexual behaviour and on research
to find a vaccine and a cure. For TB, an
effective and inexpensive cure already exists,
so the emphasis must be on setting up more
treatment programmes in more parts of the
world. Countries need strong TB programmes
as well as strong AIDS programmes.
In order to control TB,
nothing is more important than for governments
to begin putting into place effective TB
treatment programmes. We have the medicine
and know-how to control TB. Unfortunately,
we don't have the magic potion to wake up
the world's governments to the seriousness
of the TB crisis and get them to take action.
HIV/AIDS
in India
India is experiencing rapid and extensive
spread of HIV. This is particularly worrisome
since India is home to a population of
over 900 million. As a single nation it
has more people than the continents of
Africa, Australia and Latin America combined.
There are an estimated 2 to 5 million
people infected with HIV in India today,
and 50,000 to 100,000 cases of AIDS may
have already occurred in the country.
This epidemic is fueled by both married
and unmarried men visiting sex workers.
The most rapid and well-documented spread
of HIV has occurred in Bombay and the
State of Tamil Nadu. In Bombay HIV prevalence
has reached the level of 50 percent in
sex workers, 36 percent in STD patients
and 2.5 percent in women attending antenatal
clinics.
Certain regions, such as eastern India
(Calcutta area) and northern India (New
Delhi region), still show a lower prevalence
of HIV (1 to 2 percent) among sex workers.
Contrary to traditional belief, sexually
transmitted diseases and sex with multiple
partners are common in the country, both
in urban and rural areas. An estimated
3 to 4 percent of some rural populations
have a sexually transmitted disease.
Injecting drug use is a problem in Manipur,
which is in the North East region, where
55 percent of drug users are HIV-infected
and 1 percent of women attending antenatal
clinics are infected with HIV.
HIV is rapidly spreading to rural areas
through migrant workers and truck drivers.
Surveys show that 5 to 10 percent of some
truck drivers in the country are infected
with HIV.
An estimated 1 to 2 million cases of
tuberculosis occurs in India every year.
In Bombay 10 percent of the patients presenting
with tuberculosis are HIV-positive. Tuberculosis
is the presenting symptom of AIDS in over
60 percent of AIDS cases.
A major international and governmental
effort is necessary to respond effectively
to this severe epidemic.
Background
- the burden of HIV-related disease, and in particular
HIV-related TB
Of the global total of
34.3 million people living with HIV/AIDS
(PLWH) at the end of 1999, 24.5 million
(71.5%) are in sub-Saharan Africa. All 23
countries in the world with an adult HIV
seroprevalence rate in 1999 above 5% are
in sub-Saharan Africa, and in 8 of these
countries (all in Southern Africa), the
adult HIV seroprevalence rate is above 15%.
Sub-Saharan Africa thus bears the overwhelming
brunt of the HIV/AIDS epidemic.
Worldwide, the main burden
of disease in PLWH arises from a limited
number of common infections - and their
complications - to which PLWH are particularly
susceptible, namely TB, pneumonia, diarrhoea,
and candida infection of the mouth and throat.
TB is the single biggest killer of PLWH
. Diagnosis of these infections is usually
possible at health centres and district
hospitals, and they are generally amenable
to successful treatment with cheap, affordable
and effective antibiotics. In addition to
these common HIV-related diseases, there
is a variety of HIV-related infections and
cancers for which treatments are more expensive
and, in many parts of the world, not widely
available.
About a third of the 34.3
million PLWH worldwide are co-infected with
Mycobacterium tuberculosis. Since 70% of
those co-infected live in sub-Saharan Africa,
this region also bears the overwhelming
brunt of the global epidemic of HIV-associated
TB. HIV fuels the TB epidemic: HIV is the
most powerful known risk factor for reactivation
of latent TB infection to active disease;
HIV-infected persons who become newly infected
by M. tuberculosis rapidly progress to active
TB. Escalating TB case rates over the past
decade in sub-Saharan Africa are largely
attributable to the HIV epidemic. Up to
70% of patients with sputum smear-positive
pulmonary TB are HIV-positive, and up to
half of PLWH develop TB. In addition to
the adverse effect of HIV on TB, an adverse
effect of TB on HIV is suggested by studies
that show that the host immune response
to M. tuberculosis enhances HIV replication
and might accelerate the natural progression
of HIV infection.
The
international response to TB/HIV- an evolving approach
For many years, those involved
primarily with tackling TB and those involved
primarily with tackling HIV have largely
pursued separate courses. Those involved
primarily with tackling TB have concentrated
on ensuring that all TB patients have access
to the basic essentials of TB control, namely
case-detection and cure. Despite considerable
progress over the past decade, only 20-25%
of all TB patients worldwide have access
to effective diagnosis and treatment, provided
under the internationally recommended TB
control strategy, known as the DOTS strategy.
WHO is leading and coordinating global efforts
to ensure that all TB patients worldwide
have access to effective diagnosis and treatment.
Those involved primarily
with tackling HIV have formulated strategies
for care for PLWH. However, there has been
little measurable progress so far in implementing
interventions which ensure that PLWH have
access to effective diagnosis and treatment
of the common infections (and their complications)
which are responsible for the main burden
of HIV-related illness and deaths (namely
TB, pneumonia and diarrhoea). Yet in those
countries with the highest rates of TB/HIV
coinfection (all in sub-Saharan Africa)
it is apparent that those involved primarily
with tackling TB and those involved primarily
with tackling HIV have common cause. Tackling
HIV means tackling TB as the single biggest
killer of PLWH; tackling TB means tackling
HIV as the most potent force driving the
TB epidemic.
On account of the overlapping
epidemiology of TB and HIV, and the mutual
benefits of efforts in tackling TB and HIV,
there is growing recognition of the need
for increased collaboration between TB and
HIV programmes to provide a coherent health
service response to the dual TB/HIV epidemic.
Increased coordination between HIV/AIDS
and TB programmes will yield benefits for
more effective and efficient training, drug
supply, case management and surveillance.
WHO's
role in coordinating the process of delivering an
effective response to TB/HIV - the STOP TB Initiative
Coordination between agencies
at the international level is necessary
to ensure the effective delivery of these
innovative interventions. Considerable reorientation
of approach on the part of national and
international agencies is necessary for
HIV and TB programmes to ensure full coordination
of efforts (which until now have been largely
independent) to achieve common aims in tackling
HIV and TB. The STOP TB Initiative has an
important role to play, particularly through
the TB/HIV working group, consisting of
representatives of partners involved in
tackling TB/HIV.
TB/HIV
working group
The working group will provide a forum for
the coordination of activities, aimed at
promoting interventions on the ground to
decrease the dual burden of TB and HIV.
Mobilisation of more resources would enable
the scaling up of current efforts to tackle
TB in high HIV prevalence countries, and
of piloting of innovations to tackle TB/HIV
in a coherent way. Under the overall umbrella
of the working group, partners will take
the lead in activities, including policy
development and dissemination, developing
innovative approaches (e.g. the "ProTEST"
Initiative), scaling up interventions of
proven cost-effectiveness (e.g. community
contribution to TB care), the development,
production and dissemination of a manual
for clinical care and of training materials.
The
"ProTEST" Initiative
WHO is coordinating an
Initiative ("ProTEST") aimed at
operationalising the links between HIV and
TB programmes and general health services
to deliver coherent interventions for TB
and HIV prevention and care. The name "ProTEST"
embraces intention to promote both the provision
of voluntary counselling and testing (VCT)
for HIV (in a region where less than 5%
of PLWH know that they are HIV-positive),
and the demand for VCT as an entry point
for access to a range of HIV and TB prevention
and care interventions. A limited number
of ProTEST projects are under way in selected
pilot sites in countries in sub-Saharan
Africa to study the feasibility and outcomes
of an integrated health service response
to TB/HIV, rather than separate responses
to TB and HIV.
HIV-AIDS
and TB Epidemics Fueling Each Other in Deadly Spin
One in three HIV-infected people worldwide
is coinfected with the TB bacterium.
TB is responsible for the death of one
out of every three people with HIV/AIDS
worldwide.
People who are HIV-positive and infected
with TB are 30 times more likely to develop
active TB than people who are HIV-negative.
The TB bacterium enhances HIV replication
and might accelerate the natural progression
of HIV infection.
Because of the increased spread of HIV
in sub-Saharan Africa, the number of TB
cases in that region will double to 4
million new cases per year soon after
2005.
Almost half of HIV patients in sub-Saharan
Africa develop active TB, whereas only
5% to 10% of individuals infected with
TB and not infected with HIV develop active
TB.
Risk
of developing TB disease
The
following figures show the risk of developing
TB disease for three different groups of people.
Figure
1.6
TB infection and no risk
factors(about 10% over a lifetime)
TB infection and
diabetes(about 30% over a lifetime)
TB infection andHIV infection(a
very high risk over a lifetime)
For people with
TB infection and no risk factors ,
the risk is about 5% in the first
two years after infection and about
10% over a lifetime.
For people with
TB infection and diabetes, the risk
is 3 times as high, or about 30% over
a lifetime.
For people with
TB infection and HIV infection , the
risk is about 7% to 10% PER YEAR,
a very high risk over a lifetime.
In
an HIV-infected person, TB disease can develop
in either of two ways. First, a person who
has TB infection can become infected with
HIV and then develop TB disease as the immune
system is weakened. Second, a person who
has HIV infection can become infected with
M. tuberculosis and then rapidly
develop TB disease.
TB-HIV:
How Can We Stop the Twin Epidemic?
December
1, 2003 - Marking World AIDS Day
WHAT:
For World AIDS Day (December 1, 2003), the
Global Alliance for TB Drug Development
and RESULTS hosted a press call addressing
the number one health threat facing AIDS
patients worldwide: tuberculosis. Leading
experts from medicine, philanthropy, public
health and drug development discussed a
better course for reversing TB, the oldest
airborne contagion, now teaming up with
HIV/AIDS to sweep the globe.
TB is the number one killer of people
infected with HIV worldwide.
In Africa alone, TB kills people infected
with HIV/AIDS in just 5-6 weeks.
Treating TB in HIV+ patients today will
save lives tomorrow.
Better, faster drugs for TB will stop
TB in HIV+ individuals before it becomes
infectious and lethal
A
Lethal Synergy: While HIV/AIDS has exploded
over the last decade, TB has increased 20%
rise and today TB kills one out of three
AIDS patient worldwide.
The two diseases represent
a deadly combination, since both are more
destructive together than either is alone.
HIV infection is the most potent risk factor
for converting latent TB into active transmissible
TB – accelerating the spread of the
disease - while TB bacteria help accelerate
the progress of the AIDS infection in the
patient. Today TB is the leading cause of
death in persons who are HIV positive.
12 Million Co-Infected
A total of 12 million people
worldwide are co-infected with both diseases,
with a majority of them living in Southern
Africa. In sub-Saharan Africa, where the
majority of all global AIDS cases exist,
two-thirds of TB patients are co-infected
with AIDS. When someone with latent TB becomes
co-infected with HIV, his/her risk of developing
active TB increases by a factor of 30 -
50.
While policymakers are
currently developing better technical frameworks
to improve today’s strategies for
TB control in HIV hotspots, better drugs
that eliminate TB in HIV patients are key
to halting the dual infection. By developing
new drugs that effectively halt latent TB
quickly, we can give millions of co-infected
a shot at better lives. Joint treatment
programs are a must.
HIV-AIDS and TB Epidemics: A Vicious
Cycle
One in three HIV-infected people worldwide
are co-infected with the TB bacterium.
TB is responsible for the death of
one out of every three people with HIV/AIDS
worldwide.
People who are HIV-positive and infected
with TB are 30 times more likely to develop
active TB than people who are HIV-negative.
The TB bacterium enhances HIV replication
and might accelerate the natural progression
of HIV infection.
Because of the increased spread of
HIV in sub-Saharan Africa, the number
of TB cases in that region will double
to 4 million new cases per year soon after
2005.
Almost half of HIV patients in sub-Saharan
Africa develop active TB, whereas only
5% to 10% of individuals infected with
TB and not infected with HIV develop active
TB.
HIV
and TB form a lethal combination. One in
three people with HIV/AIDS will die from
tuberculosis. Currently, over 12 million
people are co-infected and rising. What
makes these two diseases such a devastating
pair?
HIV-positive individuals
do not have the internal immune-system resources
to keep the mycobacterium TB in check. In
fact, they are 30 times more likely to develop
active TB than people who are HIV-negative.
[1] As a result, they succumb to the disease
at an alarming rate.
Although people with HIV/AIDS
are dangerously susceptible to a number
of opportunistic infections, TB is clearly
the leading killer.
TB Increases Progress
of HIV
At the same time, TB appears to make matter
worse in terms of the HIV infection, iteself.
According to the Centers of Disease Control
and Prevention in the United States, studies
have shown that the host immune response
to the TB bacterium enhances HIV replication
and might accelerate the natural progression
of the HIV infection.[2]
Tackling AIDS Means
Tackling TB
For these reasons, TB poses a high level
of risk for HIV patients to develop active
tuberculosis, which will take one in three
of their lives. In order to stem the tide
of deaths from AIDS, therefore, it is crucial
to work towards new, faster-acting ways
to combat TB and develop preventive TB treatment
programs.
Current HIV/AIDS infection
rates are staggering, particularly in sub-Saharan
Africa. Given the relative ease of transmitting
TB, an airborne contagion, mortality rates
from the combined diseases will continue
to rise without a dedicated effort to combat
the TB scourge.
The key is for support
and advocacy groups to recognize the value
in promoting the common goals of fighting
the two diseases side-by-side. This need
can begin to be addressed by People Living
with HIV/AIDS (PLWHA) groups stressing that
TB and HIV programs should collaborate much
more effectively.
Joint UNAIDS/WHO Press Release. "HIV
Causing Tuberculosis Cases to Double in
Africa." Geneva, Switzerland. April
23, 2001.
CDC "HIV and TB Prevention and
Care"
The
Deadly Intersection Between TB and HIV
Tuberculosis
(TB) is a disease that is spread from person-to-person
through the air, and it is particularly
dangerous for people infected with HIV.
Worldwide, TB is the leading cause of death
among people infected with HIV.
An estimated 10-15 million
Americans are infected with TB bacteria,
with the potential to develop active TB
disease in the future. About 10 percent
of these infected individuals will develop
TB at some point in their lives. However,
the risk of developing TB disease is much
greater for those infected with HIV and
living with AIDS. Because HIV infection
so severely weakens the immune system, people
dually infected with HIV and TB have a 100
times greater risk of developing active
TB disease and becoming infectious compared
to people not infected with HIV. CDC estimates
that 10 to 15 percent of all TB cases and
nearly 30 percent of cases among people
ages 25 to 44 are occurring in HIV-infected
individuals.
This high level of risk
underscores the critical need for targeted
TB screening and preventive treatment programs
for HIV-infected people and those at greatest
risk for HIV infection. All people infected
with HIV should be tested for TB, and, if
infective, complete preventive therapy as
soon as possible to prevent TB disease.
Intersection of
Two Global Epidemics
Approximately 2 billion people (one-third
of the world's population) are infected
with Mycobacterium tuberculosis, the cause
of TB.
TB is the cause of death for one out of
every three people with AIDS worldwide.
The spread of the HIV epidemic has significantly
impacted the TB epidemic. one-third of the
increase in TB cases over the last five
years can be attributed to the HIV epidemic
The Continued Threat
of Multidrug-Resistant TB
Every nation must face the challenge of
combating multidrug-resistant (MDR) TB.
People infected with HIV and living with
AIDS are at greater risk for developing
MDR TB. MDR TB is extremely difficult to
treat and can be fatal. While the number
of cases has remained stable in the United
States over the past few years, people with
MDR TB have now been reported from 43 states
and the District of Columbia.
To prevent the continued
emergence of drug-resistant strains of TB,
treatment for TB must be improved in the
United States and across the globe. Inconsistent
or partial treatment is the main cause of
TB that is resistant to available drugs
(MDR-TB.) The most effective strategy for
ensuring completion of treatment is Directly
Observed Therapy, and its use must be expanded.
Another challenge that
individuals co-infected with HIV and TB
face is the possible complications that
can occur when taking HIV treatment regimens
along with drugs commonly used to treat
TB. Physicians prescribing these drugs must
carefully consider all potential interactions.
Addressing the
Dangers of the Interconnected TB/HIV Epidemics
Requires
Expanded Efforts
TB control is an exercise in vigilance;
the goal of controlling and eventually eliminating
TB requires a targeted and continuous effort
to address the prevention and treatment
needs for those most at risk, including
HIV-infected individuals. Efforts to eliminate
TB are therefore essential to reducing the
global toll of HIV.
