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.

• CDC HIV/AIDS Facts - January 2008
• TB/HIV Working Strategic Plan 2006-2015
• An HIV/TB strategy for the Eastern Mediterranean Region (2006–2010)
  
• Project to focus TB control programme in special groups
  
• Authorities in Andhra Pradesh grapple with deadly duo as District sees rise in HIV-TB co-infection cases.
  
• India 'must tackle tuberculosis and HIV/AIDS together
  
• Effectively treating TB will not solve the worldwide AIDS crisis, but it will significantly reduce its burden
  
• Importance of blood samples for diagnosis and drug sensitivity testing in HIV positive patients with suspected tuberculosis
  
• Two Diseases - One Patient
  
• The Rise Of "Ebola with wings"
  
• Tuberculosis, HIV On Collision Course In Asia
  
• The Situation In Asia
  
• The Global Situation
  
• HIV/AIDS In India
  
• Background - The Burden Of HIV-Related Disease, And In Particular HIV-Related TB
  
• The International Response To TB/HIV- An Evolving Approach
  
• WHO's Role In Coordinating The Process Of Delivering An Effective Response To TB/HIV - The STOP TB Initiative
  
• The "ProTest" Initiative
  
• HIV-AIDS and TB Epidemics Fueling Each Other in Deadly Spin
  
• Risk of developing TB disease
  
• Guidelines For Management of TB in HIV Infected
  
• TB-HIV: How Can We Stop the Twin Epidemic?
  
• The Global Threat
  
• TB And HIV: Deadly Symbiosis
  
• The Deadly Intersection Between TB and HIV

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.

Click here to read more:

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.

Click here to read more:
The TB/HIV Working Group Strategic Plan 2006-2015

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.

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.

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.

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.

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

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.

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.

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.

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.

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.

• 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.

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.

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.

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.

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.

• 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.

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.

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

WHO:

Experts on the call included:

• Dr. Helene Gayle, Bill & Melinda Gates Foundation
  
• Gregg Gonsalves, Gay Men's Health Crisis
  
• Dr. Mario Raviglione, World Health Organization
  
• Joelle Tanguy, Global Alliance for TB Drug Development
  
• Moderated by Dr. Joanne Carter, RESULTS
  

Click here to download the full transcript of the conference call.

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.

To Learn more about TB and HIV

• WHO report: TB-HIV Fueling Each Other (PDF 280KB)
  
• "Double Scourge: Tuberculosis and HIV Coinfection" by Wafaa El-Sadr, MD, MPH. Printed in PRN Notebook, Dec. 2001. (PDF)
  
• UNGASS statement on TB and HIV/AIDS (PDF 26KB)

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.