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TB Africa's silent challenge
Southern Africa AIDS Information Dissemination Service (SAfAIDS)
March 23, 2007

Although Tuberculosis (TB) was discovered centuries ago, its impact and spread remains unprecedented. Approximately 2 billion people (one-third of the world's population) are infected with Mycobacterium tuberculosis, the cause of TB (CDC, 2007). As a disease that is spread from person-to-person through the air, TB is particularly dangerous for people infected with HIV. Worldwide, TB is the leading cause of death among people infected with HIV (UNAIDS, 2007). Another growing concern is the development of drug-resistant strains. These strains can be created by inconsistent and inadequate treatment practices that encourage bacteria to become tougher. The multidrug-resistant strains are much more difficult and costly to treat and multidrug-resistant TB (MDR-TB) is often fatal. Mortality rates of multi drug resistant TB are comparable with those for TB in the days before the development of antibiotics. MDR-TB is present in virtually all of the 109 countries (UNAIDS, 2007).

Almost half a million MDR-TB cases are estimated to have occurred in 2003, or about 5% of all TB cases (WHO 2004). Recent surveys suggest that multidrug-resistant TB is increasing in some African countries. Not surprisingly, there are gender dimensions to TB as well. TB causes more deaths among women than all causes of maternal mortality combined, and more than 900 million women are infected with TB worldwide (UNAIDS, 2007). Once infected with TB, women of reproductive age are more susceptible to developing active TB than men of the same age. It is thus apparent that stopping the spread of TB becomes everyone's priority. As the theme for 2007 says, TB anywhere is TB everywhere. New and innovative ways of combating the disease should be develop and there needs to be global galvanization for urgency and action on the matter. Interestingly, the best way to stop TB is not to fight it in isolation to the fight against HIV.Infact, we need to stop thinking of the two diseases in separate bodies, because a third of the 40 million people living with HIV today are also co-infected with TB (France 2006)

Intersection between TB and HIV
TB kills up to half of all AIDS patients worldwide. People who are HIV-positive and infected with TB are up to 50 times more likely to develop active TB in their lifetime than people who are HIV-negative(UNAIDS,2007). In addition, HIV infection is the most potent risk factor for converting latent TB into active TB, while TB bacteria accelerate the progress of AIDS infection in the patient. Many people living with HIV in developing countries develop TB as the first manifestation of AIDS. The two diseases represent a deadly combination, since they are more destructive together than either disease alone:

  • TB is harder to diagnose in people who are HIV-positive. This is because HIV weakens the cells in the immune systems that are needed to fight TB. HIV promotes both the progression of latent TB infection to active disease and relapse of the disease in previously treated patients.
  • TB progresses faster in people who are HIV-positive;
  • TB in people who are HIV-positive is almost certain to be rapidly fatal if undiagnosed or left untreated;
  • Many HIV-positive people in developing countries develop TB as the first sign of the later stages of the disease;
  • The risk of developing TB disease is much greater for those infected with HIV and living with AIDS as compared to those who are not infected.
  • People infected with HIV and living with AIDS are at greater risk for developing MDR TB.

As earlier stated, AIDS is dramatically fuelling the TB epidemic in sub-Saharan Africa, where up to 80% of TB patients are co-infected with HIV in some countries(WHO,2004). For many years efforts to tackle TB and HIV have been largely separate, despite the overlapping epidemiology. Improved collaboration between TB and HIV programmes will lead to more effective control of TB among people who are infected with HIV and to significant public health gains. The strengthening of these activities requires reorganization of health systems at the central, intermediate and peripheral level as well as the training of health professionals and the organization of supplies and equipment among other many things.

Collaborative HIV/TB Programme activities
There is need for the setting up of a coordinating body for TB/HIV activities at all levels. HIV/AIDS and tuberculosis programmes should create a joint national tuberculosis and HIV coordinating body, working at regional, district and local levels (sensitive to country-specific factors), with equal or reasonable representation of the two programmes and including tuberculosis and HIV patient support groups (WHO, 2004). Areas of collaboration would include capacity-building and training, ensuring coherence of communications about TB/HIV, ensuring the participation of the community in joint TB/HIV overseeing the preparation of the evidence base and governance and mobilization of resources for TB/HIV. There has been talk on doing this but few countries have programmes reflective of this inter-relationship:

Other programmes to consider at the health or hospital level;

  • Offering HIV testing and counseling to all TB patients;
  • Providing cotrimoxazole and antiretroviral treatment (ART) to TB patients found
    to be infected with HIV;
  • Screening people living with HIV for TB disease and provision of TB preventive therapy once active disease is ruled out.
  • Appropriate TB treatment should be provided if disease diagnosed.
  • Expediting the diagnosis and treatment of TB in people living with HIV by using
    the revised diagnostic algorithms recommended by WHO in resource constrained
    settings. (UNAIDS, 2007)

At the Home care level

  • Include TB case detection and care in training of HIV/AIDS caregivers (family members, volunteers, and health care workers).
  • Prevent new cases of TB among PLWHA and their families with isoniazid preventive treatment when appropriate.
  • Establish referral mechanisms between HIV/AIDS home care programmes and TB clinics.

Community care

  • Provide information and education on TB and HIV to increase community awareness of both infections and their inter-relationship. The messages concerning these diseases should always go hand in hand.
  • Intensify tuberculosis case finding in areas of high HIV prevalence, where there are effective local TB programmes achieving good rates of successful treatment
  • Community-based organizations, such as those providing HIV/AIDS home-based care, may also be involved in identifying people with signs and symptoms of tuberculosis, and ensuring directly observed treatment for tuberculosis. Isoniazid preventive therapy can be provided to close contacts of HIV-positive people with infectious tuberculosis. This can be done at little additional cost by existing organizations.

In a nutshell, there is need for the operationalisation of joint programmes that are reflective of the nexus between TB and HIV.Moreso; there is need for community capacity building and mobilisation to stop the twin epidemics. Nothing will succeed without HIV/TB mainstreaming at all the levels of society.

References

  • France T, SAfAIDS News (12) 1,2006
  • WHO, Interim policy on collaborative TB/HIV activities, 2007
  • UNAIDS, Joining forces to fight TB and HIV, 2007

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