Addressing the challenges to transform the HIV-TB response
The dual HIV-TB epidemic has posed a challenge for both TB and HIV efforts at all levels. Although the number of people living with HIV (PLHIV) screened for TB increased almost 12-fold, (from nearly 200 000 to over 2.3 million people) and testing for HIV among TB patients increased 5-fold (from 470,000 to over 2.2 million) between 2005 and 2010, almost a quarter of all AIDS deaths every year are still caused by TB despite it being preventable. An estimated 910,000 lives were saved globally over the last six years through the implementation of collaborative TB/HIV activities, yet only 46% of TB patients living with HIV received ART in 2010. Not all people living with HIV who enrolled into care were screened for TB and a far smaller proportion received isoniazid preventive treatment (IPT). In many high burden countries there has been little progress in the implementation of collaborative TB/HIV activities.
The World Health Organization and the Global TB/HIV Working Group of the Stop TB Partnership, in collaboration with Georgetown University, organized a one day international consultation meeting in conjunction with the XIX International AIDS Conference (AIDS 2012) in Washington DC on July 21, 2012, with a view to seek solutions to these problems. The general objective of the meeting was to generate innovative ideas and ways to define the next decade of the global TB/HIV response and its strategic direction. The participants included TB and HIV decision makers, opinion leaders, scientists, activists and programme managers.
The way forward would be to prevent TB infection and treat HIV. This can be done through infection control in healthcare and community settings and intensified case findings. Targeted active case findings have resulted in reduction of cases. With the focus being more on new and innovative diagnostics and treatments, simple infection control measures like hand washing and cough etiquette in communities and health care settings seem to be taking a backseat, particularly in resource poor settings. Yet their importance in controlling TB cannot be undermined.
As Dr Stephen Lawn of London School of Hygiene and Tropical Medicine mentioned, poor diagnostics act as an impediment to conquer the mountain of HIV associated TB. We need diagnostics which can work at very low CD4 counts and we need rapid detection of drug resistance. The new G4 Cartridges launched in 2011 do a much better refampycin resistance screening. Having better diagnostic tools are of course necessary, but more important is their availability at point of care. Tools like the Gene Xpert have gone a long way in early diagnosis and hence better treatment outcomes for TB. Yet the prohibitive cost of the machine (despite cartridges becoming cheaper) still keeps them out of reach for many patients. It would indeed be a golden day when we have same day diagnostic and same day treatment start—enter Anti Retroviral Treatment (ART) clinic and on day one itself get to know whether there is TB or not. Testing and treating all TB-HIV co infected people irrespective of CD4 count should be the aim. ART and IPT given together to PLHIV reduce TB risk by 80%. Benefit of IPT is also enhanced in those with latent TB. Yet as of now these seem to be a tall order in countries like India where the IPT may take at least one more year to be rolled out. As diagnostics are scaled up and more people get tested demand for drugs will go up too, and it will have to be ensured that the supply does not fall short of demand.
There was an overwhelming consensus to integrate TB and HIV programmes. It was even suggested by Dr Xia Gang of the Bureau of Disease Control, China that HIV should be treated as the 6th component of the DOTS programme and TB indicators should be a part of HIV programmes. Referring PLHIV patients to another clinic for TB testing and vice versa is bound to result in defections. One stop service which entails provision of TB as well as HIV diagnostics and treatment services in the same setting by the same clinicians, or at least proximity and inter-clinic references is needed. The collaborative activities should be programme driven and not project driven. So coordination between the two programmes is a big challenge. It was suggested that there should be no two sets of programmes or two sets of doctors even if they are co located.
But as we get entangled in the intricacies of diagnostics and treatment we seem to forget about the populations who need them most. Vulnerable groups such as injecting drug users (IDUs), prisoners, pregnant women and children are still marginalized. There are an estimated 16 million IDUs in 151 countries, and they are very often unable to access HIV/TB treatment due to punitive policies and discriminatory attitudes. According to Dr Chris Beyrer from Johns Hopkins University, detention is not treatment for IDUs. We need to treat all IDUs who are PLHIV too and in many instances they are infected with the Hepatitis C Virus as well. The triple approach of Optimize efficacy, have needle exchange coverage and opioid substitution therapy in a safe environment will be able to tackle the issue, as has been seen in the case of France which has successfully used this strategy.
Dr Somya Swaminathan from the Tuberculosis Research Centre, India, stressed that TB control must be an integral part of maternal and child health programmes. We cannot neglect maternal health and mortality if we have to control the high incidence of TB. Mother cannot be separated from the child and if the mother is infected the risk for child increases. Mortality due to TB in HIV infected children is 5 to 6 times higher than in HIV negative children. As it is TB in children is grossly under reported and childhood TB is still not a public health issue. Children need to be on top of the agenda and must be included in TB drug trials early enough. There are wide implications of IPT, shorter treatment regimens, and early initiation of ART as prevention in children. Addressing food insecurity which results in malnutrition in children—a big risk factor for TB—is also important.
So as we prepare to turn the tide, let the latest machines, medicines and researches not blur and overshadow the faces of the most at risk populations. We should not forget that all scientific advancements can only be the means to end the dual epidemic of TB-HIV-- they can never be the end themselves.
Citizen News Service
http://www.citizen-news.org/2012/07/addressing-challenges-to-transform-hiv.html
