World AIDS Day message: Preventing TB deaths among people living with HIV
As countries and partners come together to commemorate World AIDS Day this year and call for intensified HIV prevention, preventing TB deaths among people living with HIV should remain firmly on the radar.
Considerable progress has been made to address HIV-associated TB since the height of the joint epidemic in the early 2000s. The TB/HIV response is estimated to have saved some 6.5 million lives globally over the past decade. However, TB still continues to be the major cause of HIV-related deaths, accounting for a third all AIDS deaths in 2015.
At this year’s UN High-Level Meeting on Ending AIDS, Member States signed up to reducing TB-related deaths among people living with HIV by 75% by 2020, compared with 2010. “As we mark World AIDS Day, we must not lose sight of this key target”, said Dr Mario Raviglione, Director of the WHO Global TB Programme. “There is no justification for TB patients who are living with HIV to go without life-saving antiretrovirals, or for people who know their positive HIV status to go without treatment to prevent TB. We won't prevent deaths without universal "test and treat" for HIV and TB.”
Bridging the case detection gap will be key to reducing mortality
According to WHO’s Global TB Report 2016, of the 1.2 million estimated people living with HIV who fell ill with TB in 2015, just over half a million were reported to have reached care and received TB treatment. “This represents a massive 57% of unreported cases which has a knock-on effect of reducing TB treatment and ART coverage. Bridging the HIV-associated TB detection gap will be critical for reducing preventable deaths,” said Dr Haileyesus Getahun, Coordinator in WHO’s Global TB Programme, heading up the response to HIV-associated TB. “There is an urgent need therefore to intensify efforts in case-finding for HIV in people attending TB care and for TB in people attending HIV care settings.”
TB services provide an incredibly important entry-point for HIV testing and ART provision. In the 30 countries with the highest burden of HIV-associated TB, 64% of TB patients knew their HIV status in 2015. Put another way, more than 1.5 million people who entered TB care in these countries did not have a documented HIV test. HIV testing should be offered as routine care to all people who are diagnosed with TB. Recently launched WHO guidance recommends additional strategies for increasing HIV case detection, namely self-testing and assisted partner notification, which can be used by TB patients and services to maximize HIV testing coverage. TB services can also offer HIV testing services to partners and family members of TB patients with confirmed HIV-positive status. Offering HIV testing services to people who access healthcare with presumptive TB (who present symptoms but their diagnosis is not yet confirmed) offers a further opportunity in such settings to increase HIV case detection and linkage to timely ART.
TB case-finding activities should also be enhanced in facilities offering HIV care. Active TB was detected in 10% of people newly enrolled in HIV care in reporting countries in 2015. Routine TB screening of people attending HIV care at each visit should be the minimum standard of care. This should be combined with strategic scale-up of WHO-recommended rapid molecular diagnostic tests such as Xpert MTB/RIF to ensure it is easily accessed as the first diagnostic tool for both TB and drug-resistant TB. Uptake of the latest algorithms as set out in the 2016 revision of the Consolidated Guidelines on the use of antiretroviral drugs for treating and preventing HIV, that promote lateral flow urine lipoarabinomannan and presumptive TB treatment for seriously ill people living with HIV, will further fast-track patients to much needed treatment and reduce mortality.
Working together to expand the reach for patient-centred care
As countries renew their national strategic plans for HIV and TB, and enter new funding cycles the importance of joint planning and implementation to enhance coverage cannot be overemphasized. Concerted efforts should be made to ensure decentralized, integrated, patient-centered care that simplifies the continuum of care,maximizes case detection and treatment, and limits the delays between each link. Working with actors beyond the public health sector such as with other ministries, civil society, and private health care practitioners will be essential for expanding the reach. And finally, integrated recording and reporting of TB and HIV interventions along with operational research will be crucial to monitor progress and address the gaps in service delivery.
