A joint response launched for TB and HIV
Tuberculosis and HIV infection have fed the furnaces of each other’s epidemics leading to a world in which TB is the leading cause of death in HIV-infected people and in which HIV infection makes it much more likely for latent TB infection to become active TB. Also, TB is spreading throughout Eastern Europe where HIV rates also are soaring and, in 2000, TB killed 1.8 million people, 12% of whom were coinfected with HIV. Worldwide, TB kills about one-third of the people who have AIDS.
Despite this long-recognized link, there have been few joint initiatives aimed at eradicating HIV and TB internationally, but this situation is now changing, according to officials with the World Health Organization (WHO) of Geneva. "Although there is a long-standing recognition of the epidemiological overlap between TB and HIV, and the ways in which these two problems interact, the formulation and implementation of a joint response have lagged behind a little," says Dermot Maher, BM, BCh, medical officer for the Stop TB Department of WHO.
"On the one hand, it has taken some time for TB programs to fully grasp the need for joint TB and HIV program activities to tackle the growing epidemic of HIV-related TB," Maher adds. "And on the other hand it has taken some time for HIV/AIDS programs to fully grasp the need for joint activities to tackle TB as a leading cause of HIV-related illness and death."
TB on the backburner
TB has been just one of a long list of problems on the HIV/AIDS agenda, prompting the HIV crowd to put it on the backburner and leave it to the TB folks to solve, Maher says. Until the mid-to-late 1990s, the HIV epidemic focus was on HIV prevention rather than treatment of TB among those infected with the AIDS virus, Maher says. "Since then, the development of highly active antiretroviral treatment (HAART) has put HIV treatment and the care of people with HIV-related diseases firmly on the agenda," Maher says.
The new international policy is described in the WHO document "Strategic Framework to Decrease the Burden of TB/HIV," which is endorsed by the Global Working Group on TB/HIV, and was jointly produced by the Stop TB Department and the Department of HIV/AIDS.
The global Stop TB Partnership has the ambitious goal of significantly reducing the burden of tuberculosis through the detection of 70% of infectious cases and curing 85%, says Ger Steenbergen, MD, from the Stop TB Partnership. But the goal is achievable, as evidenced by some notable examples, Steenbergen says. "Peru provides a good example of a high TB-burden country which has achieved these national TB program targets," Steenbergen says. "The broad support from the partners for the Global Plan to Stop TB brings political commitment, technical know-how, and operational expertise and experience together."
The forum is unique with its wide scope of interests and expertise, guided by global principles for tuberculosis control, and it offers the best opportunity for tackling the disease, Steenbergen says. "TB control is not the exclusive domain of the medical experts, but it requires input also from other disciplines," Steenbergen says. "Meeting the goals of the partnership is realistic with these multidisciplinary and multisectoral collaborations and the synergy between the partners, including a wide representation of donor-agencies."
Opportunities to work together
Now that there’s a global interest and a funding plan to make HAART more widely available to HIV patients, there are increased opportunities for TB and HIV programs to work together, and there’s a greater interest in and understanding of the need for comprehensive HIV/AIDS care that includes effective diagnosis and treatment of TB, Maher explains. "In the health sector, the international policy advocated by WHO and by the Global Working Group on TB/HIV is to promote the implementation of a strategy of expanded scope to tackle the problem of HIV-related TB," Maher says.
The strategy includes interventions against TB, such as intensified TB case finding among those most at risk, effective treatment of all TB patients, and isoniazid preventive treatment. It also involves interventions against HIV, including HAART, HIV prevention, and prevention of common HIV-related diseases through the use of medicines, such as cotrimoxazole, Maher says.
"Joint TB and HIV program activities are necessary to deliver this range of interventions," Maher says. "For example, TB and HIV programs need to collaborate in ensuring that people who test positive for HIV are screened for TB, with effective TB treatment for those found to have TB and isoniazid preventive treatment for those found not to have active TB."
A collaborative network of TB and HIV programs will more efficiently monitor and evaluate activities aimed at decreasing the burden of TB/HIV. This collaboration should come naturally, Maher notes. "The key elements of a public health program of access to HAART are similar to those for access to anti-TB treatment," he explains. "These namely are political commitment, case detection, treatment under good case management conditions, a secure drug supply, and a system of recording cases, and reporting their treatment outcomes in order to enable program evaluation."
Also, as HIV/AIDS policy-makers and health care officials begin to create infrastructure for delivering HAART to the HIV-infected in developing nations, the direct observational therapy strategy (DOTS) for TB control embraces the five key elements and provides a possible delivery model for AIDS drugs.
WHO’s joint TB/HIV plan faces many challenges, however. Among these are the increased incidence of drug-resistant TB in some places and the limited access to even the inexpensive TB drugs in many others. "Clearly a plan alone won’t do anything," says Ian Smith, MB, ChB, MPH, of WHO’s Stop TB Partnership. "It’s action on the basis of the plan that will make the difference." One new initiative that is already making a difference is the Global TB Drug Facility (GDF), which is part of the Stop TB Partnership’s plan to secure access to high TB drugs in support of DOTS expansion, Smith says.
Between March 2001 and August 2002, the GDF had already processed applications from more than 40 countries and made grants to 24 nations, representing 1.1 million patients, Smith says. "Prices of TB drugs purchased through the GDF have fallen 30% compared with previous international prices, so that a full course of six- to-eight months’ treatment now costs less than $10," Smith says. "The GDF demonstrates that there are innovative ways of rapidly increasing access to affordable drugs."
Resources to tap
Aside from the GDF initiative there are a variety of resources in each country that could assist in delivering TB drugs, Maher says. These include nongovernmental organizations, missions, em-ployer health services, military services, and others. "We want to harness all of these to deliver direct observational therapy strategy," Maher says. "We want to see the day when all other providers, etc. deliver DOT strategy."
As various government entities become involved in TB treatment and control, there are a variety of strategies that can be employed, Maher adds. These include identifying peers for support systems that would buddy support and counseling. "We know that very few people can manage such an arduous task as six months of TB treatment on their own," Maher says. "None of us are likely to do that, so we want everyone to have a TB supporter who can be a house staff person or someone in the community who is willing to be trained and supervised and be a buddy for the TB patient."
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