HIV and Tuberculosis: Turning the tide against TB and HIV co-infection

Current State of Affairs

At the United Nations (UN) General Assembly special session on HIV/AIDS (2001), the leading infectious cause of death among people living with HIV (PLHIV) – tuberculosis (TB) – was not on the agenda. The resulting Declaration of Commitment on HIV/AIDS did not even include the word ‘tuberculosis’.

It did, however, assert that by 2003 national governments would: “... in an urgent manner make every effort to provide progressively and in a sustainable manner, the highest attainable standard of treatment for HIV/AIDS, including the prevention and treatment of opportunistic infections…”

New strategies and tools are urgently needed to tackle the challenge of TB/HIV co-infection. The WHO recommended collaborative TB/HIV activities must be accelerated, and research stepped up to deliver a new generation of effective drugs and diagnostics to keep co-infected people alive. Closer coordination between national TB and HIV programmes and services is vital. TB and HIV accelerate each other’s progression. PLHIV infected with TB have much greater chances of developing active disease than HIV negative people, even at high CD4 counts.

Even where the DOTS strategy is available, current diagnostic tests fail to detect active TB among 60-80% of people with HIV due to the predominantly smear negative pulmonary or extrapulmonary nature of TB in PLHIV. Although recent studies have shown that, in some settings, over three-quarters of people presenting at TB clinics may be co-infected with HIV, only a small fraction of people with TB are also tested for HIV.

An even smaller proportion enter antiretroviral (ARV) treatment. In some countries, people with HIV-associated TB disease experience up to 33% mortality during the first two months of TB treatment. Rifampicin, a cornerstone drug in TB combination therapy, has adverse interactions with HIV treatment regimens containing nevirapine or protease inhibitors. Further, the current TB vaccine used to prevent childhood TB may not be safe for children with HIV.

Recommendations

Building on closer integration of TB and HIV programmes in the short-term, our best hope for turning the tide against TB and HIV co-infection lies in the full implementation of WHO recommended TB/HIV collaborative activities and the development of new diagnostic tests, drugs, and vaccines that can identify co-infected individuals and provide them with fast, effective and affordable treatment, or prevent TB infection altogether.

The AIDS-Care-Watch campaign calls upon national governments, international agencies, donors, and advocacy groups to explicitly recommend and commit to specific actions and investments that will generate:

• Universal access, by 2010, to the full WHOrecommended package of 12 collaborative TB/HIV activities in all health systems – public and private – and in a decentralised fashion at primary care levels.
  
• Better TB diagnostic tests for use in resource-poor settings that are rapid and effective for diagnosing pulmonary and extrapulmonary TB disease in people with HIV, including
  children.
  
• New drugs that shorten TB treatment duration and are safe for use in people being treated for HIV.
  
• Greater availability and systematic provision of drugs such as isoniazid and cotrimoxazole to prevent/treat TB and other opportunistic infections among PLHIV, including HIV-infected children.
  
• A TB vaccine safe for use in PLHIV to prevent undue suffering and death among those at high risk.
  
• Greater support for engagement by civil society organisations – including people living with or recovered from TB and PLHIV – in the design, implementation and evaluation of TB/HIV policies and services.
  

TURNING THE TIDE AGAINST TB AND HIV CO-INFECTION- This document has been adapted from a civil society position paper produced by Health and Development Networks, Treatment Action Group, OpenSociety Institute, TB Alliance, and the World AIDS campaign for the 2006 UNGASS review meeting, June 2006.

The AIDS-Care-Watch campaign is a global initiative with the goal of reducing the number of HIV-related deaths in 2006. The campaign has over 400 non-governmental and civil society partners. For more information about the campaign and its partners, please go to

www.aidscarewatch.org or email: info@aidscarewatch.org
ACWPosition IAC August 2006
HIV and Tuberculosis