In 2015, there were an estimated 10.4 million new TB cases, 1.2 million (11%) of these were among people also living with HIV.1 The two infections are strongly linked. There were an estimated 1.4 million TB deaths in 2015, and an additional 0.4 million deaths resulting from TB among people living with HIV.2 Whereas individuals with healthy immune systems may not fall ill from TB infection, people living with HIV with a low CD4 count are at greater risk of TB infection. In fact, the risk of developing active TB is estimated to be 26 times greater in people living with HIV than in those who are HIV-negative.
In 2014, TB surpassed HIV as the world’s leading infectious disease killer, a worrying trend for a disease that is essentially treatable and curable. Moreover, tuberculosis remains the leading cause of death among people living with HIV, accounting for around one in three AIDS-related deaths.3
Recognising the interconnection between HIV and TB, the World Health Organisation (WHO) has developed a policy recommending collaborative TB and HIV activities.4
Reducing the burden of HIV in people with TB
Increasing knowledge of HIV status
HIV testing and counselling (HTC) is recommended both for those with diagnosed TB and those with signs and symptoms consistent with TB infection. Combining HIV testing and TB facilities has been shown to increase the uptake of HTC.5
While the rate of testing has increased 18-fold since 2004, in 2015 only 55% of TB patients had a documented HIV test. Coverage is highest in Africa, where 81% of all TB patients had a documented HIV test result, but this varies between countries.6 Africa is also the region with the highest proportion of people with TB also living with HIV. An estimated 31% of people with TB are living with HIV in the region, this porportion exceeds 50% in some parts of southern Africa.7
Starting antiretroviral treatment
Programmes need to ensure that people with active TB who are diagnosed with HIV begin antiretroviral treatment (ART) as soon as possible, preferably within integrated services or TB facilities. ART reduces the risk of TB infection in people living with HIV by 65%.8 Data from almost 40,000 patients with HIV/TB co-infection in South Africa showed that people who received ART had almost half the risk of death than others, with particular benefit for those with a CD4 count below 350.9
Data from almost 40,000 patients with HIV/TB co-infection in South Africa showed that people who received ART had almost half the risk of death than others
ART also prevents the progression of HIV, reduces the chances of another opportunistic infection that could make management of care more complicated, and reduces the chances of TB recurring. However, treating both conditions at the same time can be challenging because of side-effects, pill burden, and drug interactions.
The proportion of TB patients known to be living with HIV accessing ART was 78% globally. This is an increase from 36% in 2005. In the 30 high TB/HIV burden countries, 80% of the TB patients known to be living with HIV were on ART and in six of these countries (India, Kenya, Malawi, Mozambique, Namibia and Swaziland) the figure was more than 90%.10
In contrast, there were nine high TB/HIV burden countries (Brazil, Chad, China, Congo, Ghana, Guinea-Bissau, Indonesia, Liberia, and Myanmar) in which less than 50% of TB patients living with HIV had access to ART in 2015.11
Co-trimoxazole preventative therapy
Another important element for individuals with co-infection is co-trimoxazole preventive therapy (CPT), an agent that prevents a range of secondary bacterial and parasitic infections.
Uptake of this daily medication has improved considerably in recent years, reaching 87% of TB patients living with HIV.
Reducing the burden of TB in people with HIV
Despite progress in providing TB preventive treatment to people living with HIV, much more remains to be done. Of the 30 high TB/HIV burden countries, 21 did not report any provision of preventive treatment in 2015. In the nine high TB/HIV burden countries that did report data, coverage among people newly enrolled in HIV care ranged from 2% in Indonesia to 79% in Malawi.12 In order to reduce the burden of TB, the WHO recommends an approach known as the Three I’s – intensified case-finding, isoniazid preventive therapy and infection control.13
Just as it is important to offer HIV testing to TB patients, it is vital to improve the diagnosis of TB in HIV patients.
Many studies have reported high rates of undiagnosed TB in people living with HIV. All people living with HIV should be regularly screened for TB symptoms, including cough, fever, weight loss or night sweats. If any of these symptoms are present, they may have active TB and should be further evaluated.
However, appropriate diagnostics are not always available, as TB activist Blessima Kumar explains:
When I started feeling ill, I was in a small town in southern India. I really couldn’t get anyone to diagnose me properly. Then, the doctors put me on treatment anyway — without a confirmed diagnosis. I took the treatment for six months without knowing whether it was TB or not. So getting access to an accurate diagnosis was definitely one of my biggest challenges.14
Historically, TB has been diagnosed by looking for evidence of TB bacteria either through the use of the chest X-ray, through sputum smear microscopy, or through the culturing of bacteria. However, each of these TB tests has their disadvantages. The newer GeneXpert test can dramatically improve case finding and is recommended as the diagnostic test for people living with HIV who have a cough, fever, weight loss or night sweats.
GeneXpert is a self-contained testing unit which does not require a sophisticated laboratory set up and can provide results within two hours. Using a sputum sample, the molecular test diagnoses TB by detecting the presence of TB bacteria, as well as testing for resistance to the drug rifampicin – a likely indication that the individual has multi-drug-resistant tuberculosis (MDR-TB).
While some countries including Ethiopia and South Africa have made the test available at primary healthcare facilities, in many others the test is restricted to secondary and tertiary healthcare facilities. It may be primarily used to diagnose MDR-TB, rather than being routinely used for case-finding in patients living with HIV.15
Isoniazid preventive therapy
In order to prevent cases of latent TB infection (where a person’s immune system is able to keep TB under control) from progressing to active TB (causing illness), people with HIV need both prompt initiation of ART and isoniazid preventive therapy (IPT).
The latter intervention involves taking the TB drug isoniazid daily for at least six months to prevent progression to active TB. Studies conducted in Brazil and South Africa show up to a 90% reduction in TB risk among people living with HIV who have latent TB infection who receive both ART and IPT.16 17
While provision of isoniazid has grown rapidly since 2008 – especially in South Africa – across the world less than a million people living with HIV received it in 2014 (compared to 15 million people receiving ART). Two-thirds of high HIV/TB burden countries do not provide IPT as part of their HIV response.18
The third ‘I’ is infection control measures in healthcare facilities and other settings where people with TB and HIV are frequently crowded together. This is to ensure that both people receiving HIV care and the staff providing it are not exposed to TB in the process.
However with many countries’ HIV programmes providing very little data on any of the Three I’s, many HIV treatment programmes have a long way to go in reducing the TB burden in their patients.
Progress in implementing HIV/TB programmes
Between 2000 and 2014, joint TB/HIV activities saved an estimated 8.4 million lives. However, much more needs to be done to ensure universal access to these services and eliminate HIV-related TB deaths.19
Of the TB patients who were known to be living with HIV in 2014, 77% (390,000) were initiated on ART and 87% (430,000) on CPT.20
Between 2013 and 2014, the number of people screened for active TB increased from 5.5 million to 7 million in 2014. Among the 49 countries that reported data in 2014, 930,000 people living with HIV received IPT, up from 600,000 in 2013.21
India is a country with a high burden of both tuberculosis (TB) and HIV, and faces a high burden of HIV-associated TB. While the TB epidemic is countrywide, the HIV epidemic is concentrated in a few states.22
India’s National AIDS Control Programme (NACP) and the revised National TB Control Programme (RNTCP) have been instrumental in reducing the burden of HIV and TB. Since 2001, they have implemented collaborative TB/HIV activities.23
These activities were initially launched in the six high HIV burden states. The adoption of the national TB/HIV policy framework in 2007 lead to a nationwide scale-up of joint TB/HIV programmes, which was achieved in 2012.24
India’s experience shows how collaboration can enable the scaling up of TB/HIV programmes and promote shared ownership of interventions. It also demonstrates that political and administrative commitment is critical.25
South Africa also has a high HIV/TB burden, and has also made robust efforts to tackle the two diseases simultaneously.
In 2009, TB was integrated into the mandate of the South African National AIDS Council (SANAC), alongside HIV and a joint HIV, TB and STI national strategic plan was developed.26
Policy has stipulated integration of HIV and TB services nationwide, by the co-location of services. In fact, 59% of people living with HIV worldwide who received isoniazid preventive therapy in 2014 were in South Africa.27
However, there remain significant disparities between provision in urban and rural areas. Factors affecting provision in in rural areas include staff unqualified to address HIV and TB, drug stock-outs, and inadequate infrastructure (such as a lack of private rooms to conduct pre- and post-test counselling).28
The treatment gap
In 2014, 77% of people living with HIV who were also diagnosed with active TB were placed on ART. However, by contrast, just 47% of people on ART were screened for TB, 51% of people diagnosed with TB were tested for HIV, and only half of people living with HIV who developed TB were diagnosed and provided with TB care.29
Currently, the success rate of TB treatment is lower for people living with HIV (73%), than for those who are HIV-negative (88%).30
Whereas the treatment gap is smaller in Africa, it is extremely wide in the European and Eastern Mediterranean regions, with success rates among HIV-positive TB patients of only 47% and 60% respectively, compared with 80% and 91% success among HIV-negative patients.
Furthermore, the proportion of TB patients who die during treatment is higher in people with HIV/TB co-infection.
Funding for TB/HIV programmes
It is thought that US$8 billion is needed per year in order to address TB in low- and middle-income countries, yet only US$6.6 billion was made available in 2015.31 Furthermore, this funding is not appropriately allocated, with only 6% of the annual available funds being directed towards HIV/TB co-infection activities.32
TB funding is dwarfed by HIV funding, with $19 billion spent on the HIV response in 2015. Despite having far fewer resources, national TB programmes include more TB/HIV activities than national HIV and AIDS programmes.33 HIV grants have been found to be 59% less likely to fund TB/HIV activities when compared with TB grants.34
Considering the huge overlap between these two infections, funding needs to be scaled up in order to successfully tackle both TB and HIV.35
Multi drug-resistant TB (MDR-TB)
One of the greatest challenges faced by both TB programmes and joint HIV/TB programmes, is multi drug-resistant tuberculosis (MDR-TB) - strains of tuberculosis that are resistant to the drugs isoniazid and rifampicin.
In 2014 an estimated 480,000 people had MDR-TB but only 123,000 of these individuals were actually diagnosed. More extensive use of GeneXpert diagnostics would improve the diagnosis rate.36
Eastern European and central Asian countries continue to have the highest levels of MDR-TB. For example, in Ukraine 22% of new TB cases are MDR-TB and 56% of people requiring re-treatment have MDR-TB. Globally, levels of drug resistance in people presenting for TB treatment for the first time are much lower at 3%, but 20% of individuals who have previously been treated and require re-treatment have MDR-TB.37
Moreover, as Ethiopian activist Endalkachew Fekadu explains, the most widely used treatments for MDR-TB have considerable side-effects:
There were eight pills and an injection each day. They were so toxic, with many adverse effects. I remember my mama waking me up every morning to take me to hospital because sometimes I just vomited all night and became faint.38
To address MDR-TB more effectively, in May 2016, the WHO recommended a new drug regimen that shortens the treatment period from two years to nine months. It also recommends a rapid diagnostic test, which can detect how resistant the patient’s form of TB is and the drugs are less toxic.39
It is hoped that these developments will lead to fewer interruptions in treatment and reduce the number of people who are lost to follow-up.40
Drug access and prices
MDR-TB puts a particular burden on already stretched health systems. Whereas treatment for drug-susceptible TB may cost between $100 and $500 in low- and middle- income countries, the price tag for treating MDR-TB is typically $5,000 to $10,000.41
After decades without new drugs in the pipeline, an opportunity has arisen with the introduction of new drugs bedaquiline and delamanid, as well as the re-purposing of drugs licenced for other conditions such as linezolid and clofazimine.
However, these remain unaffordable in low- and middle- income countries, with manufacturers often having little interest in the drugs being more widely used for TB treatment in high-burden countries. To date, only a few hundred individuals have actually used bedaquiline or delamanid.42
Photo credit: Photo by USAID Asia/CC BY-NC 2.0. Photos are used for illustrative purposes. They do not imply any health status or behaviour on the part of the people in the photo.
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