How will we achieve HIV targets without effective TB control?

Photo by desi.italyTuberculosis (TB) remains the most common opportunistic infection and the leading cause of death among people living with HIV.

The Asia-Pacific is home to more than two-thirds of the world’s TB cases, according to the Global Tuberculosis Control report released by WHO in March 2008. More than 8% of new TB infections occur among people living with HIV, who are also more vulnerable to drug resistance.

Multi-drug resistant TB, or MDR-TB, occurs when the disease becomes resistant isoniazid and rifampicin—the two most powerful first-line anti-TB drugs. People with MDR-TB are less likely to recover and global estimates indicate that about 5% of TB cases involved MDR-TB. About 50% of MDR-TB cases have been recorded in India and China.

Treatment is currently only available to about one in 10 MDR-TB patients and 90% will not receive the treatment they need.

Extensively drug-resistant TB, or XDR-TB, is virtually untreatable and is likely to emerge where second-line anti-TB drugs are widely and inappropriately used. XDR-TB is more expensive and difficult to treat than MDR-TB and the mortality rates among those affected are very high.

The transmission of TB, and in particular drug-resistant strains, is more likely to take place where there are high numbers of people living with HIV. Improper infection control procedures at healthcare facilities, such as those providing anti-retroviral treatment, can also put people at risk of TB infection, making efforts to improve control measures in these settings vital.

Developing means of rapid TB diagnosis is also vital. Most countries in the Asia-Pacific do not have the drug-susceptibility testing facilities they need to diagnose resistant strains of the disease, let alone provide treatment.

More and better quality TB drugs and diagnostics are urgently needed as well as better TB prevention and treatment programs, particularly for people living with HIV. We need to ask those fighting on the frontlines against HIV and TB in the Asia-Pacific:

- How closely integrated are TB and HIV programs in your country?

- What infection control measures are in place at healthcare facilities?

- Is your nearest hospital capable of diagnosing, preventing and treating TB in children?

- What infection control measures are in place in your country’s prisons?

- Is your nearest hospital equipped with laboratories for testing TB drug-resistance? Are infection control measures in place?

- Why do you think people with active and drug-resistant strains of TB are unable to adhere to treatment regimes?

Directly-observed treatment short-course (DOTS) is the internationally recommended TB control strategy and it includes standardized case detection, treatment and patient support. To be effective, it requires consistent drug supplies and effective monitoring systems.

But according to WHO, the emergence of drug resistant TB is a sign that DOTS programs are performing poorly. Drug-resistant strains of the disease have reached the highest levels ever recorded and if we hope to reverse this situation, surely we must look at improving the DOTS model.

Continuing current models might only compound the threat posed by drug-resistant TB. But right now many countries in the Asia-Pacific are expanding their DOTS coverage and the spread of drug resistant strains of TB is increasing exponentially.

Unless we significantly improve the performance of DOTS programs and respond effectively to drug-resistant strains of the disease we will struggle to achieve the Millennium Development Goals ‘to halt and reverse’ the spread of HIV and AIDS by 2015.

We will also fail to achieve Universal Access goals of “scaling up HIV prevention, treatment, care and support with the aim of coming as close as possible to the goal of universal access to treatment by 2010 for all those who need it.”

Bobby Ramakant-CNS

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