Despite the fact that TB is curable and HIV is treatable, an estimated 8.5 million new and relapsed TB cases were reported in 2010, and an estimated 1.4 million died, which included 350,000 people living with HIV and co-infected with TB. The two diseases are closely linked because TB is frequently the first opportunistic infection in people living with HIV (PLHIV) and is the leading cause of death among them too, with one in four AIDS-related deaths caused by TB. Yet in 2010, only 34% of TB patients (1.7 million) were screened for HIV, and only 5% of HIV patients were screened for TB worldwide.
Savitri (name changed), a 35 years old mother of 3, hails from a village in district Gonda (UP, India). She is HIV positive and has suffered from TB also. I met her at the antiretroviral therapy (ART) centre of Dr Ram Manohar Lohia Government Hospital in Lucknow and was instantly struck by her infectious smile and cheerful disposition. Three years ago both she and her husband were diagnosed with HIV. She was immediately put on ART, but not her husband as the doctor found his CD4 count okay. Ironically her husband died six months later of a fall, but Savitri is up and about. She has completed a two years anti-TB treatment regimen which was started alongside ART. Initially she bought the TB medicines from the private market spending around Rs 3500 (approximately USD 70) a month. Later on she got them for free from a government hospital in Lucknow. Every month she travels a distance of 150 km to Lucknow to collect her ART medicines. She told me happily, “I stay with my parents-in-law and work in my fields. They behave nicely with me and treat me just like any other person. I do not have any family/social problems. I have faced no stigma in my village too. Luckily my children are all negative. I will live as long as there is life for me.”
Savitri is just one of the 2.3 million PLHIV in India, 95,000 of who are co-infected with TB. The TB burden of India is the highest in the world with 1.98 million cases (8% of them are HIV positive too) and about 280,000 deaths occurring due to TB annually. Without timely diagnosis and treatment, a large number of these people who are the doubly sick with TB as well as HIV are likely to die. So there is an urgent need to shift to focus on new strategies to scale up TB prevention using existing tools, experience and evidence. The World Health Organization recommends the Three I’s as the three strategies for reducing the burden of TB-HIV co-infection: Isoniazid preventive therapy (IPT), Intensified case finding for TB, and Infection control. While IPT is a backbone for TB prevention among PLHIV, to help prevent them from developing active TB disease, ART suppresses the growth of HIV and restores the immune defence mechanisms, reducing the occurrence of opportunistic infections and improving quality of life. When given alone ART provides a 65% reduction in TB risk among PLHIV, and when given along with IPT it can reduce TB risk among PLHIV by up to 97%. ART also reduces the risk of transmission between sexual partners and mother to child transmission during pregnancy, childbirth and breastfeeding. Cotrimoxazole preventive therapy (CPT) is used as part of the management of HIV-infected TB patients to effectively protect them from several disease-causing organisms that can lead to further illness and death.
Despite guidelines of revised national TB control programme (RNTCP), National AIDS Control Organization (NACO) and the WHO, to provide ART regardless of CD4 count to PLHIV co-infected with TB, only 49% of TB-HIV co-infected people were enrolled on ART and 77% received CPT.
The main obstacles to managing patients with TB and HIV co-infection are weak coordination between TB and HIV programmes and slow integration of TB-HIV services into the public health services. Early diagnosis, timely initiation of treatment for both diseases and careful monitoring are essential to treat TB in PLHIV and identify HIV infection in people with TB. Perhaps it would be good to have a ‘one-stop outlet’ where both TB and HIV services are available. Then patients will not have to move away from the facility where they are on ART if they develop TB, nor go to a new facility as TB patients when they are already receiving ART elsewhere.
In the opinion of Dr Soumya Swaminathan, a senior Scientist at the National Institute for Research in Tuberculosis, Chennai, “All TB patients should be tested for HIV wherever there is moderate or high HIV prevalence. Likewise all HIV patients should be tested for TB on a regular basis. In India this poses a real difficulty because of the patient overload at the understaffed ART centres and no systematic method for testing TB in all the regular TB clinics. Once TB co infection is diagnosed in PLHIV, the patient has to go to the nearest DOTS centre for TB treatment, in addition to going to the ART centre for HIV treatment. Taking treatment from two different places becomes very challenging. Currently, the dropout rates of TB-HIV co-infected patients are around 50%. Either they go to the DOTS centre and take the TB treatment and do not report to the ART centre, or they go to the ART and do not start the TB treatment. Mortality is also quite high among TB-HIV co infected patients because they are not able to start on ART early enough. ART should be started immediately along with the TB treatment. As of now, unlike TB treatment which is decentralised, down to the PHC level, ART treatment for HIV is very centralised in India. HIV treatment needs to be decentralised so that even doctors in PHCs should be able to prescribe at least the first line ART treatment as it is a standardised regimen. Perhaps for the second line treatment patients can be referred to a specialized centre. Another important aspect which is generally overlooked is about the primary nutritional support which is important at least for the first few months. By the time patients develop TB and HIV, they are mostly very malnourished, and have lost a lot of weight especially because of the toxicity of medicines. We need to have a detailed and dedicated treatment programme promoting nutrition and support both for TB and HIV patients.”
Dr Riitta Dlodlo, TB-HIV programme coordinator at The International Union Against Tuberculosis and Lung Disease (The Union), rightly feels that, “Shortage of adequately trained and ably supervised health professionals, poses serious challenges to management of patients with TB and HIV infection. This situation could be eased by strengthening collaboration and coordination between national TB and HIV/AIDS control programmes. I believe that by focusing on collaboration and coordination the national ministries of health would be able to better plan, implement and monitor TB and HIV programmes better and ensure good quality services to patients, their families and communities.”
Working with national TB and AIDS programmes in sub-Saharan Africa and Asia since 2004, The Union’s Integrated HIV Care for Tuberculosis Patients Living with HIV/AIDS (IHC) Programme has successfully strengthened collaboration and built the capacity of the general health systems to deliver integrated TB and HIV care. More such programmes are needed, especially in countries like India, so that health systems coordinate their services to provide effective care and overcome challenges that adversely impact patients’ treatment access and outcomes. Till there is a cure for HIV/AIDS, the least we can do for the PLHIV is to at least save them from the scourge of TB which is curable if diagnosed timely and treated properly. It is hoped that the forthcoming XIX International AIDS Conference (AIDS 2012) will impress upon governments and stakeholders to mobilize forces to ‘Turn the Tide’ against the onslaught of TB and HIV.
Shobha Shukla - CNS
(The author is the Managing Editor of Citizen News Service (CNS). She is a J2J Fellow of National Press Foundation (NPF) USA. She has worked earlier with State Planning Institute, UP and taught physics at India's prestigious Loreto Convent. She also authored a book on childhood TB (2012), co-authored a book (translated in three languages) "Voices from the field on childhood pneumonia" and a report on Hepatitis C and HIV treatment access issues in 2011. Email: firstname.lastname@example.org, website: http://www.citizen-news.org)