HIV-TB Co-infection perils around the globe

Chhatra Karki, CNS Correspondent 
TB co-infection in people living with HIV (PLHIV) has remained alarmingly high all over the world. Studies have revealed that the  risk of developing TB is 21-26  higher in PLHIV as compared to those who are HIV negative. Also, about one in five AIDS-related deaths in 2012 were attributed to TB. This poses a great challenge to many governments worldwide, since they have not yet taken integrated steps for its effective control.

According to World Health Organization (WHO) data, in 2012, out of the 35.3 million PLHIV all over the world, 11.8 million were found infected with TB. Though TB is curable and HIV is treatable, out of the 1.3 million TB deaths in 2012, 320,000 died of HIV-associated TB and half of these deaths were in women. The number of these deaths would have been less, if TB infection in the PLHIV had been screened and treated timely. It is essential to provide HIV treatment services in TB centres jointly.

According to National Centre for AIDS and STD Control (NCASC) Nepal, in 2013, the number of PLHIV in Nepal stood at 50,200, out of which 2.4% were also found to be suffering from TB. A greater incidence of HIV infection was found in female sex workers (FSWs), people who inject drugs (PWIDs) and labour migrants. Although the first patient of HIV was reported in 1988 in Nepal, the infection massively increased after 1996. Though the government of Nepal has the goal to reduce new HIV infections by 50% and HIV related deaths by 25% by 2016, the challenges have increased as PLHIV are getting co-infected with TB.

According to chest specialist Dr. Dirgha Singh Bam, the integrated programmes to control HIV-TB are not able to ensure effective treatment for co-infected people. He says, "TB clinics and HIV Testing Centres are not available all over the country."

The Global Fund to Fight AIDS, Tuberculosis and Malaria has come forward to invest money in the eradication process of HIV, TB and Malaria in Nepal. The WHO has asked governments and responsible stakeholders to take an initiative to control the spread of TB in PLHIV. Despite being the leading cause of death for people with HIV, TB is a neglected part of the AIDS political and policy agenda. According to experts, HIV-TB co-infections could be minimized if the existing resources are properly utilized.

Dr Anthony D Harries, Senior Advisor, International Union Against Tuberculosis and Lung Disease (The Union), says that, "More attention must be paid to the Three Is of reducing the TB burden in HIV infected persons, especially infection control in health facilities and isoniazid preventive therapy. More widespread coverage of ART and earlier start of ART,has clearly shown to reduce the risk of TB in PLHIV.100% HIV testing of TB patients and ensuring that all HIV-infected TB patients are started as soon as possible on cotrimoxazole preventive therapy and ART is also necessary."

One of the main barriers to care for people affected by TB-HIV is the weak coordination between TB and HIV programmes. This bureaucratic challenge means that people affected by TB-HIV often cannot access health services to treat both illnesses together.  They range from late presentation to care (frequently, due to limited access to care, poverty, stigma etc) to delays in diagnosis and initiation of life saving treatments. Dr Riitta Dlodlo, TB-HIV programme coordinator; Stop TB TB/HIV Working Group, The Union, says  that, "Health workers need training, support supervision and clinical mentoring to perform better.  In addition, to knowledge-related issues, health workers should also examine their attitudes to become more patient-centered.  They need good communication skills to create rapport with patients, their families and communities at large. We need to be better in using data to appraise the weaknesses in the TB-HIV treatment cascade."

The World Health Organization recommends that PLHIV who do not have active TB receive 6 months of treatment with the anti-TB medicine isoniazid. The purpose of such “isoniazid preventive therapy”—or IPT—is to reduce the risk of a latent TB infection (that the PLHIV might have) from progressing to active TB disease. Research shows that IPT is safe and effective for PLHIV. However, progress in providing IPT to PLHIV has been slow and varies by country. Globally, only 31% of the PLHIV, who began ART in 2012, were also provided IPT.  But in countries like India, for example, providing IPT is not part of the National AIDS Control programme as yet, and hence it is uncommon for PLHIV to receive IPT.

Chhatra Karki, Citizen News Service - CNS 
7 August 2014