Groundbreaking Studies: There is hope still for TB-HIV co-infection care

Alice Tembe, CNS Correspondent, Swaziland
Photo credit: CNS:
“The road to new discoveries has been long, painful and yet filled with hope for our children born with HIV”, says Mrs. Mthethwa (name changed), a 43 year old caregiver in a peri-urban township in Swaziland. She was diagnosed with HIV 13 years ago and in her own words, ‘has stared at death in the face and was saved by the introduction of antiretroviral therapy (ART) for free by the government of the Kingdom of Swaziland’. She has since changed two different sets of Antiretrovirals (ARVs) to respond to HIV related complications with opportunistic infections including TB.

Mrs. Mthethwa is a mother of three-- two boys aged 21 and 17 years and a girl who is 9 years old. Her daughter was infected with HIV at birth and until she experienced the impact of ARVs herself, she did not envisage a future with her last born child.

When I explained to Mrs. Mthethwa the introduction of the ‘test and treat’ intervention-- the research study that recommends putting HIV infected patients on ART at the time of diagnosis, irrespective of their CD4 + cell count, her eyes lit up and tears streamed down her cheeks at the same time. She was optimistic in her belief that there is hope still for her daughter to live a long and quality life. She noted that even though these may be results of scientific studies, she is happy to learn that the lives of those infected with HIV and under risk of developing TB have not been forgotten. The continuing research offers a new lease of life and provides the much needed hope for the future generation.

A research paper published in the Annals of Internal Medicine on optimal timing of ART for HIV infected adults with TB, shows that starting ART within two weeks of diagnosis of TB, improved survival among patients with both infections who had very low immune-cell counts. Those with strong immune systems, however, might benefit from waiting until after the end of the six-month TB treatment before initiating anti-HIV therapy.

“Our findings support guidelines recommending early initiation of ART in patients with a high degree of immune system compromise,” Dr Nachega, lead author of the study said. “But delaying ART might be possible until the end of TB treatment with patients with CD4 counts greater than 220 cells/mm3, which could reduce the burden of taking two complex drug regimens at the same time.”

However, Dr Nachega noted that there is other emerging evidence showing the clinical and public health benefits associated with early initiation of HIV treatment, other than survival as early treatment may be beneficial by decreasing comorbidities due to ongoing inflammation caused by HIV and decreasing HIV sexual transmission.

Introduction of ART at 500 CD4 + count, has been found to (i) increase life expectancy and high quality of life, (ii) lower risk of new transmission, (iii) lower risk of developing HIV related illnesses and (iv) decrease comorbidities as an added impact .

While Swaziland has since introduced early treatment through the ART programme, then led by Dr Velephi Okello, who is now serving as Deputy Director in the Ministry of Health, there has been careful and stratified expansion to ensure that the system can manage the demand and the beneficiaries can accommodate the commitment.

Furthermore, groundbreaking research arouses new fundamental questions which must be addressed. In resource limited setting, the ‘test and treat’ approach will require in-depth understanding of several doubts and misgiving surrounding this:

  • Will introducing IPT prophylaxis for HIV infected patients breed a new kind of drug resistant TB in future?
  • In TB and HIV high burden settings like Swaziland and other countries in Sub-Saharan Africa, if people are feeling well is there really a need to travel the long and dreaded journey to the hospital and survive long queues for ART refill?
  • Is there no high risk of default and lost to follow up cases thereby allowing viral mutation?
  • Unlike in Swaziland, most Southern African governments do not self-fund the ART programmes. With increased enrolment, how is the cost and consistent supply of medicines going to be sustained?
While these concerns are valid, they should not serve as a deterrent from seeking innovative and more effective TB-HIV care interventions. Instead they should refine interventions and leave no person in need behind. As Mrs. Mthethwa explained, nobody should be forgotten as  there is hope still for the future generation.
Alice Tembe, Citizen News Service - CNS
September 7, 2015