More advocacy and collaboration needed to tackle the HIV-TB co-epidemic

Urvashi Prasad, CNS Correspondent, India
A person living with HIV (PLHIV) is 26 to 31 times more likely to develop active TB as compared to someone who is HIV negative because of a considerably weakened immune system. It is estimated that of the 1.2 million HIV deaths in 2014, one in three was attributable to HIV-TB co-infection. HIV and TB are a deadly combination. In fact, TB is able to spread more easily in PLHIV. This is why extra-pulmonary TB is more common in TB-HIV patients.

Conversely, active TB is an important factor in the acceleration of AIDS infection in people. A major challenge with HIV-TB co-infections is that TB is far more difficult to diagnose and treat in people with HIV. PLHIV with TB have a lower concentration of the TB bacterium in their sputum. Also, extra-pulmonary TB, which is more common in people with HIV as compared to TB of the lungs, cannot be detected by a sputum test or chest X-rays. This explains why post-mortem autopsies suggest that in almost half of HIV-positive people who lost their lives to TB, the disease was undiagnosed at the time of their death. Another challenge is monitoring the treatment of HIV-TB co-infected patients because of the possibility of adverse side-effects and drug-drug interactions. Treatment of TB can also take longer in patients with HIV and even after completion of their TB treatment PLHIV are vulnerable to getting re-infected with TB.

Addressing the HIV-TB co-epidemic is a global need. In 2004 the World Health Organisation endorsed a policy approach focused on tackling the two diseases in a collaborative manner, for the first time. WHO estimates that since 2005, joint interventions for HIV and TB have saved approximately 5.8 million lives. In India, there is a high dual burden of HIV and TB. It is estimated that 5% of TB patients are also infected with HIV. The situation is further complicated because India is a large country with widely varying health system capacities across different states. Late diagnosis of HIV is another challenge. During a webinar organised by CNS in the lead up to the International TB Conference and 21st International AIDS Conference, Dr KS Sachdeva, Deputy Director General of National AIDS Control Organisation (NACO), Ministry of Health and Family Welfare, India, highlighted that in India around 85% of all registered TB patients know their HIV status. There is, however wide regional disparity and in some states this is as low as 43%.

It is vital that all PLHIV are tested for TB and similarly every active TB patient must be tested for HIV. Also, all  PLHIV should be given Isoniazid preventive therapy as well as be put on ART early on, irrespective of their CD4 count. TB infection control must also be ensured in healthcare and other settings. For those who are diagnosed with both TB and HIV, Cotrimoxazole preventive therapy and ART is crucial. Close coordination between TB and HIV interventions is needed in order to control the co-epidemic. Ideally, health services focused on TB and HIV should be at the same location, as the communities that are affected by the co-epidemic are often the same. Sustained advocacy is also required so that collaboration between different types of interventions for the two diseases can be ensured.

Urvashi Prasad, Citizen News Service - CNS
July 27, 2016