Tackling TB-HIV: The importance of integrated care

Shobha Shukla, Citizen News Service - CNS
Both TB and HIV pose serious health risks. But when these two infections join together, the result is a potentially lethal co-epidemic of TB-HIV. Their coexistence is similar to opposites attracting each other despite glaring differences like two unlike poles of a magnet. They are two linked epidemics that must be fought together, in order to make significant progress in ending both. 

The facts are alarming. People living with HIV (PLHIV) are 26 times more likely to develop TB than those without HIV infection and TB is the predominant cause of death for PLHIV, responsible in 2015 for 1 in 3of these deaths. In 2015, there were an estimated 10.4 million new TB cases worldwide, 1.2 million (11%) being in PLHIV. Also of the estimated 1.4 million TB deaths in 2015, 400,000 deaths were among PLHIV. 40-80% of HIV infected people with TB have extra pulmonary disease, compared with 10-20% of people without HIV. PLHIV also face increased threat of multi drug-resistant TB (MDR-TB). Dr Gilada, President AIDS Society of India, calls them dissimilar conjoint twins. “TB is very unglamorous but HIV is very glamorous. TB is 0% preventable and 100% curable while HIV is 100% preventable and 0% curable. TB has had only 12-13 new drug molecules in over 50 years, whereas HIV has had 22 molecules within 30 years and over 30 in pipeline. TB follows in 70% HIV patients at some point of time, but HIV may not follow TB. Nearly 30% TB patients are HIV seropositive. Conversely 5-9% of all HIV patients have TB (all sites included)”, said Dr Gilada.

While speaking with CNS during the National Conference on Pulmonary Diseases (NAPCON 2016), Dr Gilada stressed upon ways and means of integrating TB-HIV control programme in india. “Offices of TB and HIV societies under one combined banner would serve in a better way. It would also be very beneficial if we can insist upon drug companies producing HIV medicines (ARVs) to do research on TB medicines as well, as TB still is the mainstay for HIV patients. Then again, a large percentage of TB in PLHIV is extra pulmonary TB (ETB), which could be in the brain, joints, lymph nodes, abdomen. Unfortunately, as these patients are not infectious to others, they are not the main focus of the national TB programme that is more geared to treating sputum smear positive pulmonary TB patients. We should not neglect ETB, if we want to end TB, ” he said. He also insisted that HIV drug management in India must be streamlined. “Many patients are still receiving nevirapine and ziduvadine based regimens, even when they should not be getting them, as they maybe on ATT or are highly anaemic. So HIV medicines given at ART centres should be according to guidelines. Bulk buying of medicines for 5-7 years should stop as it interferes with introducing new optimum treatment regimens. Supply chain management of drugs should improve so that ART centres are not plagued with any uncertainty regarding future drug supplies.

During NAPCON 2016, Dr Nesri Padayatchi, Deputy Director of CAPRISA (Centre for AIDS Programme of Research in South Africa) reiterated the importance of integrating TB and HIV treatment as it can result in 56-86% reduction in mortality. Moreover healthcare workers' shortage can be overcome to a large extent by fully integrating TB-HIV services. Improving provider-patient relationship will go a long way in increasing treatment adherence, according to her. In a webinar hosted by CNS on the eve of World AIDS Day 2016, Dr Anthony Harries, Former Senior Advisor and Director, Department of Research, International Union Against Tuberculosis and Lung Disease (The Union) reminded us that “Life time risk of TB in persons with latent TB infection is 5-15% in HIV uninfected persons. But in PLHIV, this becomes the annual risk. Risk of TB increases as CD4 cell count decreases and vice versa. ART suppresses HIV replication leading to a gradual increase in CD4 cell count, which again protects against TB. In PLHIV, ART is protective—giving better overall protection at high CD4 counts. Benefit of adding Isoniazid Preventive Therapy to ART in high HIV-TB burden settings results in 36-60% more reduction in TB as compared to using ART alone. Thus ART and IPT together to PLHIV will reduce TB incidence and hence indirectly reduce TB mortality. Duration of IPT is probably indefinite”.

In the same webinar, Nomampondo Barnabas of the Union, and Monisola Ajiboye from Nigeria insisted that improved community engagement is key to ending TB and AIDS. “To end AIDS by 2030 we have to stop neglecting TB. We need to advocate about TB as we did for HIV, and use the same strategies to educate TB community on treatment literacy in TB as we did in HIV if we want to end TB by 2030. We have to increase community mobilisation around rights based responses to TB,” said Barnabas. Monisola Ajiboye is living with HIV and has also had a brush with TB in 2005—a time when there was no comprehensive treatment regimen to address both TB and HIV at the same time. She was given nevirapine (drug for HIV) along with rifampicin (drug for TB) at the same time. This wrong medication resulted in drug-drug interaction and she lost her memory for 6 months. It was only later that doctors changed nevirapine to efavirenz. For Monisola “It is very important to involve HIV community, as awareness about TB in them is very low. Though TB is the lead killer in the PLHIV in Nigeria, still many rural communities in Nigeria know very little about TB. MDR-TB rates in PLHIV are also high. As many are living in poor congested areas they spread it fast to their near family as well”.

She also made a fervent plea that nutritional support should form an important part of TB care. Proper TB medication must go hand in hand with good nutrition to prevent PLHIV dying of TB for want of proper diet. WHO estimates that 8.4 million lives have been saved between 2000-2014 through integrated and collaborative TB-HIV care activities. Still, only 47% of people on ART were screened for TB; 51% of people diagnosed with TB were tested for HIV; 50% of the estimated number of people living with HIV who developed TB were diagnosed and provided with TB care. So a lot more needs to be done to achieve universal access and to eliminate HIV-associated TB deaths. Ending TB is crucial to the survival of those with HIV. It is only through political commitment, active engagement of public as well as private sector, active civil society and the indispensable community support that we can meet the target of ending TB and HIV by 2030.

Shobha Shukla, Citizen News Service - CNS
December 6, 2016