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HIV/AIDS |
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Tuberculosis (TB) Control in the Era of HIV |
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Each year more than eight million cases of tuberculosis (TB) and nearly three million TB deaths occur worldwide. The vast majority of cases– 95 percent – arise in developing countries. HIV has contributed significantly to the resurgence of TB. HIV infection is a strong risk factor (up to 30-fold) for developing active TV from a latent TB infection. Individuals with HIV develop active TB rapidly after becoming infected with mycobacterial tuberculosis. Between 1998 and 1999, African countries severely affected by the HIV epidemic reported a 20 percent increase in the incidence of TB; this rise was largely responsible for the increase of TB globally. Conversely, active TB seems to accelerate the course of HIV infection. Tuberculosis is an important disease to target in areas severely affected by HIV because TB is curable. Although it is fueled by the HIV epidemic, TB is an infectious disease that does not remain confined to HIV-positive individuals. And, as one of the first opportunistic infections to appear in HIV-infected people, TB may be the earliest sign of HIV infection. Addressing TB offers the opportunity for early HIV intervention. When targeting TB in countries with a high HIV prevalence, care should be taken to ensure coordination of TB and HIV services. This can be accomplished by maximizing the Directly Observed Treatment, Short-course (DOTS) strategy; establishing HIV services in TB service points; incorporating TB control activities within HIV services; and advocating for greater coordination of TB and HIV programs. The DOTS strategy can be maximized by:
HIV services can be established in TB clinics by:
TB control activities can be incorporated within HIV services by:
Coordinating HIV and TB Control Programs Eight years after its introduction, the DOTS strategy seems ineffective at containing TB in countries with a high HIV prevalence; these countries have been reporting an increase in the number of TB cases. For example, Tanzania, recognized for one of the best TB control programs in Africa, reported a 160 percent increase in TB cases (all forms) between 1984 and 1993. An estimated 24 percent of all new smear-positive TB cases during that period was attributable to HIV. Similar findings were reported in some sites in Southeast Asia. In Thailand's Chiang Rai province, the incidence of TB began a long rise upward in 1991, following a decade of steady decline. The TB increase was closely correlated with an increase in HIV among TB patients. Adding other interventions to the DOTS strategy – such as treatment of latent TB infection, active case finding and contact investigation – has helped control TB in the United States and Western Europe. Data from clinical trials have shown that anti-TB drugs can prevent latent TB infection from becoming active TB disease. Implementing treatment for latent TB infection, commonly known as TB preventive therapy (TB PT), may be an effective way to reduce the TB burden within that community. The World Health Organization (WHO), international agencies and research institutions are addressing the continued rise in TB cases and its resulting impact on health services. One strategy involves community-based organizations in TB control activities. In Bangladesh, Haiti and Peru, community-based TB programs successfully contribute to effective TB control. A WHO pilot project on community-based TB treatment in six countries (Botswana, Kenya, Malawi, Uganda, South Africa and Zambia) showed that community involvement in TB care is a cost-effective intervention. Another strategy is being piloted by WHO under the name ProTest. The ProTest project aims to Promote TESTing for HIV by using voluntary counseling and testing (VCT) for HIV as an entry point to access a range of interventions aimed at decreasing the burden of HIV-related TB. Preliminary data from pilot sites in Malawi, South Africa and Zambia reveal some achievement: progress in the developing a framework for evaluating impact; improved collaboration between TB and HIV/AIDS programs; reduced stigma; and greater access to a range of interventions and support. Data from the pilot sites indicate that VCT uptake is positively influenced by the availability of rapid HIV tests and access to care and prevention. Finally, a review of TB services conducted by UNAIDS in selected countries of Southern Africa revealed that neither HIV education and nor voluntary HIV counseling and testing were offered to TB patients. It has been shown in Côte d'Ivoire, Malawi and Thailand that implementing an HIV counseling and testing program for TB patients could be successful; there, more than 80 percent of TB patients consented to HIV testing. Resources
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