The epidemic of HIV-associated tuberculosis continues to rage, particularly in southern Africa. Urgent assessment of frequent testing for HIV and early start of antiretroviral treatment (ART) should result in short-term and long-term declines in TB incidence through individual immune reconstitution and reduced HIV transmission. The issues surrounding the burden of co-infection are discussed in the third paper in The Lancet Series on Tuberculosis, written by Professor Anthony Harries, International Union Against Tuberculosis and Lung Disease, Paris, France, and colleagues.
The authors say: "Many people with HIV infection start ART too late, especially in Africa, and have already developed TB by the time that they present to health services for care. Rigorous implementation of recent international guidelines to ensure early start of ART could prevent some of these failed opportunities."
Implementation of the 3Is policy (Intensified tuberculosis case finding, Infection control, and Isoniazid preventive therapy) for prevention of HIV-associated TB, combined with earlier start of ART, will reduce the burden of TB in people with HIV infection and provide a safe clinical environment for delivery of ART. Some progress is being made in provision of HIV care to HIV-infected patients with TB, but too few receive co-trimoxazole prophylaxis and ART. Among the suggestions to improve this situation are starting all HIV-infected TB patients on ART, irrespective of CD4 cell count; decentralising ART to health centres where TB care is decentralised; bringing HIV services to TB clinics so that patients can obtain antituberculosis drugs, co-trimoxazole prophylaxis, and ART from the same health facility; and in settings of high HIV prevalence, an HIV clinician can be deputed to the TB clinic to provide HIV services and ART. The authors say: "Early HIV diagnosis and treatment, the 3Is, and a comprehensive package of HIV care, in association with directly observed therapy, short-course (DOTS) for TB, form the basis of prevention and control of HIV-associated TB."
The Global Plan to Stop TB estimated that US$6•7 billion would be needed during 2006 to fully implement collaborative TB and HIV activities. The authors say: "With the continuing economic downturn and restricted financial support by donor countries for achievement of universal access in the immediate future, intensified advocacy is needed to ensure equitable and adequate financing to address this epidemic. Notably, short-term costs might be set to increase because of the movement towards early start of ART with drugs that are more durable and tolerable, but also more expensive."
They conclude: "From the perspective of TB control, a sound theoretical base supports much earlier start of ART, which could additionally reduce mortality from HIV/AIDS. Moreover, isoniazid preventive therapy could further reduce TB incidence for those on ART. Worldwide, more than a third of the burden of HIV and almost half of the burden of HIV-associated TB is concentrated in southern Africa—affected countries should examine such innovative strategies with urgency. Without imaginative use of available and potential strategies, the epidemic of HIV-associated TB will continue long term, robbing countries of years of productive and useful citizens' life."
In a Comment with the Series, Dr Tedros Adhanom Ghebreyesus, Minister of Health for Ethopia, and colleagues list five urgent actions needed for effective and integrated services for TB and HIV: bold national leadership, health-system restructuring, decentralised care, investment in new tools and better use of existing ones, and global leadership from donors, countries of the global south, and key health agencies. They point out the key role of the Global Fund, WHO, UNAIDS, and the Stop TB Partnership in these efforts, concluding: "In collaboration with countries, these collective efforts will contribute to an ambitious but achievable objective: virtual elimination of tuberculosis deaths in people with HIV infection and ridding the world of needless suffering from tuberculosis/HIV."
Professor Anthony Harries, International Union Against Tuberculosis and Lung Disease, Paris, France. T) (Mon 17/Tues 18 May +44 (0) 1962 714 297 / +44 (0) 7818030315) E) adharries@theunion.org
Dr Tedros Adhanom Ghebreyesus, Minister of Health for Ethopia. E) moh.vmo@ethionet.et
For full Series paper 3, see: http://press.thelancet.com/tbsp3.pdf
For full Comment see link to Comment section at end of release
Journal
The Lancet