Photo: Jeroen van Gorkom, KNCV Tuberculosis Foundation.

Namibia: HIV/AIDS does not discriminate – why should we? Photo by Jeroen van Gorkom, KNCV Tuberculosis Foundation.

Accelerating the integration of TB/HIV services

One of the current drivers of the worldwide tuberculosis epidemic is human immunodeficiency virus (HIV) infection.
In 2015, 1.2 million (HIV-positive people worldwide developed tuberculosis, 11% of all new tuberculosis cases, according to World Health Organization (WHO). Around 74% of these HIV-positive people with TB live in sub-Saharan Africa.

People living with HIV have a much higher risk of developing TB disease due to their weakened immune system. If their TB disease is not diagnosed and treated quickly, it often leads to their death. The risk of developing TB disease is much reduced by antiretroviral therapy, but remains much higher than in a person who is HIV-negative. People living with HIV also remain vulnerable to a new TB disease episode if they are re-infected with new bacteria.

Conversely, TB disease (like any infectious disease) undermines the already weakened immune system of people who are HIV-positive, thus accelerating the progression from HIV infection to AIDS.
The only way to break this life-threatening combination of TB and HIV is to treat both diseases simultaneously.
Health care workers are at a high risk for developing TB, particularly when they are HIV positive, and when TB Infection Control is not well implemented.

Antiretroviral therapy (ART)

TB remains the leading cause of death among people living with HIV, especially in Africa and Asia. This is despite the fact that antiretroviral therapy (ART) is now accessible to more HIV-positive people than ever before in the history of HIV. ART reduces the individual risk of TB disease by 65%, and when combined with isoniazid preventive therapy even over 90%. Globally, 78% (390.630/500.564) of the TB patients known to be living with HIV started ART in 2015. Countries where ART has been scaled up well have seen a steady decline in the number of TB patients, where previously the number had exploded under the burden of the HIV epidemic. ART is a powerful and effective intervention in driving down TB among people living with HIV.

Integrating and accelerating TB/HIV services

The international healthcare community has developed a package of interventions to diagnose and treat people living with HIV who have TB infection or disease. This package, called TB/HIV collaborative activities, requires close planning, coordination and collaboration between national TB and HIV/AIDS programs in implementing a package of fully integrated care and services. Much has been achieved since its launch in 2004. TB/HIV collaborative activities saved an estimated 8.4 million lives between 2000 and 2014, according to WHO. But much more needs to be done to achieve universal access to these life-saving measures, and to eliminate HIV-associated TB deaths.

The package of TB/HIV collaborative activities comprises the following:

  • Access to HIV testing and counseling for all TB patients. Much progress has been made in this regard in 2014.
  • All HIV positive TB patients also receive co-trimoxazole preventive therapy (CPT). This intervention is now generally widely implemented.
  • ART for all HIV positive TB patients.

The Three ‘I‘s:

  • Intensified TB case finding. This means that all people living with HIV who are registered in care are screened for TB symptoms on every single visit to the health facility.
    Although this practice has been adopted widely there is recent evidence from autopsy studies that many people living with HIV still die from undiagnosed TB (30-50% of people living with HIV who died).
  • Isoniazid preventive therapy (IPT). Preventive therapy is effective in preventing disease and death from TB among people living with HIV. Progress on this has been slow.
  • Infection Control (IC). Much progress has been made in recent years in implementing effective TB-IC measures, in particular in HIV care settings, but much still needs to be done before we can declare health facilities safe from the risk of TB infection.

KNCV Tuberculosis Foundation’s role

  • KNCV Tuberculosis Foundation contributes to saving the lives of people living with HIV who would otherwise die of TB by:
  • Promoting stronger collaboration between TB and HIV/AIDS programs and community organizations
  • Promoting and advocating for universal access to HIV testing and counseling for TB patients and immediate ART for all; more effective screening and diagnosis of TB for people living with HIV; expanded use of IPT for people living with HIV;
  • One-stop service for people living with HIV on ART and TB treatment, in clinics which are effectively safe from TB infection.
  • Providing our expert knowledge and experience in TB control;
  • to develop policy and strategies on integrated care delivery and training of health workers; ;
  • Scale-up screening of healthcare workers, and effective TB-IC in all health facilities;
  • Raising awareness that TB is an important (but unnecessary and preventable) cause of death for people living with HIV.

Our experts on TB and HIV co-infection

max-meis  jeroen