Developing nations must pay more than mere lip service to WHO advice on linking HIV/AIDS and tuberculosis programmes, says Peter Mugyenyi.
The HIV/AIDS pandemic raging across the developing world has fuelled a devastating parallel rise in the number of people infected with tuberculosis (TB). The Uganda National Tuberculosis and Leprosy Programme calculates that HIV has led to a four-fold increase in TB cases in that country alone. And this is almost certainly an underestimate as many patients die undiagnosed or are not reported.
Similarly, it is conservatively estimated that about 60 per cent of patients presenting with TB are co-infected with HIV — translating to more than 11 million adults living with both diseases in the world.
For developing economies already struggling to cope with HIV/AIDS, the negative socio-economic impacts of this co-infection cannot be underestimated. Indeed, the extra burden of TB may prove to be the straw that breaks the camel's back.
There is an urgent need for robust initiatives to fight these killer diseases together, by linking HIV and TB treatment and control at all levels — from coordinated screening and community monitoring to joint training and research programmes.
A deadly combination
HIV–TB co-infection is often described as "a collaboration to kill". Certainly, HIV-induced immune suppression makes AIDS patients highly susceptible to TB while also making the disease harder to diagnose. A delay in identifying TB can adversely affect the success of treatment.
HIV–TB is also a much more deadly disease than TB in HIV negative individuals — 14 per cent of co-infected patients die compared with only 0.5 per cent of those with only TB. In addition, co-infection speeds up HIV progression, resulting in higher mortality rates.
Over the past 15 years, TB has emerged as the leading cause of death among people living with HIV/AIDS throughout the world. The increasing incidence of co-infection presents a mounting risk of TB transmission into the general population, with serious implications for public health.
A collaborative approach
HIV–TB co-infection poses serious challenges to the treatment of both diseases, because of overlapping toxicities and interactions between the relevant drugs. Patients being treated for both diseases tend to present with advanced immunodeficiency and often have to take multiple drugs, which can lead to problems of tolerance or toxicity.
Moreover, anti-retroviral therapy (ART) in HIV patients frequently leads to the emergence of previously unrecognised, latent or subclinical TB as part of what is now widely recognised as ART-induced Immune Reconstitution Inflammatory Syndrome (IRIS). IRIS is often life-threatening and is responsible for the relatively high mortality among patients beginning ART.
Current treatment and control efforts targeting HIV/AIDS and TB individually cannot hope to manage all the complex connections between the diseases effectively. Indeed, without immediate action, they could even precipitate more deaths — for instance by increasing the risk of HIV and TB multidrug resistance.
It is imperative that HIV and TB treatment and control programmes across the developing world forge closer working links to develop a robust joint approach to replace the traditional separate courses initially adopted by many developing countries.
Integration — or at least, strong links — must be achieved at all levels in the system but can start straightaway, one step at a time. At a basic level, this should encompass routine screening of TB patients for HIV, and vice versa — for early detection and diagnosis.
Coordinated screening should then be extended to include joint strategic planning between all stakeholders. Research for both diseases needs to be conducted in parallel as far as is possible and relevant, along with improved laboratory infrastructure and coordinated training agendas.
Health service delivery and drug and supply logistics similarly need combined management. Efforts to monitor both diseases at a local level — including those undertaken by private practitioners, nongovernmental outreach programmes and community-based organisations — must be able to share responsibilities and results.
A mutual learning curve
Harnessing the best practice of existing programmes could help make joint initiatives like those described above cost effective.
For example, adopting the Directly Observed Therapy approach widely recognised as best practice in TB control could help improve HIV treatment adherence — especially for groups requiring special assistance in taking medications such as the mentally ill or physically impaired.
From the HIV side, the Information Education and Communication approach that has contributed tremendously to reducing HIV rates in Uganda may also be an effective tool for raising public awareness about TB.
The World Health Organization strongly recommends strong links between HIV and TB treatment and control programmes. But sadly, implementing such links has been poor in almost all developing countries. Many governments do nothing more than pay lip service to the advice, or drag their feet. Meanwhile, unacceptably large numbers of patients continue to succumb to this dangerous liaison.
The time to act is now.
Peter Mugyenyi is director of the Joint Clinical Research Centre in Kampala, Uganda.