HEALTH-AFRICA: HIV and TB – An Ever Deadlier Combination

Miriam Mannak

CAPE TOWN, Nov 2 2007 (IPS) – The prevalence of tuberculosis (TB) amongst people living with HIV in sub-Saharan Africa has reached crisis levels and will escalate further if decisive steps are not taken, says a new report by the Forum for Collaborative HIV Research HIV-TB Co-Infection: Meeting the Challenge .
The forum is a public-private initiative based in Washington.

With more than 60 percent of HIV positive people living in sub-Saharan Africa, the region has proved fertile ground for TB: the compromised immune systems of AIDS patients are often unable to combat the disease.

In addition, failing health systems and insufficient knowledge, research, data collection and funding are encouraging the spread of HIV-TB across sub-Saharan Africa and the rest of the world, notes the study released Friday. Half of new TB cases now occur amongst people in sub-Saharan Africa who have contracted the AIDS virus, while a third of the world s 40 million HIV positive people are infected with TB.

The global threat of the HIV-TB co-epidemic is not hypothetical. It is here now; yet the science and co-ordination that are needed to stop this are utterly insufficient, said Veronica Miller, co-author of the report and director of the Forum for Collaborative HIV Research.

HIV and TB programmes and research funding have run through completely different funding and administrative streams. Because of this, opportunities for taking both diseases into account, instead of tackling either one of them, have been missed.
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Miller told IPS that funding for new drugs and diagnostics to treat TB is very limited, This despite these new tools (being) urgently needed, considering the effects that HIV has on the TB disease course and vice versa.

Action is needed now, especially for sub-Saharan Africa, where not only half of new cases are HIV co-infected but where drug-resistant TB is in the rise, said Miller.

TB is an airborne disease which mostly affects the lungs and is transmitted through coughing also a symptom of the illness and sneezing, spitting or speaking.

In instances where the disease has reached an advanced stage, patients may cough up blood. Other symptoms of this highly contagious and potentially deadly condition include loss of weight and appetite, fatigue, and the development of a fever.

Tuberculosis bacteria can remain dormant in a patient, who is then unable to pass on the disease. TB becomes reactivated if a person s immune system is compromised, as occurs with HIV infection.

People who are HIV negative and have dormant TB have a 10 percent (chance) of developing active TB during their lifetime, said Stephen Lawn, a medical researcher at the University of Cape Town in South Africa. When HIV is in an advanced stage, this can be as high as 30 percent.

Lawn has done extensive work on HIV-TB, and is active in townships mainly poor areas set aside for blacks under apartheid where the rates of HIV-TB are among the highest in the world.

Those HIV positive persons who do develop TB face slim chances of survival: 90 percent of people living with HIV/AIDS die within months of contracting the disease. Their immune systems are too weak to fight both HIV and TB, Lawn explained.

TB can usually be cured with a six-month course of antibiotics to which patients must rigorously adhere. Treatment can also be used to prevent the dormant bacteria from becoming active.

We need to take into account both diseases (HIV and TB) at every single opportunity. Every time someone is tested for one, they should be tested for the other, said Miller.

Diagnosing TB in HIV patients can prove difficult, however.

One method of detecting the illness involves injecting a protein from TB bacteria into the skin of the arm. If this causes swelling, it may be a sign that the person has dormant or active TB.

But, because people with HIV have a weaker immune system, this swelling does not always appear. As a result, These people will receive their treatment too late, which increases their chances of developing active TB and infecting others, Lawn told IPS.

On average, someone who suffers from HIV-TB infects 20 to 30 people in the course of his or her illness.

In its recommendations for addressing the co-epidemic, HIV-TB Co-Infection: Meeting the Challenge calls for more funds to research TB and HIV drug interactions in adults and children. Additionally, new studies should be done on HIV-TB co-infection in children. In South Africa, for instance, almost 25 percent of HIV-infected children contract TB annually.

Improvements to treatment are also required. Health care workers, especially in Africa, are ill-equipped to deal with the challenges posed by HIV-TB, a situation worsened by the emergence of TB drug resistance.

In recent years, multi-drug resistant tuberculosis (MDR-TB) and extensively drug-resistant TB (XDR-TB) have been reported, notably in Southern Africa. MDR-TB is resistant to the top two TB drugs, and XDR-TB to the vast majority of first- and second-line drugs.

Miller noted that better laboratory infrastructure should be put in place for drug sensitivity testing, amongst others.

According to Lawn, health care systems should also monitor their patients more closely. Many people infected with TB quit their treatment when they feel better, or refuse treatment altogether because they do not feel sick.

The report also addresses the role anti-retroviral drugs (ARVs) could play in tackling the HIV-TB co-epidemic. ARVs are used to prolong the lives of AIDS patients.

As ARVs boost one s immune system, they could possibly help to prevent dormant TB from becoming active, Lawn noted.

It is definitely not the magic bullet, and at this stage we do not know what the magic bullet is. Therefore we need help from all directions, and lots of it, to find a solution to the problem.