Tackling HIV and tuberculosis
30 October 2008
Ezio Tavora dos Santos Filho, an international HIV and tuberculosis activist, asks why the global community isn’t doing more to tackle the problem of HIV and tuberculosis co-infection, which kills around half of all people living with HIV.
“In the early days of the HIV epidemic, activists didn’t pay so much attention to tuberculosis (TB) because the number one cause of death of people living with HIV was a kind of pneumonia called Pneumocystis carinii pneumonia (PCP). But with effective treatment for PCP, TB has become the number one infectious killer of people living with HIV.
Since the development of combination therapy in the 1970s, TB has been a curable disease in the vast majority of cases. However, without treatment, TB can kill someone living with HIV in a matter of weeks. Estimates suggest that globally more than a third of people living with HIV are co-infected with TB. Yet for too long the message from public health and government officials around the world, and in my home country Brazil, has been that TB is not a priority issue. The result has been a lack of integration of TB and HIV programmes and people dying from something that is both curable and preventable.
Stigma plays a central part in the dynamics of TB, just as it does for HIV, based on ignorance and fear, and this needs to be tackled. But TB can also be very hard to diagnose in people living with HIV because they don’t produce sputum in the same way HIV-negative people do. Many of the existing diagnostics for TB aren’t suitable and people die as a result. We need to find new tools and diagnostics as a matter of urgency.
Isoniazid Preventative Treatment (IPT) is a simple once daily drug treatment that prevents active TB in people living with HIV. TB is often carried without symptoms but the chance of TB becoming active and causing illness is greatly increased in people living with HIV. Taking a six month course of isoniazid can reduce the chances of developing TB between 40-60% for two years. IPT is very cheap and could make a real difference but currently only 2% of people who need it worldwide have access to it. We need to work with health authorities to make IPT much more readily available to people living with HIV.
Another challenge is the difficulty of treating HIV/TB co-infection. When I was treated for TB I had to change my treatment five times to find one that I could stand, because I have a reaction to most drugs (something that is not uncommon in people living with HIV). I’m still here today because I knew about the diseases, could inform myself, and had access to the best physicians who were patient enough to work out a way forward. However, in very resource limited settings where health systems hardly exist and drug supplies are erratic, the challenges are much, much greater. But there is already a lot of experience in the HIV community that can be used to help find solutions.
The media focuses most of its attention on drug-resistant TB, but this phenomenon is only a result of our incapacity to deal correctly with the disease in the first place. We need to start simply, do the basics, and not get sidetracked by hysteria around drug-resistant TB. Civil society and the HIV community can help by raising awareness of TB among HIV organisations and among people living with HIV. A good starting point is recommending to organisations the three ‘I’s: infection control, increasing case findings among people living with HIV, and Isoniazid Preventative Treatment.
Globally, the highest rates of TB and TB/HIV co-infection occur in sub-Saharan Africa, where HIV has hit the hardest. 80 percent of those co-infected with TB and HIV live in Africa, and the number of TB cases is growing fast on the back of HIV. Greater action in Africa is urgent, but other regions are also cause for concern. The largest number of TB cases occurs in Asia where there are also significant HIV epidemics, threatening new TB/HIV explosions. In India, where one in every two adults is infected with TB and over 300,000 people die of the disease each year, HIV infection rates are also increasing with potentially disastrous consequences.
In my home country Brazil, TB has historically been high on the health agenda. Brazil was the first country to implement TB combination therapy, but a change of government policy in the 1990s meant TB slipped down the agenda – with a consequent rise in the number of cases. To a degree TB was eclipsed by HIV and, as elsewhere, the government failed to support enough linkages between TB and HIV.
But the experience in Brazil shows what can be achieved. Until 2004 there was little leadership by the national TB programme, but with activism from civil society there was a real impact on government policy. In Brazil now we have many organisations working together on TB. We are seeing real and effective engagement of communities within just five years. We won’t reverse things in just a few years because this is a complex situation, but we are heading in the right direction.”
Ezio Tavora dos Santos Filho is a lawyer by profession and a consultant on TB/HIV mobilisation. He is a member of the Stop TB Partnership Coordinating Board and a member of the Brazilian National TB Programme Technical Advisory Committee. He is also a former Vice-Chair of Brazil’s Global Fund to fight AIDS, TB & Malaria Country Coordinating Mechanism and a former member of the Affected Communities Delegation to the Board of the Global Fund. Ezio worked for many years as a leading member of Grupo Pela Vidda, a former Alliance partner organisation and the first organisation for people living with HIV in Brazil.