Vienna — “Slow, timid, and uncoordinated.” Those were the words Tony Harries, Senior Adviser to the International Union Against Tuberculosis and Lung Disease, used to describe the response to deadly HIV/TB co-infection, with its 40 percent mortality. Harries opened the session of TB and HV Management in High-Prevalence Settings Wednesday morning at the 18th International AIDS Conference.
Lucy Chesire, a TB/HIV advocate from Kenya, identified poverty and HIV infection as the two drivers of co-infection in her country. She also outlined key benefits of HIV/TB service integration: providing patients a continuum of care and services, reducing mortality and morbidity, sustaining life long enough for patients to access antiretroviral therapy (ART), and providing an opportunity to prevent TB in HIV-infected individuals by initiating Isoniazid Preventive Therapy (IPT). She noted that the failure to engage communities in the fight against HIV/TB has contributed to the double stigma associated with having both diseases. Chesire added that it was a missed opportunity to increase peer support and accelerate advocacy for better TB tools and more patient-friendly and effective programs.
MSF (or Doctors Without Borders) physician Gilles Van Cutsen offered a field perspective by highlighting elements of effective MSF HIV/TB programs in South Africa and Lesotho, where HIV and TB program integration had produced quicker and more effective identification of TB, especially the “smear-negative” and extra-pulmonary TB more common in persons with HIV. As a result, treatment for both diseases is initiated more quickly, resulting in better patient outcomes. Stronger infection control measures, including enhanced ventilation and patient education, are key to program integration. Separate HIV and TB administrative structures continue to present challenges at the clinic level with the separate and different reporting requirements from the HIV and TB programs.
Gavin Churchyard from the Arum Institute outlined recent scientific advances in TB/HIV co-infection including studies that show a clear complementary advantage for initiating IPT in HIV patients without active TB for at least 36 months, to a screening algorithm that effectively identifies TB disease in most patients. He called for the scale up of ART with IPT and TB treatment to realize the benefits of this scientific knowledge in lives saved. He also acknowledged an effective point of care diagnostic device, Cephied Genexpert, but indicated that the cost was currently prohibitive.
Kevin DeCock, director of CDC’s Office of Global Health, offered a policy perspective and said that sound policy should be based on data, but also that evidence-based policies should be seen as a human right. Not only should policy be informed by evidence, but policy should also stimulate the search for evidence.
DeCock also warned that there could be unintended negative consequences to service integration including an erosion of technical quality and capabilities and the loss of accountability. TB programs are much better on monitoring and documenting outcomes than HIV programs, and it is important that this not be eroded in integration efforts. A one-size fits all programmatic response to HIV/TB co-infection will never be appropriate given the variability in prevalence across locales. Notwithstanding the huge burden of HIV/TB co-infection in sub-Saharan Africa, most persons with TB are not HIV- infected and the integrity and quality of TB control programs must be preserved.
He identified the questions of how to use IPT and ART most effectively in the context of HIV/TB co-infection as critical field questions.