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Posts Tagged ‘HIV/TB co-infection’

This post is by Global Center Director Christine Lubinski.

Viet Nam was an fitting spot for last week’s meeting of the Stop TB Partnership Coordinating  Board, since the country’s anti-TB efforts demonstrate both the challenges and the potential for progress in  combating this deadly disease.

Viet Nam’s Vice Prime Minister and Minister of Health welcomed members of the Stop TB Partnership Coordinating Board and expressed pride about the pace of Viet Nam’s economic development, as it stands on the threshold of moving from status as a low-income country to a lower middle-income country.

Viet Nam is one of the world’s 22 high burden TB countries, with significant rates of HIV/TB co-infection that have  contributed to an increase in TB prevalence in young adults.  Viet Nam’s national TB manager outlined the dimensions of the TB problem in the nation, as well as the response that began with a nationwide expansion of DOTS coverage in the 1990s. That effort now includes responding to co-infection and officials have also started to address the 2.7 percent of TB cases that are drug-resistant.  The country just began providing treatment to multidrug-resistant TB patients in 2009 and still only reaches a fraction of those infected with deadly resistant TB disease.  He outlined a number of critical challenges that plague highburden developing countries:

  • Human resources—about 50 percent of TB district staff are brand new and require additional training
  • Inadequate regulation of  TB drugs in the pharmacy market, leading to self-medication
  • ART access for patients co-infected with HIV and TB has improved but remains inadequate.  The 3 Is—Isoniazid preventive therapy, intensified case-finding, and infection control–also need to be strengthened.
  • MDR-TB is an emerging threat and the supply mechanism for second-line TB drugs is insufficient
  • Addressing TB in  so-called “closed settings”—prisons and re-education centers–and the coordination of these institutions with the national TB program
  • Strengthening the role of civil society in TB  control
  • Monitoring and evaluation

The TB manager identified scaling up TB/HIV activities, the response to pediatric TB, and responding to TB human resource needs as key next steps.

Viet Nam’s national TB program hosted a site visit to the Hanoi Hospital on Tuberculosis and Lung Disease, as well as a district health center making great strides in TB control with a burgeoning migratory population moving to the Hanoi area from rural areas of the country.

Outside the Hanoi Hospital on Tuberculosis and Lung Disease

The hospital director described the hospital’s key role in patient care, training, scientific research and providing leadership to the network of 29 district level clinics and providers providing T B services.

Viet Nam treats TB patients for 8 months, with the first two months using the DOTS model at the clinic daily.  After this, patients are given several weeks of medication and must check in with health providers frequently. There are more than 5,000 TB cases a year in Hanoi, and in 2009, almost 12 percent of these cases were TB/HIV co-infection.  Only about half of the TB patients were actually tested for HIV, so the number of co-infected patients is likely to be higher.  The mortality rate among the co-infected patients is 21 percent.  Half of all deaths at this hospital occur among co-infected individuals.  Notably, only 45 percent of the co-infected patients have access to ART.  

Eligibility for ART in Viet Nam is a CD4 count of under 200 or clinical symptoms of WHO Stage IV HIV infection.  Officials hope to move to a CD4 count of 250 soon for ART eligibility and to generally improve access to ART for co-infected individuals.  They have been successful in providing ART to some HIV patients with pulmonary TB.  It is also worth noting the CD4 diagnostic capability is not available everywhere.

Not all TB services are free in Viet Nam.  Patients must pay for physician services, chest X-rays and medical care related to extra-pulmonary TB, which occurs much more frequently in persons living withy HIV infection.

A visit to a district health facility offered an inspiring picture of dedicated staff working to provide TB and HIV services to a growing population of migrants.   This center has substantially ramped up screening of HIV-infected persons for tuberculosis and now ensures that nearly 100 percent of  TB patients are screened for HIV infection. The staff have engaged peer educators in their work to support co-infected patients.  The majority of persons living with HIV infection are injection drug users and center’s staff were excited to report that they are now offering methadone – the first pilot program in north Viet Nam.  They credit donor support for their ability to respond to the multiple health care needs of this complex and vulnerable population.  That donor is PEPFAR. 

The clinic director identified the need for strong support from local political leaders and the engagement of community members as key ingredients of this successful program.

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There were plenty of frightening statistics and unsettling trends highlighted at today’s World TB Day briefing on Capitol Hill. But one photo captured the true scope of the problem in scaling up diagnosis and treatment of the global TB epidemic.

Celine Gounder, MD, an IDSA member and TB/HIV specialist at Johns Hopkins University, described a recent trip to Malawi, where she saw shopkeepers volunteering to collect sputum samples from customers with chronic coughs. The accompanying photo: a man transporting the sputum samples to a laboratory in a small wooden box balanced on the back of his bicycle.

Dr. Celine Gounder discusses the TB epidemic at a Senate briefing

As Dr. Gounder noted, this small community had overcome one of the hurdles in getting suspected TB patients access to proper care. But many others remain. For starters, those specimens so carefully balanced on the bike would be examined using sputum smear microscopy, the only widely available diagnostic test for TB in Malawi. But Malawi has one of the highest HIV prevalence rates in the world, and the vast majority of HIV-related TB cases will be missed by sputum smear microscopy. A more accurate TB test, culture, is not available in the country because of lack of funding. So many of the patients will get false negative results, and continue to transmit the TB bug.

Her presentation provided compelling evidence of the need for more resources devoted to increased laboratory capacity and better diagnostics for TB. But she noted the gap between rhetoric and reality when it comes to TB funding. See Dr. Gounder’s power point here: CGounder_US Senate Briefing_20100324 and below is a video of her presentation.

“Despite the clear need for a heightened response to the global TB problem, funding that has been appropriated for these activities falls short of what was authorized by the Lantos-Hyde Act and what is needed to make decisive progress,” she said. “USAID, which is the primary US agency conducting global TB activities, received only $225 million in FY 2010 of the $650 million dollars authorized.”

She noted in particular that the White House’s Global Health Initiative includes TB treatment targets that are much lower than those set out in the Lantos-Hyde Act, which reauthorized PEPFAR. And she said HIV/TB co-infection was getting particularly short-shrift.

“Little more than lip service has been paid to delivery of TB-related interventions by HIV programs,” Gounder said.  “Only 16% of all TB patients were tested for HIV in 2007. Only 2.2% of HIV patients were screened for TB. And only 30,000 of HIV patients, 2% of the target, received isoniazid preventive therapy, which has been proven to reduce the risk of TB and mortality by one-third to two-thirds.”

Gounder’s remarks came at a Senate briefing on the global TB epidemic, which included a special focus on drug-resistant TB. The event, entitled “Bringing Methods to Scale: New Perspectives in the Changing World of TB,” also featured a presentation by Ernesto Jaramillo, team leader for MDR-TB for the World Health Organization’s Stop TB Department, who detailed the WHO’s newest data on drug-resistant TB. (more…)

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This post is by Center Director Christine Lubinski: 

Dr. Jorge Sampaio, the UN Secretary-General’s Special Envoy to Stop TB and former President of Portugal, is in Washington this week to meet with key US government officials about the urgent need for enhanced U.S. leadership to battle global tuberculosis.

Dr. Sampaio invited a small group of global health advocates to brief him on the current climate in Washington and to offer advice about TB messages that might resonate with policymakers on Capitol Hill and in the Obama Administration.

Sampaio had just returned from a trip to Africa, where he met with a number of health ministers challenged by the high prevalence of tuberculosis in their countries. Those ministers were also worried about the economic downturn and its impact both on resources for health in their own countries and the potential impact on donor support. Of particular concern is the budget shortfall at the Global Fund to Fight AIDS, TB, and Malaria—the single largest source of funding for TB programs in developing nations.

Anxiety about the availability of adequate resources comes at a time when African nations are taking big steps forward in building the healthcare infrastructure essential to responding to TB and other infectious disease killers, according to Sampaio. Ethiopia’s efforts to train 40,000 community health workers are well underway. And Rwanda has made great progress in integrating HIV and TB services, but lacks the $500,000 necessary to bring its laboratory capacity up to the level necessary to deal with deadly drug-resistant TB. (more…)

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This post is by Center Director Christine Lubinski, reporting from the 2009 IAS conference in Cape Town.

World renowned HIV/TB expert Dr. Gerry Friedland, a professor of medicine at Yale and a member of the Global Center’s Scientific Advisory Committee, opened this morning’s plenary session at the 2009 IAS conference by highlighting important operational research on HIV/TB co-infection and drug-resistant TB.

Dr. Friedland began by outlining the now all too familiar and chilling facts about the co-infection epidemic. TB is the most common presentation of AIDS in HIV infected persons—the so-called “mother of AIDS.” HIV underlies the explosive growth of TB in southern Africa. The marriage of these two deadly infections creates huge challenges for patients, communities, and health systems.

Dr. Friedland discussed the START study, published in 2004, a pioneering effort to integrate HIV care and treatment into an existing TB program. HIV counseling and testing was introduced and those identified with HIV infection were given a once daily ART regimen plus standard TB therapy. The drug regimens were well-tolerated and delivered a 90 percent TB cure rate. (more…)

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Note: From July 19-22, the Center for Global Health Policy’s staff will be live blogging from the International AIDS Society 2009 meeting in Cape Town. This post was written by Center director Christine Lubinski, who attended a two-day pre-meeting on HIV/TB co-infection.

Despite the scope and gravity of HIV/TB confection, there are glimmers of hope from the field—new diagnostics, a better vaccine, and a host of other innovations were the subject of a two-day session in Cape Town, “Catalyzing HIV/TB Research: innovation, funding, and networking,” which served as a prelude to the 2009 IAS meeting. The backdrop provided a fitting reminder of the urgency of this health crisis; South Africa is the epicenter of the co-infection epidemic, with one quarter of the world’s cases of HIV/TB co-infection.

Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases at the National Institutes of Health, headlined the meeting, organized by the World Health Organization, the International AIDS Society, the Consortium to Respond Effectively to the AIDS/TB Epidemic (CREATE), and other groups. Calling the most commonly used diagnostics for TB “ridiculous,” Fauci noted that it was “tragic and shameful” that generations of research advances had “bypassed TB research.”  As he did at the Pacific Health Summit on MDR-TB in June, Fauci called for a transformative research response to TB and by extension, HIV/TB co-infection.

Dr. Fauci’s address was followed by a series of presentations that both highlighted the enormity of the problem and its associated morbidity and mortality, but also framed the potential that further research and more widespread implementation of interventions hold. 

Dr. Robin Wood, from the Desmond Tutu HIV Research Center at the University of Cape Town, focused on the impact of ART on TB prevention. Dr. Wood reported that 67 percent of persons presenting for ART in their clinics have TB or have had TB. Analyzing the impact of ART on a high HIV prevalence township community, researchers found a 77 percent reduction in HIV/TB co-infection during the 5-year ARV rollout period.  Wood noted while there is widespread speculation about the impact of community-wide ART penetration on HIV incidence, there is little doubt that small changes in HIV prevalence produce dramatic changes in TB incidence.  The earlier ART is started, the greater the impact on TB, given the increased vulnerability to TB as HIV disease progresses. (more…)

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Update: A full video of the briefing appears at the bottom of the post.

Leading disease experts made a compelling case for strong US leadership and aggressive new policies to combat HIV/TB co-infection at a congressional briefing on Thursday. The briefing came in conjunction with the release of a new report, “Deadly Duo: The Synergy Between HIV/AIDS & Tuberculosis,” from the Center for Global Health Policy.

Dr. Diane Havlir, a professor of medicine at the University of California, San Francisco, said TB is a threat to the "miracle" of HIV therapy

Dr. Diane Havlir, a professor of medicine at the University of California, San Francisco, said TB is a threat to the "miracle" of HIV therapy

The central message of both the report and Thursday’s presentations was simple: the incredible success in treating HIV with antiretroviral therapy is at risk because of tuberculosis. The number of new TB cases has tripled in high HIV-prevalence countries over the last two decades, and TB is the No. 1 killer of people with HIV in the developing world.

“TB is the greatest threat to the miracle of HIV therapy,” said Diane Havlir, MD, a professor of medicine at the University of California, San Francisco, and chief of the HIV/AIDS Division and Positive Health Program at San Francisco General Hospital. Dr. Havlir also serves on the Center for Global Health Policy’s Scientific Advisory Committee.

(more…)

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