TWN Info Service on Health Issues (March 09/06)
31 March 2009
Third World Network

HIV-TB: International Calls for New Strategy

A WHO Report shows that the incidence of TB co-infection with HIV has been grossly underestimated.

While advocacy groups agree this problem was an international health priority it has received little funding or attention.

The following story is reproduced with permission from IPS and South-North Development Monitor SUNS #6668, 26 March 2009  

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Evelyne Hong
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Health: HIV/TB convergence sparks calls for new strategy
By Ben Case, IPS, New York, 24 March 2009

On World Tuberculosis Day Tuesday, the World Health Organisation (WHO) released a report showing that new surveillance techniques and more complete country reports reveal the incidence of tuberculosis (TB) co-infection with HIV to be almost double what was previously thought.

Tuberculosis is the leading cause of death among people who are HIV-positive, but only two percent of those diagnosed with HIV worldwide are also tested for TB. The WHO report found that a quarter of TB deaths worldwide are related to HIV, twice the number previously estimated.

According to Dr. Carol Hamilton, co-chair of the Infectious Diseases Centre for Global Health Policy and Advocacy and a professor of medicine at Duke University, to a person who is HIV-positive, tuberculosis is a guaranteed death sentence within six months, absent treatment.

The WHO reported that 1.77 million people died from TB in 2007, including 456,000 people with HIV, despite the fact that most forms of TB are curable.

Coinciding with the WHO report was an analysis written by two advocacy groups, Advocacy to Control Tuberculosis Internationally (ACTION) and Infectious Disease Centre for Global Health Policy and Advocacy, that details the severity of TB and HIV co-infections.

"The convergence of the co-epidemic is worse than we thought," said Joanne Carter, executive director at RESULTS Educational Fund, which released the joint report. "The real point is that major HIV/AIDS funding groups are not properly addressing the issue."

The RESULTS report focuses on several main HIV/AIDS prevention and treatment groups, such as the President's Emergency Plan For AIDS Relief (PEPFAR), the World Bank Multi-Country AIDS Programme (MAP) and the Global Fund.

According to the report, all of these groups published information stating that TB and HIV co-infections was a priority, but there is little evidence of the issue receiving any significant funding or attention.

Paul Jensen, global research coordinator for RESULTS, called the groups' attention to co-infection "insufficient", saying, "There is very modest resource allocation here. When HIV/TB focus does occur, it is sporadic, meager and usually voluntary."

The MAP, which has committed $1.6 billion to the HIV/AIDS crisis since its creation in 2000, does not disaggregate funding for tuberculosis programmes, making it impossible to know exactly how much is committed to them.

In addition, Jensen called the MAP budgets "incoherent", and said "The funding for specific TB programmes is very poorly tracked."

Jensen added, "The World Bank says they have a commitment to integration here but there is no strategy."

In another example, the Global Fund, which has contributed $15.2 billion towards fighting HIV/AIDS, tuberculosis and malaria, includes the issue of HIV and TB co-infection in its grant application forms only as a footnote. Out of nine grant plans analysed in the report, only $6 million was allocated to co-infection related issues.

The RESULTS report was adamant about the need for a sustained commitment to tuberculosis prevention, treatment and especially education.

"TB is a contagious lung disease that has been recognised for over a hundred years, and it has been curable for over 50 years, yet there were still more cases worldwide in 2007 than in 2006," said Dr. Hamilton.

With proper diagnostics equipment, tuberculosis is easily detectable through a sputum test and chest X-ray, but TB affects the poorest areas and effected regions often have no access to this equipment.

These areas are also the most affected by HIV. According to the WHO, in countries with high prevalence of HIV, 80% of people infected with TB also have HIV.

"Medicine used to treat TB are getting weaker as TB figures out how to evade the drugs," said Hamilton. "We need US leadership in funding for programmes and research."

But with the ongoing economic crisis, it seems more likely that funding for these programmes will be cut. "We are all waiting to hear the details but we're definitely worried," Carter said of future funding.

Funding for the Centres for Disease Control and Prevention (CDC), the government agency responsible for tracking and eliminating TB in the US, has been steadily decreasing over the past decade.

The US Congress recently passed legislation increasing funding to fight TB, but whether that money will make it to its intended purpose after the economic downturn remains to be seen.

President Obama's government stimulus package actually reduces funding for the CDC and no money was specifically allocated to TB-related projects.

There are examples of countries with positive trends in treating the HIV/TB co-infection. Since formally acknowledging a link between HIV and TB-related deaths, Kenya has managed to provide HIV testing for about 80% of patients with tuberculosis and has taken measures to prevent the transmission of TB, which is airborne, in HIV clinics.

The RESULTS report advocates for an increase in funding for programmes targeting HIV/TB co-infection.

According to Dr. Richard Chaisson, director of the Johns Hopkins Centre for Tuberculosis Research, the primary issue seems to be awareness of the convergence of these two epidemics. "People need to understand that HIV is the most important risk factor in TB patients, and visa versa."

To Chaisson's view Carter added: "What we are trying to avoid are the scenarios where people are being diagnosed with HIV and surviving it but then dying of undiagnosed TB."