So said Helen Ayles. She was quoted by Dr Diane Havlir who was speaking in the plenary of the 20th International AIDS Conference (AIDS 2014) in Melbourne, Australia. Dr Diane Havlir who is a researcher at the University of California, San Francisco, was hopeful that “Every HIV/TB case prevented and every death averted should become a public health success and put us one step closer to ending the dual epidemic of HIV and TB.”
Agreeing that policy advocacy and implementation during the last 10 years has seen a 40% decline in TB related HIV deaths and saved over 1.3 million lives, Dr Havlir rued that despite evidence based prevention for HIV-TB co-infection; despite new state of the art TB diagnostics, and despite the ability to cure TB and to reduce mortality with antiretroviral therapy (ART), there are still over 1 million new TB cases in people living with HIV (PLHIV) and 320,000 TB related deaths in people living with HIV (PLHIV) every year.
She said that, ‘To step up the we need to: understand who is dying and why they are dying; adapt evidence based care delivery systems that are patient centric; pay more attention to most at risk populations (MARPs) for HIV/TB; and invest in research to improve prevention, diagnosis and treatment.’
India stands 3rd among the top 10 countries with highest TB related deaths in PLHIV every year (42,000). All the other countries are in Africa, with South Africa topping the chart with 88,000 such deaths every year. The main reason for this high mortality is obviously not diagnosing and treating people early enough. So, the mantra is– Diagnose and treat TB and diagnose and treat HIV.
Preventing TB in PLHIV
A combination prevention treatment of ART and isoniazid preventive therapy (IPT) can result in substantial reduction of TB in PLHIV. Studies have shown that early start of ART in PLHIV results in 65% reduction in TB cases and providing ART and IPT gives an additional 35% reduction in TB in high TB transmission areas.
TB in HIV+ children
Dr Havlir agreed that children could not be left behind while we step up the pace to arrest the march of TB and HIV/AIDS. Childhood TB infection is relevant to all HIV/TB and TB control as much of the global TB reservoir is established in childhood itself. According to latest WHO estimates, over 650,000 children are infected with TB every year and around 75,000 deaths from TB occur in HIV negative children.
Dr Mario Raviglione, Director of the World Health Organization (WHO) Global Tuberculosis Programme had earlier told Citizen News Service (CNS) that, ‘In the absence of any data, TB related deaths in HIV positive children cannot be estimated. But given that HIV positive children are more vulnerable to TB, these deaths could be in the range of 100000 deaths every year.’
Dr Havlir said that, ‘Children have more rapid progression of TB from infection to disease as compared to adults. TB diagnosis is more difficult in children than adults. TB/ART dosing is more complex and cascade of care is more challenging. The way forward is to prevent all parent to child transmission of HIV; start ART in all HIV positive children and put all children exposed to TB cases on IPT. One study has shown an 8.8 fold increase in deaths in those children not starting ART compared to those stating ART within 2 months of TB diagnosis.’
Dr Steve Graham, lead author of the WHO Guidance on Childhood TB and Childhood TB Roadmap, told CNS that, ‘Study from Thailand shows that children who are living with HIV and also get TB have a much poorer survival curve than those children who do not get TB. Studies from Vietnam show that giving IPT and ART to children living with HIV give much better result in terms of child health and child survival. After Childhood TB Roadmap, we are trying to get a better handle on TB and TB-HIV in adolescents, which is another neglected area.’
There is an urgent need for more research to have better point of care diagnostics and simpler, shorter drug regimens for all forms of TB. But till then, Dr Havlir appealed for monitoring and fixing the HIV/TB care cascade with the existing tools. Early diagnosis of TB in PLHIV and early start of ART (within 2 weeks of diagnosis) in PLHIV diagnosed with TB along with TB treatment will go a long way to stem the tide of TB related deaths in people living with HIV.
Shobha Shukla, Citizen News Service (CNS)
(The author is the Managing Editor of Citizen News Service – CNS. She is reporting from the XX International AIDS Conference (AIDS 2014) with support from the World Health Organization (WHO) Global Tuberculosis Programme. She is a J2J Fellow of National Press Foundation (NPF) USA and received her editing training in Singapore. She has earlier worked with State Planning Institute, UP and taught physics at India’s prestigious Loreto Convent. She also co-authored and edited publications on gender justice, childhood TB, childhood pneumonia, Hepatitis C Virus and HIV, and MDR-TB. Email: [email protected], website: www.citizen-news.org)
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