The HIV-associated tuberculosis epidemic--when will we act?

Tuberculosis

The HIV-associated tuberculosis epidemic--when will we act?

Despite policies, strategies, and guidelines, the epidemic of HIV-associated tuberculosis continues to rage, particularly in southern Africa. This article focuses on the regions with the greatest burden of disease, especially sub-Saharan Africa, and concentrates on prevention of tuberculosis in people with HIV infection, a challenge that has been greatly neglected. The authors argue for a much more aggressive approach to early diagnosis and treatment of HIV infection in affected communities, and propose urgent assessment of frequent testing for HIV and early start of antiretroviral therapy. This approach should result in short-term and long-term declines in tuberculosis incidence through individual immune reconstitution and reduced HIV transmission. Implementation of the 3Is policy (intensified tuberculosis case finding, infection control, and isoniazid preventive therapy) for prevention of HIV-associated tuberculosis, combined with earlier start of antiretroviral therapy, will reduce the burden of tuberculosis in people with HIV infection and provide a safe clinical environment for delivery of antiretroviral therapy. Some progress is being made in provision of HIV care to HIV-infected patients with tuberculosis, but too few receive co-trimoxazole prophylaxis and antiretroviral therapy. The authors make practical recommendations about how to improve this situation. Early HIV diagnosis and treatment, the 3Is, and a comprehensive package of HIV care, in association with directly observed therapy, short-course (DOTS) for tuberculosis, form the basis of prevention and control of HIV-associated tuberculosis. This call to action recommends that both HIV and tuberculosis programmes exhort implementation of strategies that are known to be effective, and test innovative strategies that could work. The continuing HIV-associated tuberculosis epidemic needs bold but responsible action, without which the future will simply mirror the past.

Third in a series of eight recent Lancet articles on tuberculosis, this article describes the interactions that began 30 years ago between the ancient pathogen Mycobacterium tuberculosis and the new pathogen HIV – and our slow, half-hearted, uncoordinated response. An estimated 15% of people with tuberculosis are HIV-positive, with 9 countries in southern Africa (South Africa, Swaziland, Lesotho, Namibia, Botswana, Mozambique, Zambia, Zimbabwe, and Malawi) constituting the epicentre of the dual epidemic with nearly 50% of the global burden. With 40% of all people with tuberculosis still not tested for HIV and only 7% of co-infected individuals on antiretroviral therapy, the need to act decisively is evident. Rapid implementation of the new WHO antiretroviral treatment recommendations (start co-infected patients on HIV treatment as soon as possible after the initiation of tuberculosis treatment at any CD4 count) should see these figures change. Easy-to-read panels highlight: the challenges that co-infected individuals face in navigating services to meet their health-care needs, recommended collaborative tuberculosis and HIV activities, and various elements of tuberculosis infection control in health-care settings. A final panel details challenges and then provides practical considerations and ways forward for addressing 3 key problems of low uptake: HIV testing and counselling, cotrimoxasole prophylaxis, and antiretroviral therapy. If you are short of time, you can start by reading the panels and then delve in further.