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.
Dr. Gavin Churchyard provided an exciting update on a CREATE research study that is evaluating a massive scale-up of isoniazid preventive therapy (IPT) in South African miners. The scale-up of IPT in thousands of miners has been successful and there has been little evidence if isoniazid resistance—a frequent excuse used to not implement IPT.
Helen Ayles and Liz Corbett updated meeting participants on another CREATE project—ZAMSTAR—a community approach to increasing TB detection. Community workers have been trained to collect sputum samples in outdoor settings near clinics, regardless of whether TB symptoms are present. In addition, the project has targeted school children for TB education so that the school children become agents of change and encourage the adults in their lives to be screened for TB. Ayles reported that it is clear that the number of TB diagnoses in the community is increasing, but formal results of the study will be forthcoming. Liz Corbett argued that operationalizing these kinds of interventions and exploring others must be as high a priority as other kinds of research exploring new technologies.
Amita Gupta and others highlighted the profound impact of HIV/TB co-infection on mothers and children. More women die of TB than from all other causes of maternal causes of mortality combined.
Maternal TB/HIV is an important risk factor for pediatric TB and mortality in children. Rates of pediatric TB infection are extraordinarily high in some communities in the Western Cape region of South Africa, with nearly 50 percent of children infected with TB by the time they reach the age of five. Twenty-five to sixty percent of children in South Africa hospitalized with TB are HIV positive. Diagnosis and treatment are even more challenging in children given current tools.
The last session addressed drug-resistant TB in the face of HIV infection. More than five percent of detected TB cases are drug resistant and that number is growing. The convergence of HIV infection and drug-resistant TB is especially deadly. Neel Gandhi reported from the now infamous community of Tugela Ferry where XDR-TB was first identified. The mortality from XDR-TB is 85 percent, with an average time from identification to death of one month. Outcomes for HIV patients with MDR-TB are only slightly better with 70 percent mortality at two months.
Despite these dire facts, the presentations came with a dose of energy and determination to tackle these synergistic infections aggressively. Updates on diagnostics from Giorgio Roscigno and on vaccine studies from Jerry Sadoff provided some of the oomph and optimism. The eloquent call for increased activism and advocacy by Treatment Action Group leader, Mark Harrington, also lent a sense of empowerment and force.
The Stop TB partnership, another organizer of the session, has posted presentations from this meeting online at http://www.stoptb.org/wg/tb_hiv/meetingsevents.asp.