HIV/TB Co-infection–The Deadly Duo Take Center Stage at IAS

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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.

Onward to the Sizonquba project, providing home-based treatment using family and community support, while assisting patients in developing tools such as monthly patient-constructed medication calendars. Mortality was 12 percent compared to 40 percent historically, but researchers still wondered why mortality was so high given the apparent effectiveness of the program. They later learned that drug-resistant TB was the culprit. This realization led to the discovery of XDR-TB and the now famous paper describing the rapid mortality of 52 patients who all died within 2 weeks of being cultured and weeks before the culture results were in.

Now XDR-TB has been identified in all nine South African provinces, and in numerous southern African countries, but the extent of the problem is unknown because use of culture and drug-susceptibility testing is very limited in the region.

Friedland called for a number of actions to help stem the tide of this deadly super-infection:

• Scale-up HIV-TB integration. He said there are many successful demonstration programs, but we need much more.

• A rapid, massive infusion of resources to:

Characterize the epidemic

Strengthen TB programs

Fast-track ART access (ART is critical to survival in co-infected patients with X-DR and was the single most important reason why XDR patients survive, but mortality remains 82 percent!)

Implement combination infection control strategies

Implement IPT

Friedland also described an important MDR-TB integration project in Tugela Ferry that provides community-based care and treatment. Nurses go out daily and provide patients with second-line TB therapy, including injectible drugs and ARV medications. Friedland noted that operational research to evaluate programs like this for innovation, outcomes and combination approaches is critical to the success of our response to these twin epidemics.

Click here to read an Aidsmap story on a new co-infection study outlined at the IAS conference.

Aidsmap also posted this chilling story about a “rapid rise in TB cases” in Zimbabwe caused by that country’s economic crisis. “This study is the first to demonstrate an association between rising TB incidence and national economic decline in the absence of armed conflict,” Aidsmap reports.

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