Part of the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) program’s recently released 2012 Country Operational Plan Guidance, the TB/HIV Technical Considerations highlight the important role of tuberculosis prevention and treatment in successfully combating the HIV pandemic. The updated “considerations” take into account the 2011 World Health Organization (WHO) “Guidelines for intensified tuberculosis case-finding and isoniazid preventive therapy for people living with HIV in resource-constrained settings,” as well as guidance released by the U.S. government on rollout of the GeneXpert rapid TB diagnostic.
According to the WHO, the risk of developing TB is between 20 and 37 times greater in people living with HIV (PLWH) than among those who are not infected, and TB is responsible for more than a quarter of deaths in PLWH. The 2010 WHO Global TB Report noted that in 2009 26 percent of individuals with TB knew their HIV status, an increase from 22 percent in 2008. Nearly 80,000 PLWH also received isoniazid preventive therapy (IPT) to keep TB at bay, less than one percent of the estimated number of PLWH worldwide, the majority whom are eligible to receive IPT.
“Studies of individuals on antiretroviral therapy (ART) in sub-Saharan Africa document high rates of TB not only among those initiating ART, but also among those one ART, particularly in the first six months of therapy,” according to the guidance. This emphasizes the need to adequately address tuberculosis or risk undermining the progress and ongoing efforts being made in the fight against HIV.
Starting on page 134 of the broader Technical Considerations for the overall PEPFAR guidance, the TB/HIV recommendations list various priorities in addressing the co-epidemics:
- Provider-initiated HIV testing and counseling and linkage to HIV care and treatment for people with TB;
- TB intensified case finding and TB treatment among people living with HIV;
- TB infection control activities in both TB and HIV care and treatment settings;
- IPT for PLWH who do not have active TB disease;
- Laboratory services to support TB diagnosis and treatment;
- Provision of cotrimoxazole prophylaxis in TB clinics to PLWH diagnosed with TB disease (with the ultimate goal of ART provision in TB clinics);
- Strengthening program monitoring and evaluation);
- Surveillance and management of multi-drug resistant TB; and
- Strengthening general TB control through directly observed therapy short course.
These and other effective ways to address HIV/TB co-infection are fleshed out in the technical considerations, including a push for phased implementation and evaluation of the GeneXpert rapid TB diagnostic test. The GeneXpert, which can also detect rifampicin drug resistance, guidance includes an outline of the laboratory infrastructure requirements for Xpert, current implementation costs, and which TB “suspects” would most benefit from receiving Xpert activities among all partners.