AIDS 2014: HIV and tuberculosis are one disease in Southern Africa

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AIDS2014postScience Speaks is live-blogging from AIDS 2014 in Melbourne, Australia through the coming week, with updates on research, policy and insights from the 20th International AIDS Conference.

MELBOURNE, AUSTRALIA - “We must ensure that the worlds of HIV and TB focus on individual human beings instead of individual diseases”

This message headlined remarks from Mark Dybul, executive director of the Global Fund to fight HIV, Tuberculosis and Malaria and Ambassador Deborah Birx, global AIDS coordinator for the President’s Emergency Program for AIDS Relief  both members of a high-level international consultation of the World Health Organization in Melbourne today in advance of the opening of the 20th International AIDS Conference. The consultation “Eliminating TB Deaths: time to step up the HIV Response” also featured an update on progress to date and remaining challenges from WHO HIV lead, Gottfried Hirnschall and an overview of relevant biomedical research issues from Dr. Anthony Fauci, director of the National Institute of Allergies and Infectious Diseases, a major funding source for tuberculosis research.

But first the update from Dr. Hirnschall—progress has been made and much of it in highly impacted countries in southern Africa.  Of notified TB patients with HIV, 70 percent received antiretroviral therapy. Integration of TB and HIV treatment services has also improved with 67 percent of TB clinics offering antiretroviral therapy to their co-infected patients and 63 percent of HIV clinics reporting providing TB treatment in 2013. PEPFAR, the Global Fund and the World Health Organization are now in alignment with their TB/HIV policies and goals.  But while many deaths were likely averted as a result, 300,000 people living with HIV still died of tuberculosis in 2012, a death toll Hirnschall called “unacceptable.”

Hirnschall also noted that GeneXpert availability has expanded rapidly in some high prevalence setting, particularly South Africa, Kenya, Zimbabwe, and Nigeria, but further expansion is needed. He called for the development of more tailored service delivery models for different epidemics and for high risk and marginalized populations including miners, prisoners, injection drug users, children, healthcare workers and those with multidrug-resistant-TB and HIV, who continue to have very poor outcomes.

Country-level data on TB/HIV and monitoring and evaluation systems are also not near where they need to be. Hirnschall illustrated this noting that in 32 countries, the HIV and TB programs reported different figures for the numbers of people with TB/HIV co-infection receiving antiretroviral therapy. “We need a one-stop service for patients with TB/HIV,” said Hirnschall, and he called for joint resource mobilization as well to get the job done.

Dybul called this a historic moment of moving from when it was “all about stopping the deaths” to controlling the three major infectious diseases—HIV, tuberculosis and malaria through science, implementation and partnerships.

“TB is advancing in part because of a change in paradigm—the ambition is different,” Dybul said.  He talked about targeting resources to where transmission is occurring and to populations where infections are concentrated, flagging miners who he described as the possible source of one-third of new TB infections in southern Africa, and prisoners as two key groups.  He also discussed the new Global Fund requirement for joint HIV-TB concept notes in countries with high prevalence of both diseases and the challenges the requirement presents to countries with different planning processes and timelines for TB and HIV.  “All public health communities must come together in the interest of individuals suffering from and at risk for multiple diseases,” Dybul said.

Birx

Ambassador Deborah Birx

Ambassador Birx focused her remarks on prioritizing reaching 100 percent antiretroviral coverage for co-infected patients. “If 70 percent of TB patients with HIV know their status, it is unacceptable that only 50 percent of them are being treated for both diseases in a number of sub-Saharan African countries,” Birx said.  She highlighted evidence from Malawi that there is “less TB with more ART” and reported that an analysis of 21 high burden TB/HIV countries found an HIV treatment gap of 192,674 individuals.  She pointed to a gap of TB diagnoses in PEPFAR-funded HIV clinics and a failure to respond to diagnostic results from GeneXpert with seamless access to treatment for both diseases as two roadblocks. Birx also added young women and children to the high risk groups that merit more effective responses.

During the discussion, Peter Godfrey Fawcett from UNAIDS pushed back on the exclusive focus of the conversation on TB/HIV interventions, reminding the speakers and the audience that most people with HIV acquire tuberculosis from an HIV-uninfected individual, making community TB control critical to reducing illness and death from tuberculosis in people living with HIV.

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