Blueprint: Plan for HIV must specify TB response

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Dr. Lucica Ditiu, executive secretary of the Stop TB Partnership, began her career with the World Health Organization as a medical officer for TB in Albania, Kosovo and Macedonia working with all institutions involved in TB care, including ministers of health and justice. She directly supported civil society and communities, funding their efforts through a grant from the European Commission for Humanitarian Assistance. In 2006 she was selected to be a medical officer in the TB unit of the European Regional Office in Copenhagen. Dr Ditiu joined the Stop TB Partnership Secretariat in Geneva to lead the TB REACH initiative, whose goal is to improve access to TB treatment.

Dr. Ditiu wrote the following for Science Speaks’ Blueprint series, in which clinicians, researchers and advocates address the key elements they would like to see in the Global AIDS response blueprint that Secretary of State Hillary Clinton called at the 2012 International AIDS Conference in Washington.

Tackle HIV and TB together

By Lucica Ditiu

A person living with HIV dies of TB every minute. At present one in four AIDS-related deaths is precipitated by TB.

Our message is clear and simple: this has to change. All people living with HIV need to get tested for TB and receive TB treatment if they have the disease. People living with HIV who are routinely exposed to TB should receive preventive treatment with isoniazid (IPT). Any person living with HIV who has TB should receive antiretroviral therapy (ART), regardless of their CD4 count.

To achieve these goals we have to tackle HIV and TB together. This will not happen in countries where the programs providing HIV care operate in isolation from those providing TB care.  Every country seeking to prevent deaths from TB among people living with HIV needs to drive integration of its HIV and TB programs.

The World Health Organization reported last week that scale-up of collaborative TB/HIV activities saved 1.3 million lives between 2005 and the end of 2011. We know what it takes to save an additional 200 000 lives each year, as set forth in Time to Act: Save a million lives by 2015, released by the Stop TB Partnership, World Health Organization and UNAIDS last year. But tragically we are not seeing the kind of scale-up that we should expect if we want to reach that goal.

There is only limited progress on accelerating on-the-ground integration of TB/HIV services and access to IPT. In 2011, 3.2 million HIV-positive people were screened for TB; but just 450 000 received IPT – a small fraction of the number of people who would have benefited from this life-saving preventive treatment. We are seeing progress on scale-up of ART. In 2011, 258 000 people with HIV-associated TB received it. But this is not enough. We should be looking towards 100 percent coverage with ART for people with HIV-associated TB.

South Africa and a number of other countries have committed to ending deaths from TB among people living with HIV.  PEPFAR can play a vital role in supporting them as they reach for this goal by providing specific TB/HIV targets in its global AIDS blueprint.

We urge PEPFAR to include in the blueprint explicit TB/HIV indicators and activities, such as, but not limited to, the following; and indicate its eagerness to support countries in achieving them.

  • Require country programs to track and report on progress toward all relevant TB/HIV indicators, including universal access to ART for people living with HIV who are diagnosed with TB and access to IPT.
  • Help countries provide immediate access to anti-retroviral treatment (ART), regardless of CD4 count, to all patients living with HIV who are found to have TB; and also for TB patients found to be HIV-positive.
  • Move rapidly to enable the utilization of the larger, more decentralized infrastructure of TB clinics to identify HIV cases and deliver care; and encourage countries to allow nurses to initiate both ART and TB treatment.
  •  Support countries to adopt, procure and make optimal use of the latest technologies, such as the Xpert MTB/RIF diagnostic test, to be used for detection of TB in people living with HIV.
  •  Support rapid adoption of low-cost environmental controls and administrative measures to provide urgently needed infection control, and track progress in this area.

It would additionally be an excellent move for the blueprint to acknowledge the limitations of current TB tools, call for continued and stepped-up research and development and commit to integrating new tools into PEPFAR-funded programs as soon as they become available.

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