Around much of the world where rates of HIV-tuberculosis co-infection are highest, one of the challenges killing patients has been the wait to discover if their TB would respond to the most common treatments. A four-year South Africa study of co-infected patients showed starting treatment for HIV during the course of anti-tuberculosis treatment, rather than waiting until TB treatment was completed, improved survival rates among those whose tuberculosis was responsive to first-line treatment. Now, an analysis of data from the study has shown that benefit applies to people with drug-resistant tuberculosis, as well.
The analysis compared survival and death rates among 23 patients diagnosed with multidrug-resistant TB in the 2008-to-2012 trial dubbed “SAPiT” for Starting Antiretroviral Therapy at Three Points in Tuberculosis. Of the 23 patients, seven died — two who started antiretroviral treatment during anti-tuberculosis treatment, and five who did not begin antiretroviral treatment until completing TB treatment. Of the two receiving simultaneous treatment who died, one had committed suicide. The other, as well as four of the five who had not begun antiretroviral treatment until completion of treatment for TB, were not discovered to have multidrug-resistant tuberculosis until after their deaths. The fifth in that “sequential treatment” group only began treatment for drug-resistant tuberculosis in the last 19 days of his life. Among the conclusions of the analysis: beginning treatment for HIV during treatment for TB improved the chances for patients to survive long enough to receive appropriate treatment for multi-drug resistant tuberculosis.
Under the funding model of the Global Fund to Fight AIDS Tuberculosis and Malaria this year, countries with high TB-HIV co-infection rates will be required to submit joint TB-HIV concept notes which present integrated and joint programming for the two diseases. Most of the 41 high-burden countries, as identified by the World Health Organization, are in sub-Saharan Africa, which saw 1.1 million new TB cases among people living with HIV in 2012.
Despite advocacy for TB-HIV collaborative activities since 2004, uptake of evidence-based global policies for TB-HIV integration has been slow, according to the Global Fund’s Board, which announced the new requirement in October. Although the WHO recommends that all people co-infected with TB and HIV receive antiretroviral treatment, which is the most powerful intervention for preventing illness, death, and transmission, only 57 percent of patients are on antiretroviral treatment. This figure reflects patients funded from all sources, not just the Global Fund
Global Fund cumulative expenditures from 2002 to 2011 for combined TB-HIV interventions represented only four percent of TB grants and one percent of HIV grants.
Requiring Global Fund recipients to integrate TB and HIV programming will align critical components of the health system, including health workforces, financing, and laboratory systems, as well as improve procurement and supply chain management, according to a presentation at the TB and HIV Working Group meeting held in Washington, DC, last week.
“By integrating HIV and TB from the beginning, we will ultimately make it easier for people to not only access HIV and TB testing but also life-saving treatment,” said Luiz Loures, Deputy Executive Director of Programmes at UNAIDS, in a statement released by AIDSPAN.
The Global Fund will soon disseminate guidance on how to complete and submit the new concept note to recipient countries and partners. They acknowledge that country-specific responses will differ, but the approach will provide a new way of doing business, and will allow for better targeting of resources, scale up of services and improvements in their effectiveness, quality and sustainability.