MELBOURNE, AUSTRALIA – “Why do we still have 320,000 deaths from TB in people living with HIV each year?”
This was Dr. Diane Havlir’s question in an opening plenary talk on Wednesday, as she noted the potential of evidence-based prevention for HIV/TB, new TB diagnostic tools and the ability to cure most TB in six months and to reduce morality with antiretroviral therapy. She identified three key answers to her question — failing to scale-up evidence-based interventions, neglecting populations that are most at risk, and care delivery that is often focused on disease (HIV or TB) rather than on patients.
Her talk provided guidance for the way forward in 2014 beginning with what she termed “combination prevention for HIV/TB.” She called antiretroviral therapy the cornerstone of this prevention package, but noted that timing was key — within 2 weeks of starting TB treatment for persons with CD4 counts lower that 50 and no later than eight weeks for everyone else.
“Most programs are not documenting the time to ART initiation and this is critical to propel us forward to further reduce mortality,” said Havlir. For HIV-infected persons without active tuberculosis, adding isoniazid preventive therapy provides an additional 35 percent reduction in TB in high TB transmission areas, another key element of prevention, she said. Finally, proven strategies to reduce transmission including enhanced case finding for both TB and HIV and infection control must be implemented, she said.
Maximizing use of the new and better tuberculosis diagnostics — GeneXpert and the LAM point-of-care urine test will also help save more lives. The LAM test is especially effective in individuals with very low CD4 counts and can be a critical tool to detect TB in people with late stage HIV infection, who are most vulnerable for early mortality.
She called for more attention to who is dying and identified most-at-risk populations who require a greater response — children, people who work in mines, incarcerated persons, people who use drugs. Illustrating the neglect of HIV-infected children she cited findings from a Malawi cohort where 32 percent of enrolled HIV infected children were diagnosed with tuberculosis and 20 percent of them died. Preventing HIV in children, starting antiretroviral treatment in all HIV-infected children and providing IPT for all children exposed to active TB were actions she flagged to reduce TB illness and death among children with HIV.
Working in mines is the second largest driver of tuberculosis in South Africa, after HIV, and Havlir termed “HIV and mining a lethal combination.” She said miners need improved housing and mining conditions, HIV/TB prevention and screening as part of the employee health contact and continuity in care when miners come and go from employment.
Highlighting high rates of TB infection among persons who inject drugs, one-third of whom are HIV infected and two-thirds of whom have hepatitis C, she noted that human rights violations drive these people away from care, and harm reduction services need to be coupled with HIV and TB interventions.
High rates of incarceration exacerbate TB spread with the crowded conditions and limited healthcare access that characterize prisons and jails. Housing for both prisoners and people who inject drugs and provide on site HIV/TB prevention and screening services must be improved, said Havlir.
She identified best care settings for HIV/TB services as those that are most convenient for patients. Where HIV and TB clinics remain separate, she called for stepping up the use of community health workers to help patients navigate their care in the two settings.
Finally, Havlir said, research must provide better understanding of tuberculosis and it must continue to develop more effective, less toxic, and shorter treatment and prevention regimens. She referenced research looking at using some of the available drugs at high doses to shorten the course of treatment and new drug combinations that may effectively treat both drug-susceptible and drug-resistant tuberculosis.