Tuberculosis (TB) and Human Immunodeficiency Virus (HIV) – can we continue to tackle these separately? According to the Global TB Report (2012), in 2011, out of 8.7 million people who developed TB worldwide 1.1 million (13%) were HIV positive. An approximate of 0.4 million HIV-associated TB deaths took place in 2011 and TB is the most common opportunistic infection among people living with HIV (PLWH). HIV increases chances that latent TB infection can become active TB disease and also increases the risk of death due to this.
While all of us know the individual effect of each of these diseases and the challenges faced by the patient to get diagnosed, endure the treatment and side effects, it is difficult to even begin to realize the interactions of the drugs and the complexities of these two diseases that many a patient is in. Having HIV with TB, or TB with HIV then means too many drugs for a very long time and the need for constant monitoring and compliance. More the drugs, more the side effects and struggle to keep it going. While one takes these drugs to be alive despite all odds, damage is done to the liver and kidneys among other organs. Socially, the patient endures a double stigma: the taboo along with the isolation. If one thinks this is enough on the list for a lifetime, the list isn’t finished yet.
A day in the life of TB-HIV patient involves travelling long distances to be seen by a doctor for a little more than 30 seconds, being pushed from one facility to another, from one long queue to another longer one in order to get a test done, a packet of drugs or the next bus home. Given their current body strength, they have to keep to this system of medical services to find out, very often with much delay, that they have managed to get two very big diseases. The delay is due to logistics, no co-ordination between doctors and their documentation, or defaulters. The individual loss of the day’s work, energy, meals, coupled with an accompanying caretaker’s loss of day’s work only adds on to the overall situation. A woman who also needs to manage her home, children and job is left to wait for hours in a facility which, at the end of the day, will inevitably send her to another site for further management.
The potential threat of disease doesn’t remain with the patient but spreads to society as these patients travel in crowded transportation from one place to the other. “There are 3 main measures that can be implemented”, according to Dr Valerie Schwoebel, from the International Union Against Tuberculosis and Lung Disease (The Union). “They are called “the three I’s: Infection control, Intensified case-finding and Isoniazid preventive therapy. Infection control consists in taking precautions in order to reduce the transmission of the tubercle bacilli, which are disseminated in air by TB coughing patients. This includes diagnosing and treating TB early in the family and contacts of the HIV-infected person, implementing airborne infection control measures at health facilities. Intensified case-finding means that searching for TB should be always part of the medical follow-up of people living with HIV: health workers should always be on the alert for TB at all times and TB diagnostic and treatment services should be easily available and accessible. Isoniazid preventive therapy is a treatment that can prevent the development of active TB disease in PLWH already infected by the bacilli but not yet sick. The treatment lasts at least 6 months and must be delivered in settings where careful evaluation and follow-up of patients is organized.
Presently, we see divided management in both government and private health systems who have taken up TB or HIV management and care around the world. Vertical national TB and HIV programs, both recognize the need for early detection of diseases in their respective cohort. However, not much has been done so far to facilitate that. Many doctors still do not follow the mandatory testing of TB and HIV in respective diseases, but only test TB patients for HIV, when in doubt of the same. While some organisations focus on TB treatment close to areas of low socio economic populations, others focus on HIV in areas like targeted intervention among commercial sex workers, truck drivers, the MSM community and IV drug users.
While many programs are still weighing out and arguing the benefits of the same, some integration programs internationally and in India, have shown to be successful and possible to save many lives. Dr. Paula Fujiwara, Scientific Director at the International Union Against Tuberculosis and Lung Disease (The Union) shares the organisation’s extensive experience in this. She said to Citizen News Service – CNS in an exclusive interview: “Key issues required to scale up collaborative activities include: 1. Commitment and ownership at national level by BOTH the TB and HIV programs to integrate services. 2. At the level where services are provided, linking and integrating the needs of the dually-affected person.”
Swaziland has one of the highest incidences of TB in the world and one of the highest prevalence of HIV. COMDIS, a research programme consortium that works to drive research and development to combat communicable diseases in low-income countries works here. COMDIS supported the rural hospital Good Shepherd Hospital to introduce HIV testing by TB nurses. They implemented the ‘3 Is’ for people living with HIV/AIDS. The national program soon followed suit. International HIV/AIDS Alliance, in its projects, links TB and HIV by increasing awareness of TB/HIV and educating patients and counseling them on TB infection control measures. TB case detection among people with HIV and HIV testing of TB patients is carried out.
Adherence support for both TB and HIV patients is done. Closer to home, the state of Karnataka began integrative services following the model put forth by Samastha project funded by USAID and Karnataka State AIDS Prevention Society (KSAPS). This requires training of district project officer, nurses, and other caretakers to make sure that quality management is given to the patients. Although assessments done show that collaboration between the two programs is relatively inexpensive, the investments lie in reducing the gaps in knowledge and skills among health workers, laboratory diagnostics, staffing levels, medical supplies and infrastructure.
In order to combat these two public health problems there has to be a sustained effort in strengthening and integrate the health system to provide quality health care. In March 2012, World Health Organisation (WHO) made some recommendation towards TB-HIV collaborative activities. The recommendations included: A.) To establish and strengthen the mechanism for delivering and integrating TB and HIV services, B.) To reduce the burden of TB in people living with HIV and initiate early ART by the three Is. C.) Reduce the burden of HIV in patients with presumptive and diagnosed TB. The question remains, as Dr. Michel Sidibe, UNAIDS Executive Director asked at the Stop TB Partner’s Forum in 2009, “When a virus (HIV) and a bacteria (TB) can work so well together, why can’t we”? (CNS)