The Chasm between HIV and TB

Some Thoughts on World TB Day- March 24

A quiet shift took place a few years ago in the impact of global infectious diseases: The human immunodeficiency virus (HIV) epidemic surpassed that of age-old tuberculosis (TB).

In the past five years annual spending on HIV programmes increased 16-fold - from USD 500 million to around USD 8 billion per year. The same period saw a paltry 70% increase in funding for anti-TB efforts.

The cost to humanity? HIV kills around three million people every year. TB kills two million. The point, however, is not to tally up marks for a macabre competition; it is precisely the opposite: We need to stop thinking of the two diseases in separate bodies, because a third of the 40 million people living with HIV today are also co-infected with TB.

In 2006 and for at least the next decade, HIV's biggest challenge is TB. One in every three people harbours the TB bacteria in their body. That's two billion people. TB stays inactive, but transforms into active TB disease in about nine million of us every year. Crucially, people with HIV are about 30 times more likely to develop active TB than those without HIV - fuelling a resurgence of TB in sub-Saharan Africa and some states of the former Soviet Union. East and South Asian countries are next in line.

Imagine the two diseases in one body. Jolting enough to be told you have TB - then to be called back to hear your HIV test was also positive. The doctor is fully aware that TB progresses faster in HIV-infected people, and that TB in those who also have HIV is more likely to be fatal. Their task now is to explain to you that the two diseases often cannot be treated at the same time; the two sets of drugs can interfere with one another.

Sadly, the ease with which the two diseases intensify one another is not mirrored by the groups of people and institutions working to fight them. Despite years of knowing how TB and HIV interact with one another, and how programmes to address them should also work together, this is how they continue to think about HIV and TB: Separately.

It is astounding to find that the heads of three of the main actors responsible for controlling the two diseases - the World Health Organization (WHO), the Joint United Nations Programme on HIV/AIDS (UNAIDS), and the international Stop-TB Partnership - do little more than nominally reflect each other's experience and advice. All the more surprising when you consider that the offices of the three men are no more than a kilometre apart in Geneva. Each programme continues to eye the others from across the car park and in the process, lose vital lessons in political strategy, resource mobilisation and clearing of service delivery bottlenecks.

The solution is absurdly simple: Break down the walls of established thought between the two diseases and you hold out the biggest promise for saving million of lives.

There is much that the relatively new HIV world has to learn from the old guard. TB has been around for centuries and is one of the areas of public health where we know the most. It is a curable disease with available medicines, and a long demonstrated track record of success. The doctors, the detection and treatment centres, the drugs - much is already in place.

Since it was set up in 2001, for example, the TB Global Drug Facility - aimed at increasing access to high quality TB drugs - has delivered over 4.5 million TB patient treatments. Something that the WHO-supported '3 by 5' anti-HIV drug initiative has been trying to emulate, as yet incompletely.

TB is not only curable, it is preventable. The failure to effectively deliver TB diagnosis, treatment and prevention to people with HIV means that many are dying needlessly.

The most frequently used method for detecting active and infectious TB is a microscopic analysis of a patient's sputum. The trouble is that the test is antiquated and unreliable in people with HIV. The test result may be negative even though a person has active TB, making reliable TB diagnosis impossible. Commonly-used TB drug treatments are also outdated, with patients often required to take large numbers of tablets every day for up to eight months.

These technical obstacles are far from new; they have been written about and discussed for years now. Less often highlighted are some of the divisions between TB and HIV/AIDS established thinking that prevent synergy.

The TB world can learn from some of the accepted tactics of the movement against HIV. These include obvious lessons on how to raise more money as well as a loyalty to community- and rights-based approaches.

For example, the mainstay of the WHO gold standard policy and treatment package for TB control - known as Directly Observed Treatment, Shortcourse (or DOTS) - is a standard drug treatment for all confirmed cases. This originally meant health workers literally watched patients take their drugs (hence 'directly-observed') to ensure the drugs were, in fact, ingested.

"That, for me, is unacceptable because it limits the autonomy and dignity of every person," commented Zackie Achmat, one of the founders of the South African Treatment Action Campaign, at a recent TB conference.

The HIV/AIDS sector sees clinical care as necessary but not sufficient for the best results. People have to make changes in their lifestyles, develop new skills, and must learn to interact with health care providers to successfully manage their conditions. Similarly, people with TB can no longer can be viewed, nor see themselves, as passive recipients of health care services. These issues are dealt with in a newly published TB 'Patient's Charter', which aims to empower people with TB and their communities by highlighting their rights and responsibilities, and need to be put into practice widely and immediately.

Connecting with the expertise of community groups has been embraced to extreme degrees by responses to TB and HIV. TB services rarely integrate community resources into the care of patients to the same degree as HIV/AIDS services, leaving a broad array of consumer groups, patient advocates, and nongovernmental organisations (NGOs) virtually untapped.

On the other hand, HIV/AIDS NGOs fill many service gaps to greatly enhance the care of people living with HIV and help to meet goals for service coverage and treatment outcomes.

A new global plan to address TB head-on over the next decade was recently launched by the Stop TB Partnership. Actions for Life - Towards a World Free of Tuberculosis proposes some bold shifts towards empowerment of TB patients and communities, and asks governments and foundations to foot the bill. They should, despite the ten-year, USD 56 billion price tag.

Some demonstrated behaviour change will probably be required to convince donors. If they can learn to speak the same language, leaders of local and international organisations, NGOs and community-based support groups are perfectly positioned to raise awareness about the two conditions simultaneously. Community leaders are positioned to sensitise the public about TB and HIV, and reduce the stigma associated with them.

Foremost though, is the need for greater cooperation and coherence at the level of international institutions and agencies that help governments to set policies, priorities and good practices in dealing with HIV and TB.

In 2000, at the launch of the Stop-TB Partnership, Peter Piot, still the head of UNAIDS today, may have foreseen today's organisational stalemate quite clearly: "We are not in competition. We are as intimately allied as are the human immunodeficiency virus and the TB bacillus," he explained. "We must work together. If we are serious about our missions to stop TB and stop HIV, finding new realistic pathways to the future is imperative."

Six years on, we have waited too long to see their coherent joint actions on TB and HIV. The first step is simple: Someone get Drs Piot, Raviglione and Espinal to match their schedules and talk.

Dr Tim France is the Director of Health and Development Networks (HDN).

Chest Imaging

Routinely, chest x-rays are taken from the back to front, but sometimes this view is supplemented with a side view. Chest x-rays provide a good out-line of the heart and major blood vessels and usually can reveal a serious disease in the lungs, the adjacent spaces, and the chest wall including the ribs. For example, chest x-rays can clearly show pneumonias, lung tumors, a collapsed lung (pneumothorax), fluid in the pleural space (pleural effusion), and emphysema. Although chest x-rays seldom give enough information to determine the exact cause of the abnormality, they can help a doctor determine which other tests are needed to make a diagnosis.

Computed tomography (CT) scanning of the chest provides more detail than a plain x-ray. With CT scanning, a series of x-rays is analyzed by a computer, which then provides several cross-sectional views. During CT scanning, a dye may be injected into the bloodstream or given by mouth. The dye helps clarify certain abnormalities in the chest.

Magnetic resonance imaging (MRI) also produces highly detailed pictures that are especially useful when a doctor suspects blood vessel abnormalities in the chest, such as an aortic aneurysm. Unlike CT scanning, MRI doesn't use radiation. In-stead, it records the magnetic characteristics of atoms within the body.

Ultrasound scanning creates a picture on a monitor from the reflection of sound waves in the body. Ultrasound is often used to detect fluid in the pleural space (the space between the two layers of pleura covering the lung). Ultrasound also can be used for guidance when using a needle to aspirate the fluid.

Nuclear lung scanning uses minute amounts of short-lived radioactive materials to show the flow of air and blood through the lungs. Usually, the test is done in two stages. In the first stage, a person inhales a radioactive gas, and a scanner creates a picture of how the gas is distributed throughout the airways and the air sacs (alveoli). In the second stage, a radioactive substance is injected into a vein, and a scanner creates a picture of how it's distributed throughout the blood vessels of the lung. This type of imaging is particularly useful in detecting blood clots in the lungs (pulmonary emboli); it also may be used during the preoperative assessment of lung cancer patients.

Angiography accurately shows the blood supply to the lungs: Dye that can be seen on x-rays is injected into a blood vessel, and pictures are taken of the arteries and veins in the lungs. Angiography is used most often when pulmonary embolism is suspected, usually on the basis of abnormal lung scan results. Pulmonary artery angiography is considered the definitive test (gold standard) for diagnosing and for ruling out pulmonary embolism.

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