Stop TB Partnership

Speech by Dr Peter Piot

STATEMENT BY DR PETER PIOT, EXECUTIVE DIRECTOR, UNAIDS, SWITZERLAND
AT THE MINISTERIAL CONFERENCE ON TB & SUSTAINABLE DEVELOPMENT

23 MARCH 2000

TB, HIV/AIDS AND THE GLOBAL RESPONSE

The film we have just seen reminded me of my first contact with TB, and the village in Belgium where I come from, which is 200km south of here. When I was 9 years old, my mother told me that I should stop playing with a girl because her father had ‘consumption’. They were a poor family of immigrants. This was my first conscious encounter with stigma – and I remember the experience so well. Fighting stigma is one of the most crucial aspects of our work against HIV/AIDS and TB.

I bring three simple messages today:

Firstly, anything that stops the HIV epidemic will also stop TB

Second, to stop TB we need to go beyond DOTS

and

Third, the HIV and TB establishments, if I can use that term, are not in competition.

Let me take my first message: anything that stops the HIV epidemic, will also stop TB. Any investment we make in preventing HIV will impact on the burden of TB that poor communities carry.

Indeed, in many parts of the world, the TB epidemic will not be stopped without serious HIV prevention. Let’s look at Zambia. In this country, one in five adults is infected with HIV. The number of new TB cases has risen from 7,000 in 1984 to over 40,000 in 1998. This is a six-fold increase in just over ten years. It is estimated that a full three quarters of new TB cases are due to HIV infection. Do we need a clearer illustration why slowing down the epidemic of HIV is critical to stopping TB?

You are familiar with the facts of these twin epidemics: a person living with HIV is thirty times more likely to develop TB than someone who is not. HIV is now the major cause of the rise of TB cases in southern and south-east Africa. In Thailand TB is now the most common opportunistic infection among AIDS patients, and the HIV epidemic is one of the biggest threats to effective TB control.

Like no other contemporary disease, aside from the magnitude of its spread, and its erosion of human capital, AIDS continues to bring a stigma unprecedented in modern times. HIV is undermining the stability of families and communities – rich and poor, skilled and unskilled alike. For most of us, comprehending the scale of the epidemic is almost impossible, but I won’t bore you with more figures. Gains in life expectancy are being reversed, and the current estimate of 11 million orphans is an unprecedented - and highly destabilising - ‘rip’ in the social fabric. As was stated in the UN Security Council debate on AIDS in Africa in January of this year, the epidemic is rapidly becoming more devastating than war. The AIDS epidemic has become, an issue of human security.

But you may also not be familiar with the positive stories too. Like the TB epidemic, we are far from powerless against HIV. In countries where strong political leadership, openness about the issues, strong community involvement, and broad, cross-cutting responses come together, the tide is turning, and clear success is being demonstrated. It is clearly documented on a large scale in countries as diverse as Thailand, Brasil, Uganda, Australia and Senegal. We know what works.

If we want to stop TB, we cannot avoid this wider context of HIV today. So, to reiterate my first message to you today, Anything that stops the HIV epidemic, will also stop TB. Any investment we make in preventing HIV will impact on the burden of TB that poor communities carry. Without that investment, the message is simple: we will be unable to stop TB.

Let me turn to the second message that I bring you today is intimately related to the first: to stop TB, we need to go beyond DOTS.

The inadequacy of TB services worldwide and the resulting poor access of HIV infected people to TB services is the main reason for UNAIDS’ support to the Stop TB initiative. This support is more than verbal: we are supporting WHO to implement six pilot programmes introducing DOTS into community-based organisations in Africa. These pilot programmes documented that community organisations of people living with HIV infection can and should be important actors in TB control. But DOTS programmes, while desperately needed, have two important limitations.

Firstly, DOTS is insufficient to address the TB concerns of HIV infected people, because they develop pulmonary TB and disseminated forms of TB in roughly equal portions.

What then, beyond DOTS, can TB control programmes do to deal more effectively with TB in HIV infected people.

First is to prevent the occurrence of TB in people infected with HIV. We know that preventive therapy for TB prevents 60 per cent of cases that would otherwise have occurred in HIV infected people. And we know that this intervention is about as cost effective as DOTS.

Second is to be on the lookout for TB among HIV infected people, through active case finding.

Third, focus far more on a community-based approach to improve access to services.

The second limitation of DOTS is that DOTS does little to address the HIV concerns of people with tuberculosis.

This could and should change. In many developing countries where TB patients are also HIV positive, TB is perceived as synonymous with AIDS. As a consequence, the stigma that already impedes access to TB treatment is amplified. Dealing with this stigma requires people involved in TB control to address the fears of their clients that they might have HIV infection. This can be done only if they have. This also means that we need an all out effort against the stigma associated with AIDS and with TB.

Sometimes, there is a perception that people in TB control perceive the fight against HIV as a competing issue with their main interest, and vice versa.

So the third message that I bring today simply reinforces the other two. We are not in competition. We are as intimately allied as are the Human Immunodeficiency Virus and the TB bacillus. We must work together. If we are serious about our missions, to stop HIV and to stop TB, finding new realistic pathways into the future is imperative. How else can we respond meaningfully to the enormous challenges that confront us all?

Thank you.