Stop TB Partnership - TB/HIV Working Group


TB/HIV Working Group

Publications

HATIP - HIV & AIDS Treatment in Practice

Childhood TB - the overlooked epidemic

These editions of HATIP are a two-part clinical review of the management of TB in children with HIV.

Childhood TB has been a long overlooked area of TB control, but childhood cases of TB contribute around 15% of the total burden of TB cases worldwide. Infants are at particularly high risk of dying quickly from TB, and children with HIV have up to a tenfold greater risk of dying from TB than children with TB alone. Most programs seem to be poorly equipped to deal with most aspects of TB disease in children. There seems to be uncertainty about the size of the problem, which is directly related to problems diagnosing it -or how to distinguish an infection from a case of progressive active TB with limited diagnostic tools. How can programs with limited resources find cases or act to prevent them; are the existing treatment regimens adequate and how should TB care and HIV care be coordinated for HIV-infected children?

There's a wealth of literature published about these problems, but relatively little reliable prospective clinical data to guide management of TB in children. With some notable exceptions, researchers and policy developers have mostly neglected the matter.

"At policy meetings, childhood TB just falls off the table," Mark Harrington of the Treatment Action Group told HATIP. "It's usually left until the end of the agenda, and then it's, 'oh sorry, we've run out of time.'"

Three Is

This edition of HATIP reviews the Three Is, those measures that reduce the burden of TB in people living with HIV.

Key activities that are critical to continued success of ART-scale up are the Three Is (Intensified case finding, provision isoniazid preventive therapy, and infection control)

This year, approximately 750,000 people with HIV will develop TB, mostly in sub-Saharan Africa. About 230,000 of them will die. Needlessly. But TB is both a preventable and treatable illness so it does not have to be a death sentence in people with HIV. There are three essential activities that all HIV programs should be doing that could protect people with HIV from TB infection, help prevent active disease from developing, and identify active TB disease early and improve the chances of cure - the 'Three I's. HIV programs have been failing to take advantage of the key strategies to manage TB in people with HIV - and it is undermining those very HIV/AIDS services we have been working so hard to establish.

Infection control

This special edition of HATIP covers infection control. It is aimed at health care workers, program planners, community organizations and treatment advocates - all groups that have an important role in TB infection control.

Almost two years have passed since news of the outbreak of extensively drug resistant tuberculosis (XDR-TB) at the Church of Scotland Hospital in Tugela Ferry, South Africa was first announced to the world. XDR-TB is defined as TB with resistance to at least rifampicin, isoniazid, a second line injectable drug (capreomycin, kanamycin or amikacin) and a fluoroquinolone. As HATIP reported previously (see December 2006 and January 2008) there was strong evidence that the initial outbreak in Tugela Ferry evolved locally and was spread to other patients at the hospital or possibly within HIV patient support groups. The discovery led to panic and calls for compulsory detention of MDR TB patients, and highlighted the spread of TB within hospitals filled with people with HIV. But after all the hoopla, have our health facilities, prisons, mines, or HIV care services, become any safer? With a few exceptions, there has been little action in many other resource-limited settings.

Intensified Case Finding

This is a special double edition of HIV & AIDS Treatment in Practice on intensified TB case finding in people with HIV, kindly supported by the World Health Organization Stop TB Department.

"Intensified TB case finding" (ICF) is an activity, recommended by the World Health Organization (WHO), intended to detect possible TB cases as early as possible among people living with HIV - usually by using a simple questionnaire for the signs and symptoms of TB. ICF does not mean making a TB diagnosis, but it is the first step towards making a diagnosis. Ultimately for ICF to make a difference, people suspected of having TB should receive a thorough diagnostic evaluation, with timely results, and begin appropriate treatment, either to cure active TB or prevent it.

TB control programs generally rely on passive TB case finding - where the onus is on the individual with TB to come in for diagnosis and care.

There isn't time for that in people with HIV, who are at much greater risk of getting TB (often aggressive cases including hard-to-diagnose smear-negative or extrapulmonary disease) and, if not treated soon enough, dying from it. And wherever there is a high burden of TB/HIV co-infection, these effects have been amplified - leading to the breakdown of TB control, with the number of new cases of TB growing dramatically in the last 15 years.

Read more about intensified case finding

ICF routinely screen for TB now

ICF developing an action plan

Isoniazid Preventive Therapy

This is a special double edition of HIV & AIDS Treatment in Practice on the provision of isoniazid preventive therapy in people with HIV, kindly supported by the World Health Organization Stop TB Department.

Studies discussed in these article underscore that enough is known about IPT that its risks can be kept to a minimum in large programs in resource limited settings, and that it may markedly reduce active TB and improve survival.

Theoretically, it might even reduce onward transmission, and the overall burden of TB.

So given these benefits, what is holding up national implementation?

Read more about isoniazid preventive therapy