Background

Understanding TB and its link to HIV

South African Experiences of the ProTest Iniative

Story Ideas

Additional On-line Resources on TB and HIV/AIDS

Acknowledgements

Prepared by Dr Harry Hausler
Clinical Research Unit, Department of Infectious and Tropical Diseases
London School of Hygiene and Tropical Medicine

Background

TB and HIV Statistics in South Africa

» South Africa is facing one of the worst dual epidemics of tuberculosis (TB) and HIV in the world.

» It is estimated that 4.7 million South Africans are infected with HIV of whom 1.6 million will get sick with TB before they die.

» The prevalence of HIV in pregnant women has increased from less than 1% in 1990 to 24.8% in 2001.

» It is estimated that 350 000 South Africans will die of AIDS this year and that there will be nearly one million AIDS orphans by 2005.

» The number of TB cases reported in South Africa was relatively stable between 1980 and 1989. Fuelled by the rise in HIV prevalence, the number of incident TB cases increased from 68,027 TB cases (187/100,000) in 1989 to 188,695 TB cases (424/100,000) in 2001, an increase of 276%.

» TB is the most common opportunistic infection and the leading cause of death amongst people living with HIV in South Africa. HIV, by attacking the immune system, increases the lifetime risk of getting sick with TB after being infected with TB from 10% to 50%.

» TB also accelerates HIV disease. It is estimated that more than 50% of TB patients in South Africa are infected with HIV. HIV-positive TB patients have mortality rates that are 2 to 4 times higher than HIV-negative patients, ranging from 6% to 39% in sub-Saharan Africa.

» Higher death rates among HIV-positive TB patients are the result of weakened immune systems not being able to control TB and other infections.

Stigma and Discrimination

» Because of the similarity of symptoms in TB patients and people living with AIDS, some people are unclear that the diseases can occur independently.

» It is important for the public to realise that although HIV increases the risk of developing TB, not all HIV-positive people have TB and not all people with TB are HIV-positive.

» People with TB or HIV face similar problems of stigmatisation, fear and discrimination and have shared needs for counselling, care and support.

» Both HIV/AIDS and TB are more common in poor communities. Innovative approaches to poverty alleviation are required to help HIV and TB prevention.

Responses to TB and HIV/AIDS

International Response to TB/HIV and the ProTest Initiative

» Internationally TB/HIV collaboration is coordinated by WHO and UNAIDS who jointly coordinate the Global TB/HIV Working Group which forms part of the Stop TB Initiative.

» The Global TB/HIV Working Group met for the first time in April 2001 to develop a strategic framework for TB/HIV collaboration and recommended the expansion of the ProTEST Initiative.

» WHO in collaboration with UNAIDS is coordinating the “ProTEST Initiative” which is investigating how to interrupt the sequence of events by which HIV infection fuels the tuberculosis epidemic, by promoting voluntary counselling and testing for HIV as an entry point to access to a range of HIV and TB prevention and care interventions.

» South Africa is participating in the ProTEST Initiative through the TB/HIV Pilot Districts.

TB and HIV/AIDS in Africa

» The Heads of State and Government of the Organisation of African Unity (OAU) met in Abuja, Nigeria from 26 to 27 April 2001 at a Special Summit devoted specifically to address the exceptional challenges of HIV/AIDS, TB and other related infectious diseases.

» The Summit declared that AIDS is a State of Emergency in the continent and committed participants to take personal responsibility to provide leadership in the battle against HIV/AIDS, TB and other related infectious diseases.

» It set a target of allocating 15% of national budgets on health and undertook to mobilise all the human, material and financial resources required to provide care and support and quality treatment.

Coordinating the South African response to TB and HIV

» Recognizing the strong interaction of these diseases, one of the major recommendations of the national reviews of the TB Control Programme in 1996 and the HIV/AIDS&STD Programme in 1997 was to improve collaboration between the HIV/AIDS&STD and the TB Programmes at all levels.

» At national level, there have already been many activities of collaboration in the areas of policy formulation, advocacy, training and provincial support visits.

» A Joint Strategy for HIV/AIDS&STD and TB Control in South Africa was developed and endorsed by provinces and senior management at the Department of Health in 2000.

» At provincial level, all provincial coordinators for HIV/AIDS&STDs and TB have met to identify areas for collaboration and conduct joint operational planning.

» TB/HIV pilot districts were established in 1999 to implement and evaluate a comprehensive package of HIV/AIDS/STI/TB prevention, care and support at district level.

» Provincial Heads of Health have decided to use the lessons learned from the TB/HIV Pilot Districts in well functioning TB Demonstration and Training Districts from 2002 to 2006. Districts that introduce TB/HIV activities will be called TB/HIV Training Districts. All provinces established a TB/HIV Training District in 2002 (see further description of TB/HIV Pilot Districts below).

Understanding TB and its link to HIV

TB Diagnosis

» TB is diagnosed by looking at the fluid a person coughs up under a microscope (TB smear microscopy). Most HIV-positive TB patients have TB of the lungs (pulmonary TB) that can be detected with a microscope (smear-positive).

» HIV-positive patients are more likely than HIV-negative patients to get TB of the Lungs that is not detectable with the microscope (smear-negative pulmonary TB) or TB in another part of their bodies (extrapulmonary TB).

» Diagnosis of TB in HIV-infected patients is therefore more difficult. TB patients who are early in their HIV disease with intact immune systems will present with a similar clinical picture as those who are not infected with HIV.

» In HIV-positive patients whose immune systems are weak, there is a higher likelihood of smear-negative pulmonary TB and extrapulmonary TB (for example, in the lymph glands, bones, spine, kidneys, liver, intestines and skin).

» The chest X-ray findings in a pulmonary TB patient who is also infected with HIV may be atypical (i.e., pulmonary infiltrates throughout the lungs rather than cavities in the upper lobes of the lungs).

» This tends to delay diagnosis and treatment, thus increasing the number of infectious TB patients able to spread the disease for longer periods. The diagnostic protocol in the national guidelines addresses the need for chest x-rays and TB cultures if smear-negative TB suspects do not respond to a one week course of broad spectrum antibiotics. The guidelines also explain how to diagnose extrapulmonary TB.

HIV Voluntary Counselling and Testing and TB

» Only about 10% of South Africans who are infected with HIV are aware of their HIV status. Voluntary HIV counselling and testing (VCT) has been shown to decrease HIV risk behaviours and to decrease HIV incidence in other countries.

» It is estimated that for every 10 people who receive VCT, one HIV infection is prevented. This means that providing VCT to 1000 people will prevent 100 HIV infections. Since about 30% of HIV-positive people will develop TB, counselling 1000 people will also prevent 30 cases of TB.

» People who are identified to be HIV-positive need to be counselled on the symptoms of TB, encouraged to seek care if they develop TB symptoms and linked into a package of care and support.

» Given that more than 50% of TB patients are HIV-positive, all TB patients should routinely be offered VCT. Currently, access to VCT services for TB patients remain limited.

» The South African government views increased access to VCT as a major priority. Through the Integrated Plan for Children Infected and Affected by HIV/AIDS, cabinet has committed funding to train 2 people in every health facility in the country to do HIV counselling and rapid HIV testing and to purchase enough rapid HIV kits to test 12.5% of the adult population over 3 years.

» TB hospitals should ensure that they participate in this process and that they develop the capacity to provide VCT.

Directly Observed Treatment Short-Course (DOTS) Strategy

» TB can be cured whether a person is infected with HIV or not using the same drug regimens for the same length of time.

» As in all cases, HIV-positive TB patients should be linked with a treatment supporter who will encourage and observe the patient to ensure treatment completion.

» DOTS is the TB control strategy that is being promoted by the World Health Organisation (WHO) and has been implemented in South Africa since 1996.

» The key elements of the strategy are political commitment, identifying infectious cases using sputum smear microscopy, ensuring uninterrupted supplies of standardised short-course TB treatment, providing directly observed TB treatment and using standardised recording and reporting to assess treatment results.

» The most effective way to control TB is through a combination of DOTS and HIV prevention (voluntary HIV counselling and testing, condom promotion, syndromic management of sexually transmitted infections).

Cotrimoxazole Prophylaxis

» Cotrimoxazole is a broad-spectrum antibiotic that prevents diarrhea, pneumonia and brain infections caused by different bacteri and parasites.

» In July 2000, the World Health Organisation (WHO) and the Joint United Programme on HIV/AIDS (UNAIDS) recommended that cotrimoxazole prophylaxis should be provided to symptomatic people living with HIV as part of a package of care.

» These recommendations are based on studies in the Ivory Coast that showed that cotimoxazole decreased hospitalisations by 50% in all HIV-positive clients. More importantly, cotrimoxazole prophylaxis given to HIV-positive TB patients decreased mortality by 50%.

» In South African national policy dictates that symptomatic HIV-positive clients including all HIV-positive TB patients should receive cotrimoxazole prophylaxis (960 mg daily for life) starting one month after initiation of TB treatment.

» The key is to take control over their own well being and need not feel powerless over their infection.

Management of Opportunistic Infections

» Although TB is the leading cause of death among HIV-positive patients, more tha half of HIV-positive TB patients die from a variety of opportunistic infections other than TB.

» In order to decrease TB mortality, it is essential for health workers who provide care for TB patients to learn how to manage opportunistic infections according to national HIV/AIDS policy guidelines.

Palliative and Home Based Care

» Palliative care is active care of a person with a terminal illness to improve their quality of life. Since AIDS is a terminal illness, health workers who provide care for HIV-positive TB patients need training on palliative care or to be able to refer their patients to receive palliative care.

» Home based care is the provision of care for people with chronic and terminal illnesses including HIV/AIDS in their homes. Some HIV-positive TB patients may be well enough to be discharged from hospital but still be sick enough to require care in their homes. Families of these patients need to be trained on home based care and to be supported by home based care teams. It will be important to establish adequate referral mechanisms to ensure a continuum of care and to avoid “home based neglect”.

Multidrug resistant TB

» TB can become resistant to anti-TB drugs if health care workers prescribe incorrectly and if TB patients do not complete their TB treatment.

» When TB becomes resistant to isoniazid and rifampicin, it is called multidrug resistant (MDR) TB.

» MDR TB is twenty times as expensive to treat as drug susceptible TB, the treatment lasts from 16 to 22 months, 30% of cases are fatal and less than half of patients are cured.

» It is estimated that there are more than 5000 new cases of MDR TB in South Africa each year. Although people infected with HIV are not more prone to infection with MDR TB than other people, they do progress more quickly from infection to disease.

» The most important way to prevent MDR TB is to ensure that TB patients are given the correct TB treatment regimens and that they are cured through directly observed treatment.

TB Preventive Therapy

» WHO and UNAIDS recommended in February 1998 that isoniazid preventive therapy (IPT) should be offered as part of a comprehensive package of care for people living with HIV/AIDS to prevent TB.

» This recommendation is based on the results of several large randomised clinical trials which show that giving isoniazid to HIV-positive people decreases their risk of developing active TB by 40%.

» TB preventive therapy is one of the only effective interventions available to offer to people who are living with HIV in the early stages of their disease.

» Clients of IPT are given isoniazid 300mg daily for 6 months and monitored for side effects and symptoms.

» Although the efficacy of IPT has been proven, adherence to IPT is variable. Reasons for good and poor adherence to TB preventive therapy and its feasibility and cost-effectiveness are being evaluated in the TB/HIV pilot districts.

» There is no evidence to suggest that IPT increases community levels of isoniazid resistance. TB preventive therapy must only given to clients who have no signs or symptoms of TB. These clients either have no TB infection or only latent TB infection.

» They therefore do not have a high enough bacillary load to allow the multiplication and survival of mutant isoniazid resistant TB strains. Isoniazid resistance will not develop unless a patient with active TB is inappropriately started on IPT.

South African Experiences of the ProTest Iniative

ProTest Initiative in South Africa - TB/HIV Pilot Districts

» The National Department of Health is participating in the WHO/UNAIDS- sponsored ProTEST Initiative by coordinating 4 TB/HIV Pilot Districts (East London, Eastern Cape; Ugu, Kwazulu-Natal; Bohlabela, Limpopo; Central, Western Cape).

» The goal of the TB/HIV Pilot Districts is to implement and evaluate a comprehensive package of HIV/AIDS/STI/TB prevention, care and support.

» The objectives are to:

o Facilitate collaboration between TB/HIV public and private stakeholders at district level.

o Increase access to voluntary HIV counselling and rapid testing (VCT).

o Improve TB case finding, TB treatment completion and TB cure rates among people living with HIV/AIDS through community involvement.

o Improve access to sustainable isoniazid TB preventive therapy (IPT) for people living with HIV/AIDS and evaluate its feasibility and cost-effectiveness.

o Improve comprehensive HIV/AIDS/STD/TB care and referral (including cotrimoxazole prophylaxis) to ensure continuity of care for people living with HIV/AIDS.

» The benefits expected from the above interventions are:

o Improved TB/HIV and community collaboration should make more efficient use of limited resources at district level and improve TB case finding and treatment completion.

o Increased access to VCT services decreases risk behaviours and may help to reduce stigma.

o Rapid HIV testing is reliable and inexpensive. It also ensures that people receive their HIV test results and helps them to access HIV care and support.

o Isoniazid TB preventive therapy (IPT) decreases the incidence of TB in HIV-infected individuals.

o Cotrimoxazole is effective in decreasing morbidity in HIV-positive patients and in decreasing mortality in HIV-positive TB patients. Isoniazid and cotrimoxazole are inexpensive and available in South Africa.

o The provision of prophylactic regimens may serve as an incentive for people to come forward for voluntary HIV counselling and testing.

o Improved HIV care will help to decrease morbidity and mortality in HIV-positive patients including TB/HIV dually infected patients.

Results from the ProTest Initiative in South Africa

» District TB/HIV committees were established in all sites and collaboration has improved

» Between April 1999 and September 2002, 61,132 people were given HIV counselling and testing in four TB/HIV pilot districts and 21,206 people were diagnosed as HIV-positive.

» It is estimated that VCT has prevented about 6,100 new HIV infections and about 1,830 new cases of TB. The introduction of rapid HIV testing resulted in an increase in the number of people coming for HIV testing from 825 people in the fourth quarter of 1999 to 8,946 people in the third quarter of 2002 (10 fold increase).

» Prior to the introduction of rapid testing most HIV testing was clinically referred. After the introduction of rapid HIV testing, the proportion of people self-referred increased to over 60% in two of the four sites.

» The proportion of people receiving their HIV test results increased from as low as 10% to over 99%. A total of 2,878 HIV-positive people have been started on IPT to prevent TB and 2,366 people were started on cotrimoxazole prophylaxis.

» Reasons for good and poor adherence were investigated through in depth interviews with people who completed and who interrupted prophylaxis. This research will be used to develop support systems for HIV-positive clients to take these drugs and to stay healthy.

» When antiretroviral drugs are introduced in the country, systems must be in place to ensure good adherence to avoid the development of drug resistance.

» In conclusion, rapid HIV testing increases the number of people tested for HIV and the proportion receiving results. TB preventive therapy and cotrimoxazole prophylaxis can be offered in primary health care facilities but further research is required to determine reasons for good and poor adherence and cost-effectiveness.

Expanding the TB/HIV Training Districts

» The Provincial Heads of Health have agreed to implement the lessons learned from the TB/HIV pilots throughout South Africa in TB/HIV Training Districts.

» The vision is to build on the success of the TB Control Programme’s establishment of TB Demonstration and Training Districts over the next 5 years by adding VCT and better management of opportunistic infections.

» The Department of Health receives financial and technical support for this programme from the Belgian government and the Global Fund Against AIDS/TB and Malaria.

» The phased implementation of a comprehensive programme of TB/HIV/STI prevention, care and support is critical to address the dual burden of TB and HIV in South Africa.

» It will also strengthen health systems in preparation for antiretotroviral implementation in the future.

Story Ideas

o Patients with TB often experience stigma and discrimination and are perceived as being HIV positive. In addition less than two thirds of patients with TB adhere to their treatment, despite the fact that this has now been made simpler with the introduction of fixed dose combination tablets. Visit a TB Hospital and speak to patients to find out what their experiences are regarding stigma and discrimination, treatment and other issues affecting patients with TB.

o The ProTest Initiative is successful in enhancing VCT services. Investigate the availability of HIV VCT services in South Africa. Speak to counsellors and beneficiaries regarding HIV counselling and testing, what counselling is provided to those who are positive and those who test negative. What has been the experience of the rapid HIV test?

o What quality of treatment are people who are living with HIV/AIDS receive at medical instutitions if they have TB?

o Aventis Pharmaceuticals has been working with the Nelson Mandela Foundation on the TB Free Project which aims to establish nine TB centres one in each province, and to use mobile units to reach outlying communities. The project aims to convey the message that TB is curable and to eliminate the stigma of TB associated with TB. Join in on a roadshow to see how the programme works? Interview workers and clients to hear their experiences of TB and HIV/AIDS. What are the linkages between the TB Free Project and the ProTest Initiative?

Contacts

Government

Dr Rose Mulumba
Director: HIV/AIDS&STIs
Tel: (012)312-0060
Email: mulumr@health.gov.za

Dr Refiloe Matji
National TB Control Programme Manager
Tel: 012 312 0106
Email: matjir@health.gov.za

Dr Lindiwe Mvusi
Medical Officer
National TB Control Programme
Tel: 012 312 0900
Email: mvusil@health.gov.za

Dr Kgomotso Vilakazi
TB/HIV/STI Medical Officer
Directorate: HIV/AIDS&STIs
Tel: (012) 312-3145
Email: vilakazia@health.gov.za

Phumlani Ximiya
National Advocacy Officer
National TB Control Programme
Tel: 012 312 0113
Tel: 082 780 6227
Email: ximiyap@health.gov.za

MRC

Dr Bernard Fourie
Tel: 012 339 8547
Email: bfourie@mrc.ac.za
Website: www.mrc.ac.za
Website: www.sahealthinfo.org.za

United Nations

Stop TB Partnership
Michael Luhan
World Health organisation
Email: luhan@who.int
Website: www.stoptb.org

International NGOs

International Union Against TB and Lung Disease
Ms Wendy Atkinson
Email: Watkinson@iuatld.org
Website: www.iuatld.org

Researchers

Dr Harry Hausler
Clinical Research Unit
Department of Infectious and Tropical Diseases
London School of Hygiene and Tropical Medicine
Tel: +27 (0)21 434-9087
Cell: +27 (0)82 600-5439
Fax: +27 (0)21 439-5363
Email: harkeith@netactive.co.za

Additional On-line Resources on TB and HIV/AIDS

The Global Plan to Stop TB

This document describes the action and resources needed over the next five years to expand, adapt, and improve the effort in order to meet the 2005 global targets and set the world on the road to eliminating TB. The Global Plan incorporates contributions from over 150 experts in TB control, public health, and development around the world.
http://www.comminit.com/Materials/sld-4458.html

Frequently Asked Questions about the 4-drug Fixed-dose Combination Tablet

Recommended by the WHO for Treating Tuberculosis
http://www.comminit.com/Materials/sld-6438.html

Stop TB Communique

An e-newsletter issued monthly to share information and updates on progress in the global partnership movement to stop tuberculosis.
http://www.stoptb.org/contact.html#E-mail
Contact: stoptb@who.int

TB-Update - Division of TB Elimination, CDC Weekly Update

Provides synopses of key scientific articles and lay media reports on tuberculosis.

To subscribe to the list, see:
http://lists.asciences.com/mailman/listinfo/tb-update

TB/HIV Research Laboratory of Brown University, USA
http://www.brown.edu/Research/TB-HIV_Lab

STOP TB Initiative
http://www.stoptb.org

The Global Fund to Fight AIDS, Tuberculosis & Malaria
http://www.globalfundatm.org

Global Alliance for TB Drug Development
http://www.tballiance.or

Acknowledgements

The TB/HIV Pilot Districts were funded by the South African Department of Health (DOH). implementation of the pilot activities was done by the following Pilot District Coordinators who ensured high quality training and research: Dr Laura Campbell; Dr Barbara Karpakis, City of Cape Town; Dr Pren Naidoo, City of Cape Town; Ms Audrey Penrose, South Coast Hospice; Dr Paul Pronyk, Health Systems Development Unit, University of the Witwatersrand; Ms Jackie Sallet, Equity Project; Ms Carol Sheard, East London. Technical support was received from the following organisations: Canadian Institutes for Health Research (CIHR), Department for International Development Southern Africa (DFID), Equity Project (Management Sciences for Health), London School of Hygiene and Tropical Medicine (LSHTM), South African Medical Research Council (MRC), Joint United Nations Programme on HIV/AIDS (UNAIDS), the United States Agnecy for International Development (USAID) and the World Health Organisation (WHO). The TB/HIV Training Districts will be funded by the DOH with support from the Belgian Technical Cooperation (BTC) and the Global Fund Against AIDS, TB and Malaria.