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A deadly combination

Ramya Kannan

Tuberculosis and HIV/AIDS are twin dangers. The focus of public health policies is on combined programmes to tackle them.

PUBLIC HEALTH experts now know that tuberculosis is the most common opportunistic infection in persons living with HIV/AIDS and one of the main reasons for mortality. Even in the West, TB has made a re-entry — it is often the first warning sign of HIV/AIDS infection.

And because of reduced immunity, the progression of TB is accelerated. To make matters worse, poor treatment adherence leads to increasing cases of multi-drug resistant TB. According to the World Health Organisation's Global Tuberculosis Control Report, 2004, "The urgent need to address HIV-associated TB and multi-drug resistant TB pose an additional burden to the national TB control programmes and to general health services as a whole."

The report identifies the South East Asian region (India tops the list) as having the highest burden of TB cases among all the WHO regions — eight million cases to which three million new ones are added every year. India alone bears 20 per cent of the global burden.

According to the WHO report, between 2.5 million and 3 million people in this region are currently estimated to be infected with both HIV and TB; between 50-82 per cent of diagnosed AIDS cases suffer from TB. It also quotes data for a 10 year-period available from Pune showing that HIV seropositivity rate among newly diagnosed TB patients had steadily increased from about 4 per cent in 1991 to about 30 per cent in 2001.

A South Asian Association for Regional Co-operation Tuberculosis Centre (STC) publication (of October 2003) says that in South Asia areas with highest rates of HIV also report the most cases of TB. Hence, the need to treat the twin conditions under a single plan becomes crucial.

The STC in Kathmandu has proposed to rechristen itself "TB and HIV centre," at the November SAARC summit, a step forward for the region. Health care services will be forced to, if they have not already, acknowledge and respond to the mutually aggravating links between the two biggest epidemiological challenges.

As evidence indicating the HIV-TB link built up over the years, the SAARC countries including India, Bhutan, Nepal, Sri Lanka, Pakistan, and Bangladesh decided to adopt a policy to interlink their hitherto divergent approaches in the treatment of the two infections. "We have already developed a SAARC Regional Strategy on TB/HIV Co-infection and a separate action plan on HIV in consultation with all the member-states. The latter is to be signed in the Standing Committee. Once this has been done, we will have a set of activities and a time bound action plan to implement," says K.K. Jha, director, STC.

WHO helped evolve a broad initiative, the Promotion of Voluntary testing, with voluntary counselling and testing at the core. However, it involves establishing facilities and training staff, often unavailable in developing countries. It also sounds a note of caution: Diagnosis of HIV-positive status in TB patients may increase the likelihood of default in treatment, derailing the progress of the Directly Observed Treatment Short-Course (DOTS) therapy. In addition, ethical issues regarding the treatment of those diagnosed as HIV-positive should also be considered.

"Between 60-70 per cent of PLWHA [people living with HIV/AIDS] will eventually develop TB, which is a major cause of death among them. Clearly, the HIV epidemic will worsen the TB epidemic," says S.Y. Quraishi, Special Secretary and Director-General, National AIDS Control Organisation (NACO). "Forty per cent of the Indian population are already carriers of the TB bacteria (Mycobacterium tuberculosis) but only 10 per cent of them will develop the disease. However, co-infection with HIV will increase this risk to 60 per cent because of the decline of immunity," explains Dr. Quraishi.

Action plan

Recognition of this problem eventually led to the development of a national level HIV/TB Action plan. The Revised National Tuberculosis Control Programme, which had by then essayed success stories in many Indian States, joined hands with the more high profile NACO.

The national joint action plan was launched in 2001 in the six high prevalence States of Maharashtra, Tamil Nadu, Nagaland, Manipur, Andhra Pradesh, and Karnataka. The fact that the DOTS programme was being implemented effectively in these States helped the integration, according to sources in NACO, Delhi.

This action plan seeks to establish national, State and district level co-ordination meetings between both programmes, train HIV staff on TB and TB workers on HIV infection, says L.S. Chauhan, Deputy Director-General, TB, in the Union Ministry of Health. It also envisages creation of new linkages between the DOTS centres and the Voluntary Counselling and Testing Centres (for HIV).

In the second phase of the programme, the Joint Action plan was implemented in eight other States: Gujarat, Rajasthan, Himachal Pradesh, Punjab, Orissa, Kerala, West Bengal, and Delhi. Termed `mid prevalence' States (in terms of HIV infection), they were chosen also because they had a well established RNTC programme. Sources add that it was likely that the Joint Action Plan will be introduced in all States next year.

Debates are on at the national level on the advisability of integrating the voluntary counselling and testing centres with DOTS or TB treatment centres, or providing TB patients referrals to VCTCs. On the one hand, Tamil Nadu, has introduced VCTCs in its 10 TB sanatoria and 50 other microscopy centres in two months under Global Fund-Round III to empower TB patients with information and provide them an option to test for HIV after counselling.

On the other, there are public health experts who are apprehensive that this will lead to "double stigma," besides putting TB patients off even their DOTS regimen. They call for caution and while admitting that the integration of the DOTS and VCTC clinics might be inevitable eventually, it will have to be preceded by a campaign to educate people about both the conditions.

The Senior Advisor and Coordinator, UNDP Regional HIV and Development Programme for Asia, Sonam Yangchen Rana, stresses another angle — the need to acknowledge the human development context of HIV and TB. "Both have undeniable development causes and consequences. Look at the data — it is very clear that issues such as poverty, gender inequality, marginalisation of people and lack of access to information and services play a major role in aggravating the situation," she says. "We need to go beyond health paradigms and strive for fundamental changes in the human development landscape of the region. Only that will bring a reasonably lasting solution."

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