Saving lives from TB-HIV co-infection
She lies frail on Ward 3A’s bed at Queen Elizabeth Central Hospital in Blantyre.
Faines (not real name) is wearing a flowery pink top and a black beret covering her head. Her lips look dry and cracked but she tries to purse them as she tells her experience with recurrence TB.
“This is the second time I’m receiving TB treatment. I first had it two years ago,” says Faines, a Chileka resident, who has been receiving treatment at the hospital for two months now.
She successfully completed her first treatment but months later, she developed breathing difficulties, lost appetite and became weaker.
“I was unable to do household chores and work in my garden. I’m still weak.
“I was diagnosed with TB again. I’m not so sure why but I have accepted and I’m adhering to treatment,” Faines says.
Elvis, also a Blantyre resident, is also admitted to the same hospital for the second time due to TB.
But his case is slightly different from that of Faines in that his lifestyle increased his chances of having another episode of TB.
Elvis was first diagnosed with TB in 2004 and claims to have adhered to the six months regimen then.
“I suspect the TB has recurred because I didn’t follow medical advice. After successfully completing treatment, I was carried away by peer pressure. I resumed drinking and smoking. This increases one’s risk of developing TB,” he confesses.
Some months ago, Elvis noticed that he was always weak, experienced shortness of breath when walking, had lots of sweat, especially at night, and had no appetite.
“I rarely ate. If I did, it was very little food, almost that which would satisfy a child not an adult like me,” he recalls, adding: “I’m hopeful that I will be fine because I’m adhering to treatment. I will even change my lifestyle.”
In Malawi, TB is common, especially in people infected with HIV. Over 50 percent of people living with HIV develop TB at some point, Faines and Elvis are cases of such.
The International Union against Tuberculosis and Lung Disease press statement titled TB 2016 and Aids 2016: Jointly Tackling the Co-epidemic released in July 2016 says the diseases together make up a co-epidemic, posing unique challenges to individuals and communities that bear the burden of both diseases at the same time.
The statement was released amid an international Aids conference which took place in Durban, South Africa in July 2016.
It further says the co-epidemic is entangled, particularly in sub-Saharan African countries like Malawi.
“TB has become the leading cause of death among those who are HIV-positive. This is despite the fact that (today) HIV infection can be managed with antiretroviral (ARV) medication, and TB can be cured in the vast majority of cases,” says the statement.
Programme Director for National TB Control Programme Dr James Mpunga admits that TB and HIV co-infection is still a public health concern despite that Malawi has made strides in this area.
He says the proportion of HIV-positive TB patients initiated on antiretroviral therapy (ART) has increased from 81 percent in 2012 to 88 percent in 2013 and the proportion of TB/HIV co-infected people has decreased from 77 percent in 2000 to 57 percent in 2013.
“The proportion of TB patients that unfortunately die while on treatment is seven percent for smear positive TB cases,” he says.
Information from a TB prevalence survey that the programme did in 2014 indicates that half of the people who have TB may still be missing as there are many TB patients in the community who are not detected and treated. Close to 19,000 TB cases were reported in 2013.
Clinical Researcher at the Malawi-Liverpool-Wellcome Trust Clinical Research Programme (MLW), Dr Henry Mwandumba says TB is a huge problem in people living with HIV.
“HIV-positive people not receiving ART are 25-30 times more likely to develop TB than someone who is HIV-free. If one goes on ART, the incidence drops dramatically. But even when one is doing well, they still have five to six times more risk of developing TB,” he explains.
MLW is conducting a study aiming at understanding why people living with HIV (PLHIV) including those on ARV are still at risk of developing TB. The study wants to find a way of preventing recurrence of TB.
“This will help policy makers to understand and decide what interventions to put in place such as vaccines that will protect people against TB,” he says, adding that some districts are piloting the use of Isoniazid Preventive Therapy (IPT) to prevent development of active TB in HIV-positive people.
Mwandumba says, at the moment, there is no policy in Malawi for TB prophylaxis to prevent recurrent TB, saying the current policy is about preventing infections from happening but not to prevent reappearance of TB in PLHIV.
Citizen News Service (CNS) fellows and International Union against TB and Lung disease (The Union) brief says when a person develops HIV, their immune system loses its ability to fight off infections, making him or her more vulnerable to developing other diseases like TB.
“PLHIV are especially vulnerable to TB in countries where TB is common. Roughly, 75 percent of PLHIV who contract TB live in sub-Saharan Africa. In some countries in this region, up to 80 percent of individuals with active TB disease are also HIV-positive,” reads the brief in part.
It says even though steps have been taken to integrate TB-HIV care in countries around the world, opportunities are still being missed.
The Union has committed to addressing this deadly co-epidemic through an integrated care approach known as Integrated HIV Care for Tuberculosis Patients Living with HIV/Aids (IHC).
This approach aims to strengthen collaboration and build capacity of affected countries’ general health systems to deliver high-quality HIV and TB care.
The World Health Organisation (WHO) says between years 2000 and 2014, an estimated 8.4 million lives were saved through integrated and collaborative TB-HIV activities.
WHO also recommends that all patients with presumptive or diagnosed TB should be tested for HIV.
Professor Anthony Harries of the London School of Hygiene and Tropical Medicine notes that ART suppresses HIV replication and this leads to a gradual increase in CD4 cell counts and they are these cells that protect one against TB.
Harries says this is why health systems want to adopt IPT which reduces overall TB risk by 33 percent in PLHIV.
Family Health international (FHI 360) says IPT is for the prevention of TB in PLHIV.
It says HIV infection is the strongest risk factor for a person to develop TB, as TB is responsible for over a quarter of all Aids-related deaths worldwide
It is believed that giving ART and IPT to people with HIV will reduce incidence and indirectly lessen TB mortality.
WHO stresses that TB continues to pose a significant challenge to the HIV response, stressing that TB is still the main cause of hospitalisation and deaths among PLHIV.
It further highlights that bold targets for HIV are included in the Fast Track Strategy to end the Aids epidemic by 2030 and implicit in these targets is the urgent need to address HIV-associated TB.
One of the targets for goal three of the United Nations Sustainable Development Goals states that by 2030, there is need to end the epidemics of Aids, TB, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases.
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