The Twin Epidemics: HIV and TB Co-infection

USAID Fights Rising Tuberculosis Rates in Cambodia A woman covers her mouth in a TB ward of a hospital in Cambodia, where USAID supports TB and HIV/AIDS programs. Source: Chris Thomas, USAID

Setting the Scope

An estimated one-third – 2 billion people – of the global population is infected with tuberculosis (TB). Tuberculosis kills more than 1.7 million people per year and is economically devastating to families and communities worldwide. Although TB is a global problem, its geographic distribution is drastically disproportionate. Ninety-five percent of all TB cases and 98 percent of all TB deaths occur in developing countries. Tuberculosis is a major killer among women of reproductive age and the leading cause of death in HIV-positive people. Only 22 high-burden countries (HBCs) account for 80 percent of the global TB burden, with half of these countries located in Asia. In Africa, 25 countries have an estimated TB case notification rate greater than 100/100,000, as compared to an estimated case notification rate of 5/100,000 in the United States.

The global resurgence of TB has been fueled by a combination of factors, including increasing human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) prevalence and multidrug resistance, inadequate investments in public health infrastructure, insufficient political commitment, limited awareness of TB, disparities in access to and quality of health care services, and insufficient investments in new tools, including drugs, diagnostics, and vaccines. The disease threatens the poorest and most marginalized groups, disrupts the social fabric of society, and slows or undermines gains in economic development.

Progress on the Stop TB Partnership and DOTS Expansion

Significant progress has been made since the Stop TB Partnership (of which USAID is a member) was launched in 2000. The Amsterdam Ministerial Conference on Tuberculosis and Sustainable Development, held in March 2000, established global targets of 70 percent TB case detection and 85 percent treatment success rates in sputum smear-positive pulmonary TB cases to be achieved by the year 2005 in the 22 HBCs. The first Global Plan 2001–2005 served to catalyze governments and donors to address TB. The number of countries implementing DOTS (directly observed treatment shortcourse), the most effective strategy available for the treatment and control of TB, increased from 112 in 1998 to 184 in 2006, and one high burden country (Peru) reduced TB incidence sufficiently to graduate from the list of 22 HBCs. India recently reported a 50 percent decline in TB mortality due to rapid scale up of DOTS and implementation of the Stop TB Strategy.

Building on this momentum, in January 2006, the Stop TB Partnership launched the Global Plan to Stop TB 2006–2015, which includes the Millennium Development Goal target of halting and beginning to reverse the incidence of TB by 2015, as well as the more ambitious STOP TB targets of reducing TB prevalence and deaths by 50 percent by 2015, relative to the 1990 baseline. The Global Plan describes the actions and resources needed to combat the epidemic and achieve the above targets. The World Health Organization (WHO) and other Stop TB partners also launched a more robust technical approach known as the Stop TB Strategy, which builds on DOTS. There is strong global commitment to combat TB and to collaborate on that effort: the Partnership has grown to include more than 700 members, including endemic countries, donors, nongovernmental organizations (NGOs), research organizations, and other institutions.

HIV and TB Co-infection

HIV/AIDS and TB co-infection presents special challenges to the expansion and effectiveness of DOTS programs and the Stop TB Strategy. Tuberculosis accounts for one-third of AIDS deaths worldwide and is one of the most common causes of morbidity in people living with HIV/AIDS (PLWHA). Currently, about 33 million people are HIV infected, and at least one-third are also infected with TB. The dual epidemics of TB and HIV are particularly pervasive in Africa, where HIV has been the single most important factor contributing to the increasing incidence of TB over the last 10 years. In some countries in sub-Saharan Africa, up to 70 percent of patients with active TB disease are also HIV positive. The dual epidemics are also of growing concern in Asia, where two-thirds of TB-infected people live and where TB now accounts for 40 percent of AIDS deaths. Eastern Europe and the former Soviet Union have the fastest growing HIV epidemic in the world, and is a factor that could exacerbate problems with the multidrug-resistant tuberculosis (MDR-TB) epidemic in these regions. The overlap of TB/HIV co-infection with MDR-TB and extensively drug-resistant TB presents a tremendous challenge and threatens progress in controlling both TB and HIV/AIDS.

Persons co-infected with HIV and TB are 30 times more likely to progress to active TB disease. Infection with TB enhances replication of HIV and may accelerate the progression of HIV infection to AIDS. Fortunately, TB treatment for HIV-positive patients under DOTS is just as effective as it is for people who are HIV negative. In addition, clinical trials have shown that prophylaxis using anti-TB drugs can prevent or decrease the likelihood of TB infection from progressing to active TB disease in an HIV-infected person, making it an important intervention for increasing the length and quality of life of HIV-infected people, with benefits to their families and communities.

Strategic Engagement with the U.S. President’s Emergency Plan for AIDS Relief

Within the U.S. Government, the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) leads funding and implementation of HIV/TB co-infection activities, but USAID’s TB activities are closely coordinated with PEPFAR. Given the importance of HIV/TB as part of a comprehensive TB program, USAID supports some specific HIV/TB activities within the Agency’s TB programs and closely coordinates efforts with PEPFAR. Specifically, USAID supports the three-fold strategy established in 2004 by the World Health Organization (WHO): to enhance collaborative efforts between TB and HIV/AIDS programs; to decrease the burden of TB in PLWHA; and to decrease the burden of HIV in TB patients.

USAID’s Three-Fold Strategy for HIV/TB

To address the first strategy, USAID supports coordination of TB and HIV/AIDS services by improving collaboration among both programs, host countries and donor agencies, NGOs, and research institutions; developing training programs for TB specialists/programs managers on HIV counseling and testing and management of co-infected patients; strengthening the links between TB services to HIV testing and HIV care services; and exploring the use of alternative service delivery approaches, such as community- and home-based care, and involving faith-based organizations in such approaches. Such coordination is essential in ensuring early diagnosis, appropriate referral, and prompt, quality care for each disease.

To decrease the burden of TB in people living with HIV/AIDS, USAID assistance is designed to support improvements in TB prevention, screening, and treatment through links with facilities providing antiretroviral therapy (ART) services. In 2006, only 0.9 percent of HIV-positive patients were screened for TB. Such a low rate of screening for TB among PLWHA, as well as the difficulties associated with diagnosis of TB in persons with HIV/AIDS, contributes to delayed diagnosis of TB. USAID supports programs that strengthen and expand HIV surveillance to improve the quality of data on co-infection and epidemiological trends. USAID also supports programs that promulgate WHO standards in the provision of isoniazid preventive therapy to HIV/AIDS patients with latent infection to prevent progression to active disease, in accordance with national policies. Infection control measures in clinical settings where patients with HIV/AIDS and TB mix are also supported.

Finally, USAID supports programs and operations research that seek to decrease the burden of HIV in TB patients. Support is provided to increase access to HIV testing and counseling and establish a system of referrals with HIV/AIDS programs, and by training TB program personnel in HIV testing. Based on WHO recommendations, USAID supports programs that promote the use of co-trimoxazole preventive therapy in adults and children living with HIV/AIDS and antiretroviral drugs in eligible TB patients. USAID supports pilot service delivery models for reaching co-infected patients, monitors and analyzes the effectiveness of such models, and documents these experiences.

How USAID Supports HIV/TB Collaboration: The Example of Ethiopia

In 2008, USAID’s Private Sector Program (PSP) in Ethiopia organized TB and HIV advocacy workshops in the Amhara Region, the purpose of which was to build understanding between the public health system and private sector facilities toward the strengthening of TB referrals between the public and private sectors. The workshops were organized in five towns, for a total of 366 participants from five different districts. Participants included representatives from Zonal and Woreda (district) health offices, hospitals, health centers, HIV/TB focal persons from health offices and private facilities, and owners and medical directors of private facilities supported by the program.

The advocacy workshops in Amhara were aimed at creating awareness and understanding on the general progress made in TB and HIV interventions generally and the engagement of USAID PSP in TB and HIV interventions through the private health sector in the region. The workshops succeeded in enhancing synergy and dialogue between the public and private health sectors in Amhara. Since project inception, USAID has been working to build the capacity of private health facilities and workplace clinics to strengthen the TB and HIV referral network between the private and public health sectors in Addis Ababa, Amhara, and Oromiya. The project is now extending its interventions in TB and HIV prevention, care, and treatment services to more than 35 private facilities in Amhara. In total, USAID PSP is supporting more than 160 private facilities in the capital city, Addis Ababa, and Oromiya, and Amhara.

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