Abstract
IntroductionEvery year, HIV-associated tuberculosis (TB) deprives 350,000 mainly young people of productive and healthy lives. People die because TB is not diagnosed and treated in those with known HIV infection and HIV infection is not diagnosed in those with TB. Even in those in whom both HIV and TB are diagnosed and treated, this often happens far too late. These deficiencies can be addressed through the application of new scientific evidence and diagnostic tools.DiscussionA strategy of starting antiretroviral therapy (ART) early in the course of HIV infection has the potential to considerably reduce both individual and community burden of TB and needs urgent evaluation for efficacy, feasibility and broader social and economic impact. Isoniazid preventive therapy can reduce the risk of TB and, if given strategically in addition to ART, provides synergistic benefit. Intensified TB screening as part of the “Three I's” strategy should be conducted at every clinic, home or community-based attendance using a symptoms-based algorithm, and new diagnostic tools should increasingly be used to confirm or refute TB diagnoses. Until such time when more sensitive and specific TB diagnostic assays are widely available, bolder approaches such as empirical anti-TB treatment need to be considered and evaluated. Patients with suspected or diagnosed TB must be screened for HIV and given cotrimoxazole preventive therapy and ART if HIV-positive. Three large randomized trials provide conclusive evidence that ART initiated within two to four weeks of start of anti-TB treatment saves lives, particularly in those with severe immunosuppression. The key to ensuring that these collaborative activities are delivered is the co-location and integration of TB and HIV services within the health system and the community.ConclusionsProgress towards reducing HIV-associated TB deaths can be achieved through attention to simple and deliverable actions on the ground. John Donne, Meditation XVII, Devotions upon Emergent Occasions: … any mans death diminishes me because I am involved in Mankinde; And therefore never send to know for whom the bell tolls; it tolls for thee ….
Highlights
Every year, HIV-associated tuberculosis (TB) deprives 350,000 mainly young people of productive and healthy lives
Given that TB is a curable disease and that HIV/AIDS can be treated, albeit with life-long drug therapy, why did this high mortality occur? People died for three main reasons: (i) TB was not diagnosed in those known to have HIV infection and who were accessing antiretroviral therapy (ART); (ii) HIV was not diagnosed in those with TB and these patients were not offered HIV care and treatment, and (iii) when the two diseases were diagnosed and treated, these interventions happened far too late
In a study in Haiti, TB incidence was reduced by 50% in patients starting ART at CD4 counts between 200 and 350 cells/mL compared with those starting ART when the CD4 count dropped to below 200 cells/mL or when treatment was deferred until the onset of AIDS [22]
Summary
In 2010, an estimated 34 million adults and children were living with HIV/AIDS [persons living with HIV (PLHIV)] worldwide: 1.1 million had HIV-associated tuberculosis (TB) and 350,000 with HIV-associated TB died [1]. Given that TB is a curable disease and that HIV/AIDS can be treated, albeit with life-long drug therapy, why did this high mortality occur? People died for three main reasons: (i) TB was not diagnosed in those known to have HIV infection and who were accessing antiretroviral therapy (ART); (ii) HIV was not diagnosed in those with TB and these patients were not offered HIV care and treatment, and (iii) when the two diseases were diagnosed and treated, these interventions happened far too late.
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