Paradigm shift to address drug resistant tuberculosis in people living with HIV needed, and needed now

Abstract

People living with HIV have a higher risk of multi-drug resistant (MDR) (Wells et al. 2007; Dubrovina et al. 2008; WHO 2008b) and extensively drug resistant (XDR) tuberculosis (Gandhi et al. 2006) with increased mortality, and greatly reduced survival time. Only 6% (less than 30,000) of the half million estimated incident MDR cases were diagnosed and notified globally by the end of 2007. Fifty-four countries had reported at least one case of XDRTB (WHO 2009a,b). Data on the HIV prevalence among these notified cases and the extent of the problem in children are not available. In the latest global antituberculosis drug resistance survey of WHO, only seven countries, none of which have a generalized HIV epidemic, reported tuberculosis (TB) drug resistance stratified by HIV status (WHO 2008a). However, people living with HIV are particularly vulnerable to the impact of drug resistant TB due to the difficulties and delays in the diagnosis (Wells et al. 2007), complications of concomitant treatment with TB and antiretroviral therapy (ART) (Havlir et al. 2008) and poor TB infection control measures in many HIV care settings (Gandhi et al. 2006; Kawai et al. 2006). Diagnosis of drug resistant TB requires sophisticated infrastructure and expertise, which at the moment is scarcely available in most resource constrained and HIV prevalent settings. The emergence of XDR TB, and its fatal association with HIV, has exposed the failures of implementing the measures recommended in the Stop TB Strategy of WHO (Raviglione & Smith 2007). It is encouraging to note that a global momentum is building towards accelerated nationwide implementation of collaborative TB/HIV activities(WHO 2004) and the scalingup of the management of MDR-TB(WHO 2008b), critical components of the Stop TB Strategy (WHO 2009a). In this editorial, we argue that not enough attention has yet been given to the interface between MDR and XDR with HIV and a framework of priority actions is needed to address the problem and consolidate synergy between TB and HIV stakeholders at all levels. The first step is to understand the extent of the problem systematically and promptly. Although current global surveillance activities identified countries in the former Soviet Union and regions of China as having a high proportion of MDR TB cases, and nearly half of the estimated MDR cases reside in China and India (WHO 2008a) the extent of the MDR problem in people living with HIV, including children, has not been properly documented. Furthermore, the situation in subSaharan Africa is largely unknown (Ben Amor et al. 2008; Zager & McNerney 2008) due mainly to lack of laboratory infrastructure. However, the XDR-TB outbreaks affecting primarily people living with HIV in KwaZulu Natal (Gandhi et al. 2006) and other provinces of South Africa (O’Donnell et al. 2009) give cause for serious concern. New HIV infections are on the rise in those countries with higher proportions of MDR TB cases including China, the Russian Federation and Ukraine (UNAIDS 2008). Data on the risk of MDR TB among HIV positive TB patients is available from just two places in the former Soviet Union, Donetsk, Ukraine, and Latvia which showed TB patients living with HIV are almost nearly twice as likely to have MDR-TB as patients without HIV (Dubrovina et al. 2008; WHO 2008a). Therefore, an urgent and systematic review of the extent and magnitude of the convergence of the HIV and drug resistant TB epidemics is needed, particularly in Africa and Eastern Europe. High quality anti-TB drug resistance surveys are needed which include HIV testing as an essential component, and synergistic opportunities between the expansion of global HIV Tropical Medicine and International Health doi:10.1111/j.1365-3156.2009.02266.x