Shared goals for tuberculosis and HIV

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The theme of this year's World Tuberculosis Day March 24 is “Unite to end TB”. As part of the UN's sustainable development goals (SDGs), WHO has set ambitious targets for 2030 to reduce the number of tuberculosis deaths by 90% and disease incidence by 80%. These sit beside the 95–95–95 UNAIDS goals for 95% of people living with HIV to know their status, 95% of people who know their status receiving treatment, and 95% of people on HIV treatment having a suppressed viral load by 2030. Tuberculosis causes substantial morbidity and mortality, but it hits those living with HIV particularly hard. Tuberculosis is the biggest cause of AIDS-related deaths worldwide, accounting for around a third of these. Globally 10–15% of people with tuberculosis are also living with HIV, estimated to be around 1·2 million people worldwide. The highest burden is in sub-Saharan Africa where 50–80% of people with tuberculosis are also living with HIV and where, in 2016, there were 318 000 AIDS-related tuberculosis deaths, 86% of the total. Despite these figures there has been some cause for cautious optimism. In the decade preceding 2016 AIDS-related tuberculosis deaths fell by a third. This reduction has been accompanied by an increasing number of people with tuberculosis receiving HIV tests and, for those testing positive, increased access to antiretroviral therapy (ART). In some high-burden parts of sub-Saharan Africa, more than 80% of people with tuberculosis have had HIV tests, and ART coverage can be as high as 90%. Treatment success for people with both tuberculosis and HIV has risen from 68% to 78% since 2012. In many areas, however, the picture is not so encouraging. Although HIV testing in people with tuberculosis has increased, globally it is still only 57%. In Indonesia, deemed by WHO to have a high burden of HIV and tuberculosis, only 14% of people with tuberculosis have received an HIV test. Even when HIV status is known, access to ART can be challenging and in several high tuberculosis and HIV burden countries, including Congo (Brazzaville) and Ghana, less than 50% of HIV-positive people with tuberculosis had started ART in 2016. Prompt initiation of ART for HIV-positive people with tuberculosis is crucial to reduce mortality. Technical challenges also hamper efforts to control the spread of tuberculosis in people living with HIV as tuberculosis testing in this population is notoriously challenging. The high rate of false-negative tests seen means many cases of tuberculosis have been, and continue to be, missed. Major obstacles need to be overcome if the 2030 targets for tuberculosis are to be met. Some of the solutions are obvious, although easy to state and much harder to implement, especially in countries with weak health-care infrastructures and shortfalls in funding. In high-burden areas screening for tuberculosis should be incorporated into standard care for those living with HIV. Likewise, it is essential that all patients are offered HIV testing as soon as possible after receiving a diagnosis of tuberculosis. When a positive HIV test result is recorded, ART must be started as soon as is clinically appropriate. Increasing integration of health-care services for people co-infected with HIV and tuberculosis would reduce mortality and incidence of both. Such integration is feasible, as shown by initiatives such as ProTEST, but evidence is mixed on the best model to use. The low testing and treatment rates seen in some regions highlight the need for more country-specific support and targeted efforts. Encouraging data from parts of sub-Saharan Africa show that high rates of testing and treatment can be achieved even in resource limited settings. More sensitive and specific tests for tuberculosis diagnosis in people living with HIV are needed. Grants, such as those awarded as part of the Discover biomarkers of tuberculosis programme by the Bill & Melinda Gates Foundation, dedicated to development of new tuberculosis diagnostics, will help; but, the road from laboratory to clinical practice is long. Development of a single, rapid, point-of-care test allowing health-care workers to monitor and manage both diseases concurrently would transform disease detection. Continued integration of tuberculosis and HIV services to increase testing and treatment of both diseases is important; however, additional diagnostic approaches are needed to ensure that the related SDGs can be met. HIV testing and treatment in people with tuberculosis is encouragingly on the rise, but more tailored solutions are needed in some of the countries hardest hit. Hopefully the call to “Unite to end TB” will also be taken as a call to “Unite to end HIV” and work will continue to tackle these diseases in parallel.