Tuberculosis TB

Much more needs to be done to prevent tuberculosis (TB) which affects at least half a million of the world’s children every year.
Credit: WHO/Stop TB Partnership

Much more needs to be done to prevent tuberculosis (TB) which affects at least half a million of the world’s children every year, with as many as 70 000 losing their lives. According to WHO and the Stop TB Partnership, most children can be saved from this curable illness with better diagnosis of the condition, greater access to health services and improved coordination of healthcare programmes.

One key area where such coordination is critical is in relation to HIV. Children living with the virus are highly vulnerable to TB infection given their compromised immune systems. HIV-positive people are 20 to 30 times more likely to develop tuberculosis, which is responsible for one quarter of AIDS-related deaths. The situation can be especially dangerous for children as TB is often not routinely considered as a possible diagnosis and can therefore remain undetected.

"We have made progress on TB. Death rates are down 40% overall compared to 1990 and millions of lives have been saved," said Dr Mario Raviglione, Director of the WHO Stop TB Department. "But unfortunately, to a large extent, children have been left behind, and childhood TB remains a hidden epidemic in most countries. It is time to act and address it everywhere," he added.

WHO and the Stop TB Partnership recognize that TB can be hard to diagnose, especially in developing countries where the method used to diagnose it—the analysis of a sputum sample—was developed 130 years ago. Nonetheless, a recent study in Bangladesh found that the detection rate of children with TB more than trebled when workers in 18 community centres received special training on childhood tuberculosis.

Addressing TB in children is relatively inexpensive. According to estimates, tuberculosis prevention for a child costs less than 3 cents a day and treatment around 50 cents a day.

Integrated services needed

Integration of maternal and child health services, HIV care and tuberculosis care to save the lives of children with TB is seen to be an absolute necessity, requiring bold political leadership. This is especially the case if the commitment made by countries in the 2011 Political Declaration on AIDS—to cut in half the number of deaths among people living with HIV by 2015—is to be realised.

According to WHO/Stop TB Partnership, all HIV-positive pregnant women, babies and children at clinic visits should be checked for signs of tuberculosis and given appropriate treatment if required. When detected in children living with HIV, TB treatment needs to begin immediately and, after two to eight weeks on such treatment, antiretroviral therapy (ART) should be started. Furthermore, relevant personnel need to be trained to check patients for TB risk, signs and symptoms and refer them for TB preventive therapy or TB treatment as needed.

Other recommendations to get to zero TB deaths among children are the inclusion of children and pregnant women among the participants of research studies on new TB diagnostics and drugs; more accurate national estimates of the number of childhood TB cases and deaths; and increased funding for TB diagnostics, drugs and vaccines.

According to Dr Lucica Ditiu, Executive Secretary of the Stop TB Partnership, the key to the ultimate goal of preventing TB deaths in children is for partners to work together to pinpoint those most in need: “Before we can give prevention or treatment we have to find the children at risk of TB, and this will only happen if governments, civil society and the private sector work together."

Message from UNAIDS Executive Director Mr. Michel Sidibé

UNAIDS Executive Director (center) visited the Prince Cyril Zulu TB and STD Clinic and the CAPRISA eThekwini Research Clinic on September 2011 during an official visit to South Africa. The Prince Cyril Zulu clinic treats about 8 000 new TB patients a year with an HIV prevalence of 74%. The SAPiT TB-HIV trial which provided the evidence for the current WHO TB-HIV co-treatment guidelines was conducted in the adjoining CAPRISA clinic.
Credit: UNAIDS/A. Debiky

GENEVA, 22 March 2012—On World TB Day, let’s celebrate a partnership, which in just a few years is helping to transform the AIDS epidemic.

By improving collaboration between HIV and TB services almost one million lives around the world have been saved in the past six years.

The number of people living with HIV screened for TB increased almost 12-fold from 2005 to 2010.

For patients, integrating HIV and TB services means a better quality of life. They spend less time going from clinic to clinic and waste less money on visits to multiple care providers.

It can also mean the difference between life and death.

Together we can be proud of our achievements.

But we haven’t reached our goal of stopping TB-related HIV deaths.

Every day a thousand people living with HIV die of TB.

These deaths just aren’t acceptable when TB is preventable and curable with inexpensive drugs.

We need to intensify the integration of HIV and TB services at every level of the health system.

We need a stronger focus on preventing, diagnosing and treating TB in children living with HIV, who are particularly vulnerable to TB infection.

All TB patients living with HIV must be put on antiretroviral therapy as quickly as possible.

Last year countries committed for the first time to cut in half the number of deaths among people living with HIV by 2015.

Having travelled so far together, I am sure we will reach the final mile.

(Left to Right): Dr Jorge Sampaio, UN Secretary-General Special Envoy to Stop TB; Lucica Ditiu, Executive Secretary, The Stop TB Partnership; Michel Sidibé, UNAIDS Executive Director; Osas Ighodaro, Miss Black USA; Ray Chambers, UN Secretary-General Special Envoy for Malaria. UN Headquarters, NYC, on June 6, 2011. Credit: UNAIDS/B.Hamilton

A new epidemiological model produced by the Stop TB Partnership, World Health Organization (WHO) and UNAIDS shows that it is possible to sharply reduce AIDS deaths worldwide by preventing and treating tuberculosis (TB). At present one in four people living with HIV die of TB; the vast majority of these deaths could be averted, since TB is curable.

“Halving TB deaths in people living with HIV by 2015 is possible and is within our reach. We could save up to a million lives by 2015 and bring us one step closer to the UNAIDS vision of zero AIDS-related deaths,” said UNAIDS Executive Director Michel Sidibé.

Building on well-established methods for preventing and treating HIV-associated TB that are recommended by WHO and UNAIDS, the model shows that by scaling up these approaches worldwide a million lives could be saved by the end of 2015.

“There has been a surge in awareness about the deadly TB epidemic among people living with HIV, but insufficient action. Now new scientific work has shown that we can prevent a million deaths among people living with HIV by end 2015 by providing integrated HIV and TB care,” said Dr Jorge Sampaio, the UN Secretary-General's Special Envoy to Stop TB and former President of Portugal. “I call on the world's leaders to take up this challenge. It is time to take bold action. Not to do so would be an outrage.”

A publication that outlines the new model, Time to act: Save a million lives by 2015 - Prevent and treat tuberculosis among people living with HIV, was launched on 6 June at United Nations Headquarters. It calls for the following actions:

• Testing for HIV and TB should be provided every three years in places where both diseases are prevalent.
• Prompt TB treatment needs to be provided to every person living with HIV with active TB—or else treatment to prevent TB.
• HIV and TB treatment must be accessible and of good quality so that people living with HIV are cured of TB.
• Antiretroviral therapy (ART) should be started early, which will help prevent TB, since people living with HIV are far less likely to become ill with and die of TB if they begin ART before their immune systems begin serious decline.
• People who are HIV-positive and diagnosed with active TB should start ART regardless of the status of their immune systems.

In 2010 the Stop TB Partnership and UNAIDS set the joint goal of reducing by half the number of deaths among people living with HIV, compared to 2004 levels, between 2011 and end 2015. With the new model, they have agreed to aim to avert one million deaths.

Civil society is also calling on their governments to fully adopt this TB/HIV plan. “Our message is clear and simple. If people living with HIV don't get tested and treated for TB, many of us will die from this disease, even though we are receiving life-saving antiretroviral treatment. It's a terrible waste, because TB is curable,” said Lucy Chesire, a leading international advocate on behalf of people affected by HIV-associated TB.

It is estimated that the cost of all the elements needed to prevent one million TB deaths among HIV-positive people worldwide would come to about US$ 790 million per year.

UN General Assembly High Level Meeting on AIDS

Thirty years into the AIDS epidemic, and 10 years since the landmark UN General Assembly Special Session on HIV/AIDS, the world has come together to review progress and chart the future course of the global AIDS response at the 2011 UN General Assembly High Level Meeting on AIDS from 8–10 June 2011 in New York. Member States are expected to adopt a new Declaration that will reaffirm current commitments and commit to actions to guide and sustain the global AIDS response.

A version of this story also appears at who.int

Credit: WHO

Drug resistance is becoming more severe and many infections are no longer easily cured, leading to prolonged and expensive treatment and greater risk of death, warns the World Health Organization (WHO) on World Health Day, 7 April 2011.

Under the theme "combat drug resistance", WHO calls for urgent and concerted action by governments, health professionals, industry, civil society and patients to slow down the spread of drug resistance, limiting its impact today and preserving medical advances for future generations.

Drug resistance is a natural process in which microorganisms acquire resistance to the drugs meant to kill them. With each new generation, the microorganism carrying the resistant gene becomes ever more dominant until the drug is completely ineffective. Inappropriate use of infection-fighting drugs (underuse, overuse or misuse) causes resistance to emerge more quickly.

On the brink of losing miracle cures

“The message on this World Health Day is loud and clear. The world is on the brink of losing these miracle cures,” said WHO Director-General Dr Margaret Chan. She added, “The trends are clear and ominous. No action today means no cure tomorrow.”

Measures to combat drug resistance

WHO has published a policy package that sets out the measures governments and their national partners need to combat drug resistance. These include:

• Develop and implement a comprehensive, financed national plan
• Strengthen surveillance and laboratory capacity
• Ensure uninterrupted access to essential medicines of assured quality
• Regulate and promote rational use of medicines
• Enhance infection prevention and control
• Foster innovation and research and development for new tools.

Resistance detected in a number of diseases

According to latest WHO figures, at least 440 000 of new cases of multidrug resistant-tuberculosis (MDR-TB) emerge each year, and by the end of 2010, 69 countries had reported extensively drug-resistant tuberculosis (XDR-TB). Resistance is also emerging to the antiretroviral drugs used to treat people living with HIV.

Getting everyone on the right track

Dr Mario Raviglione, Director of WHO Stop TB Department, who has been leading the preparations for World Health Day 2011, called for measures against drug resistance to be strengthened and implemented urgently. He added, “New collaborations, led by governments working alongside civil society and health professionals, if accountable, can halt the public health threat of drug resistance."

Message from UNAIDS Executive Director Mr. Michel Sidibé

GENEVA, 24 March 2011—I am pleased to see that growing collaboration between HIV and tuberculosis (TB) programmes is bearing fruit. Since 2002 there has been an 80-fold increase in the number of TB patients who were tested for HIV.

For TB patients who test positive for HIV, knowing their status will allow them to seek access to life-saving HIV treatment and care.

However, on this World TB day, I am concerned. We are seeing an emerging epidemic of drug resistant TB. It is a sobering thought that an estimated two million people living with HIV could die of TB between now and 2015, if urgent action is not taken.

The tools are now available to prevent many of these deaths––A faster, more accurate TB test has been developed––and access to antiretroviral therapy has been significantly improved. TB and HIV communities must continue to scale-up joint efforts to rapidly roll-out these services and save lives.

Let us not forget that HIV and TB are two diseases –– but we are talking about one life.

UNAIDS has committed to halving TB deaths in people living with HIV by 2015. I believe we can not only achieve this goal, but surpass it.

http://www.youtube.com/watch?v=yaldyxe3tI8

A version of this story also appears at www.who.int.

Credit: WHO

To mark World TB Day, the World Health Organization (WHO), the Global Fund to Fight AIDS, Tuberculosis and Malaria and the Stop TB Partnership are calling on world leaders to step up their commitment and contributions to meet the goal of diagnosing and treating one million people with multidrug-resistant tuberculosis (MDR-TB) between 2011 and 2015.

WHO has released a report, Towards universal access to diagnosis and treatment of MDR-TB and XDR-TB by 2015, which presents progress in the MDR-TB response in the countries with the highest burden of drug-resistant TB. "Many countries have made progress, but despite the recent scale-up in efforts, the world needs to do much more to get care to all MDR-TB patients who need it," says Dr Margaret Chan, WHO Director-General. "We cannot allow MDR-TB to spread unchecked."

The risk of leaving multidrug-resistant tuberculosis untreated

Leaving MDR-TB untreated increases the risk of spread of drug resistant strains of TB. WHO estimates there will be more than 2 million new cases of MDR-TB between 2011 and 2015.

Treatment programmes

Programmes financed by the Global Fund and that follow WHO treatment standards are expected to diagnose and treat about 200 000 people for MDR-TB by 2015, a fourfold increase from those 50 000 patients who are currently undergoing treatment.

It is anticipated that the Global Fund will provide 84% of all international investments in TB in 2011. However, both domestic and international resources need to be scaled up to cope with MDR-TB if progress in the response to TB is to be maintained.  

“MDR-TB is a threat to all countries as it is difficult and expensive to treat. Unless we make an extraordinary effort to tackle this problem our ability to finance and secure continued progress against TB in general will be threatened” says Professor Michel Kazatchkine, Executive Director of the Global Fund.

Time to step up commitments

According to Dr Jorge Sampaio, the UN Secretary-General's Special Envoy to Stop TB, "It is time for countries with rapidly growing economies and a heavy burden of MDR-TB to step up their commitment and financing for their own MDR-TB programmes. Several have the capacity to show new leadership on south-south cooperation and aid to neighbouring countries that are also affected."

Since 2009, the 23 countries most heavily affected by TB drug resistance have nearly doubled their budgets for MDR-TB. According to the Global Fund, from 2002 to 2010, they have financed TB programmes around the world that have provided treatment to 7.7 million people and saved the lives of 4.1 million.

"The Global Fund's success can be measured in the number of lives that have been saved through care provided by the TB programmes it finances," says Dr Lucica Ditiu, Executive Secretary of the Stop TB Partnership. "Every TB patient should have access to proper care...To reach a million people with effective care for MDR-TB over the next five years, we will need to work closely with all partners, especially with affected communities."

MDR-TB is a form of TB that fails to respond to standard first-line drugs. In 2009, WHO reported that 9.4 million people became ill with TB and 1.7 million died, including 380 000 people with HIV-associated TB. There were some 440 000 cases of MDR-TB and 150 000 deaths in 2008, the latest year for which estimates are available.

Tuberculosis (TB) is a leading cause of death among people with HIV and, in order to mitigate this threat, low-cost preventive therapy is essential. In new guidelines released today, the World Health Organization (WHO) sets out how such therapy can be accessed safely and effectively.

According to WHO, the anti-TB drug isoniazid has a dramatic positive impact and the guidelines, aimed at resource-constrained settings, promote the use of Isoniazid Preventive Therapy (IPT) as a simple and cost-effective method that stops TB bacteria becoming active. A quarter of the nearly two million AIDS-related deaths each year is associated with TB and in some communities up to 80% of people who test positive for tuberculosis are also living with HIV.

WHO is committed to increasing the use of IPT. Coverage is currently extremely low with only 0.2% of all people with HIV having had access to this therapy last year. Additionally, around the globe just one in 20 HIV-positive people has ever been screened for TB.

“World AIDS Day reminds us that business as usual is unacceptable and HIV programmes need to significantly expand their efforts to address TB,” said Dr Gottfried Hirnschall, Director of WHO’s HIV Department. “We need to fully implement the WHO Three I’s for HIV/TB strategy in collaboration with all partners”.

The Three I’s are: Isoniazid Preventive Therapy, Intensified TB screening and Infection control for TB. According to WHO, these measures should be delivered as part of comprehensive HIV services. 
“In many countries HIV is a major driver of the TB epidemic. TB is preventable and curable and the new guidelines show how to break the chain that links TB and HIV leading to death,” said Dr Mario Raviglione, Director of WHO’s Stop TB Department. “All countries and communities need to implement the new guidelines and WHO can provide the necessary support to ensure that this can happen.”

To encourage access to IPT for the millions in need, the WHO guidelines, which are based on recent scientific evidence used to update 1998 policy, address some of the misconceptions  seen to be partly responsible for the IPT’s low coverage. There is no scientific evidence, for example, to support concerns that the treatment causes drug resistance to isoniazid. Also, IPT can be started following simple clinical screening without the need for costly mandatory tests as had been feared.

There are several key recommendations in the new WHO guidelines:

• All children and adults living with HIV, including those on antiretroviral treatment and pregnant women, should receive IPT.

• IPT should be provided for 6 to 36 months, or as a life-long treatment in settings with high HIV and TB prevalence.

• People living with HIV who may have TB symptoms should befurther screened for active TB or other conditions to enable them to access appropriate treatment.

Preventing people living with HIV from dying of tuberculosis is one of UNAIDS’ priority areas.

The latest WHO Global Tuberculosis Control Report 2010, launched today, highlights the need to reinvigorate efforts to prevent deaths from tuberculosis (TB) in people living with HIV. In 2009 there were an estimated 1.1 million cases of TB disease in people living with HIV, resulting in 0.4 million deaths. Yet TB is mostly preventable and curable.

According to the report, access to HIV testing, prevention, treatment and care for TB patients continues to expand. At least 75% of TB patients knew their HIV status in 55 countries, including 11 African countries such as Burkina Faso, Cote d’Ivoire, Mozambique and Zambia.

There are other examples of good practice. Namibia has improved its monitoring and evaluation systems and has reported around 15 000 people living with HIV are on isoniazid preventive therapy (IPR) in 2009. This therapy can prevent and reduce active TB among people living with HIV.

"The findings in the Global Tuberculosis Control 2010 publication confirm that when WHO's best practices are put in place, and with the right amount of funding and commitments from governments, we can turn the tide on the TB epidemic," said Dr Mario Raviglione, Director of the WHO Stop TB Department.

However, globally only 26% of TB patients knew their HIV status in 2009. People living with HIV who know their HIV status can benefit from appropriate treatment. In 2009 only about 140,000 HIV-positive TB patients were treated with antiretroviral therapy, this is only about 40% of all people living with HIV co-infected with TB.

“UNAIDS and Cosponsors have set an ambitious target of halving TB deaths in people living with HIV by 2015. This report highlights the need for us to work together on bold actions to achieve this goal,” said Alasdair Reid, UNAIDS HIV/TB Adviser.

The Stop TB partnership has launched a Global Plan to Stop TB (2011-2015) aimed at halving tuberculosis (TB) prevalence and death rates by 2015 to reach the Millennium Development Goal of halting and beginning to reverse the epidemic by 2015.

The Plan, launched in South Africa, identifies research gaps that need to be filled to bring rapid TB tests, faster treatment regimens and a fully effective vaccine to the market. It also shows how public health programmes can modernise diagnostic laboratories and adopt the new TB tests which have become available, replacing the century old diagnostic methods still used in many countries.

The Stop TB partnership are calling for US$ 37 billion to finance the plan from 2011-2015 which they estimate will allow them to diagnose and treat 32 million people over the next five years.

Without dramatic increases in funding and political commitment between 2010 and 2015 the Stop TB Partnership estimates that over 50 million people will develop active TB and that over 10 million lives will be lost to the disease which is both preventable and curable.

Every year around half a million people die from HIV-associated TB. If the plan's targets are met, by the end of 2015, all TB patients will be tested for HIV and, if the test is positive, receive anti-retroviral drugs and other appropriate HIV care. In HIV treatment settings, all patients will be screened for TB and receive appropriate preventive therapy or treatment as needed.

“Over a million people living with HIV fall ill with TB every year,” said Dr Paul De Lay, Deputy Executive Director, Programme, UNAIDS. “We need to make sure that all people living with HIV who need it, receive antiretroviral therapy, and that all people living with HIV are screened for TB every time they see a health care worker. This will help us to prevent diagnose and treat TB early and effectively in people living with HIV and avoid unnecessary deaths.”

In July this year the Joint United Nations Programme on HIV/AIDS (UNAIDS) and the Stop TB Partnership signed a memorandum of understanding to combine efforts to halve the number of people living with HIV who die from TB by 2015, compared to 2004 levels. The memorandum also outlines the importance of providing life-saving antiretroviral treatment for all TB patients living with HIV.

The Global Plan to Stop TB was launched by the South African Minister of Health, Dr Aaron Motsoaledi at a press conference held in the Pholosho Primary School in Alexandra which teaches more than 2000 children from the region.

Following the launch speakers from the press conference, together with children from the school, participated in a football tournament as part of the Kick TB Campaign. This is a campaign which seeks to combat TB as well as the stigma associated with it, by fusing sport and social mobilization to create a platform through which TB messages can be effectively conveyed.