Tuberculosis TB

Preventing people living with HIV from dying of tuberculosis is one of the 10 priority areas outlined in the UNAIDS Outcome Framework for the period 2009-2011. Credit: UNAIDS/P.Virot

The 18th Stop TB Partnership Coordinating Board meeting is being held from 4 – 5 May 2010 in Hanoi, Viet Nam. The meeting will bring together UNAIDS and the Stop TB Partnership to strengthen their joint response to HIV/TB co-infection and to agree on a compact intended to halve TB deaths in people living with HIV by 2015.

‘One in four AIDS deaths is linked to tuberculosis. This compact represents an important milestone in ensuring that no person living with HIV dies of TB, a preventable and curable condition’ noted UNAIDS Deputy Director, Programme Paul De Lay

Every three minutes a person living with HIV dies of tuberculosis. Mortality rates have escalated (to an estimated 500,000 a year) over the past 10 years. The emergence of drug resistant strains of TB is a particularly lethal threat in populations with high rates of HIV infection.

Preventing people living with HIV from dying of tuberculosis is one of the 10 priority areas outlined in the UNAIDS Outcome Framework for the period 2009-2011. UNAIDS hopes to achieve this goal by ensuring an effective integrated delivery of services for HIV and tuberculosis as well as nutritional support in all settings.

Universal access and MDG targets for HIV and TB will be difficult, if not impossible, to achieve without greater attention to marginalized and vulnerable groups, such as prisoners, drug users, women, and migrants, and the strengthening of a human rights approach to ensure equitable access and risk-reduction.

A wide variety of participants are expected to attend the meeting, including Ministers of Health of Viet Nam, South Africa and Myanmar, the Regional Director of the World Health Organization Western Pacific Region as well as high-level representatives from UNAIDS, the Stop TB Partnership and the Global Fund to Fight AIDS, Tuberculosis and Malaria.

Discussions will range from an overview of the TB epidemic in Viet Nam and the Western Pacific Region to a review of progress in the development of new TB drugs, diagnostics and vaccines.

The Board meeting is also meant to be a follow-up from the Beijing Ministerial Meeting held in April 2009 where ministers from countries with high burden of multi-drug-resistant tuberculosis (MDR-TB) and extremely drug-resistant tuberculosis (XDR-TB) met to address the disease’s alarming threat. The 18th Stop TB Partnership Coordinating Board meeting will review the progress made by countries since Beijing and recommend further actions to overcome bottlenecks and accelerate action.

The Stop TB Partnership is a leading public-private global health partnership, established in 2001, with the aim of eliminating tuberculosis as a public health problem and, ultimately, to obtain a world free of TB. It comprises a network of more than 900 international organizations, countries, donors from the public and private sectors, governmental and nongovernmental organizations and individuals.

(from left) Dr Mario Raviglione, Director WHO Stop TB Department; Ms Gerry Elsdon, International Federation of Red Cross and Red Crescent (IFRC) Advocate for TB, Mr Michel Sidibé UNAIDS Executive Director; and Dr Marcos Espinal, Executive Secretary of the Stop TB Partnership. Credit: UNAIDS

Gerry Elsdon was at the height of her professional career as a popular TV personality in South Africa when she was diagnosed with tuberculosis. Living in an affluent Johannesburg suburb, Gerry was shocked to find her nearest TB clinic was hidden behind a number of buildings, “as if it was something to be ashamed of”. It was this experience that prompted her to become an advocate for the rights of people affected by TB.

Nine years on, Ms Elsdon is a passionate voice speaking out about the gaps in TB services. Gerry visited the UNAIDS Secretariat headquarters on 29 April and joined a panel with Dr Mario Raviglione, Director WHO Stop TB Department and Dr Marcos Espinal, Executive Secretary of the Stop TB Partnership. The discussion with staff was chaired by Mr Michel Sidibé, executive director of UNAIDS.

Ms Elsdon is now an International Federation of Red Cross and Red Crescent (IFRC) Advocate for TB and volunteer for CHOC Childhood Cancer Foundation, the Othandweni Children’s Home and the Lilly MDR-TB Partnership.

TB is thought to be responsible for one in four deaths of HIV-positive people, yet it is a curable disease. More TB screening and treatment for people living with HIV—through fully integrated TB/HIV services—would be an important and an essential step to reduce TB’s burden on people living with HIV. It’s an approach Ms Elsdon believes would make a difference. She spoke of the value of a clinic facility where a person get be counselled and tested for HIV followed by a TB test in an adjacent room.

In 2007, there were an estimated 1.37 million new cases of tuberculosis among people living with HIV and TB was responsible for 456 000 deaths. Preventing people living with HIV dying from tuberculosis is one of the priorities in the UNAIDS Outcome Framework 2009-11.

For the first time, the WHO global report includes an assessment of progress countries are making in the diagnosis and treatment of multidrug-resistant TB.

Up to a quarter of people with tuberculosis in some regions can no longer be treated with standard drug regimens. This is the stark finding of a new World Health Organization report which estimates that 440,000 people had multidrug-resistant TB (MDR-TB) in 2008, a third of whom died.

Multidrug and Extensively Drug-Resistant Tuberculosis (M/XDR-TB): 2010 Global Report on Surveillance and Response presents data from 114 countries. It underlines that almost half of all cases of MDR-TB are estimated to occur in China and India. In Africa an estimated 69,000 cases emerged.

The report also explores the relationship between HIV and MDR-TB and notes that drug resistant TB among people living with HIV has been widely documented in certain settings, such as hospitals. It further states that TB patients co-infected with HIV in three Eastern European countries, Estonia, Latvia, and the Republic of Moldova, were found to be at greater risk of having multidrug-resistant tuberculosis compared to TB patients without HIV infection.  Studies in Lithuania, Ukraine and Mozambique show similar results. More research is required to ascertain whether these findings would be replicated worldwide and the report notes that no data have been received from countries with the highest HIV prevalence.

According to UNAIDS, HIV-positive people are especially vulnerable to the impact of TB and MDR-TB. They are at increased risk of contracting the disease and experiencing serious side effects and are more likely to die if infected. HIV and TB are seen as so closely connected that they are often referred to as ‘co-epidemics’. To appropriately respond to both epidemics and avoid more widespread drug resistance, fully integrated TB/HIV services should be priority concern of all TB and HIV programmes.

Preventing people living with HIV dying from tuberculosis is one of the nine priority areas in the UNAIDS Outcome Framework 2009-11. 

According to the WHO report only an estimated 7% of all MDR-TB patients are diagnosed. Credit: WHO/D.Orr

For the first time, the WHO global report includes an assessment of progress countries are making in the diagnosis and treatment of multidrug-resistant TB. Six countries are the subject of special focus. Bangladesh is one of the few developing nations carrying out continuous surveillance among TB cases which were previously treated in selected areas. China has reported results from its first ever drug resistance survey; Ethiopia was among the first countries to introduce rapid molecular laboratory tests. Nepal and Romania both have successful treatment programmes for MDR-TB and South Africa has introduced policy changes for improving management and care for those living with the disease.

Although there has been notable success in some countries, world-wide progress in controlling multidrug-resistant TB remains slow. According to the WHO report only an estimated 7% of all MDR-TB patients are diagnosed.

Of major concern is the very high cost of treating this form of the disease. The price of drugs alone is 50 to 200 times higher than treating a drug-susceptible TB patient. However, WHO maintains that treatment of MDR-TB has been shown to be cost-effective.

According to the report, there is an urgent need for drug regimens which are shorter than the current two year span, improvements in laboratory facilities and access to rapid diagnosis and treatment. WHO is undertaking a five-year project aimed at strengthening TB laboratories with rapid tests in some 30 countries. It is also working closely with a number of organisations to increase access to treatment so that more lives can be saved.

Note: Multi-drug resistant TB (MDR-TB) is tuberculosis that is resistant to at least Rifampicin and Isoniazid, the two most powerful anti-tuberculosis drugs. Extensively drug- resistant TB (XDR-TB) is MDR-TB that is also resistant to at least two out of the three classes of second line TB medicines.

 

Some 36 million people have been cured of tuberculosis (TB) over the past 15 years through a rigorous approach to treatment endorsed by the World Health Organization (WHO). New data, released by WHO, also indicate that up to 8 million TB deaths have been averted, confirming the Stop TB Strategy as the most cost-effective approach in the fight against TB.

The WHO update also shows continued progress on addressing the lethal combination of TB and HIV. Between 2007 and 2008, 1.4 million TB patients were tested for HIV, an increase of 200, 000. Of those who tested HIV positive, one-third benefited from life-saving HIV anti-retroviral therapy (ART) and two-thirds were enrolled on co-trimoxazole prophylaxis to prevent the risk of fatal bacterial infections. In addition, screening for tuberculosis and access to isoniazid preventive therapy for TB among people living with HIV more than doubled, although the total number is still far short of what it should be.

"Fifteen years of TB investments are bringing visible results in terms of human lives saved. Together, national programmes, WHO, UNAIDS, the Global Fund and other partners have helped save millions of lives from TB," said Dr Mario Raviglione, Director of WHO's Stop TB Department. "But the current pace of progress is far from sufficient to decisively target our goal of TB elimination."

The WHO Stop TB Strategy has five elements: political commitment with increased and sustained financing, case detection through quality-assured bacteriology, standardized treatment with supervision and patient support, an effective drug supply and management system, monitoring and evaluation system and impact measurement.

Data from the latest 12 month period now show that the highest ever number of infectious patients - 2.3 million people - were cured. With 87% of treated patients cured, the 85% global target was exceeded for the first time since it was established in 1991. Furthermore, a total of 53 countries surpassed this treatment milestone.

Although more and more patients are being cured, there are millions who are being let down because they are unable to access high-quality care. TB remains second only to AIDS in terms of the number of people it kills. In 2008, 1.8 million people died from TB including half a million deaths in HIV related illness–many of them because they were not enrolled on ART.

A persistent challenge that is largely left unchecked in many parts of the world is multidrug-resistant TB (MDR-TB) and its even more dangerous form, extensively drug-resistant TB (XDR-TB). Of the estimated half a million MDR-TB cases occurring per year, almost 30 000 were officially reported and 6 000 were known to be treated according to WHO international standards in 2008. A major expansion of services is currently in an early and difficult phase but almost 29 000 people are expected to be treated in 2010.

Of the estimated 9.4 million TB cases in 2008 (including 1.4 million TB/HIV cases), 3.6 million cases occurred among women.

"Half a million women died from TB last year. It is a disease that destroys lives, damages families and stifles development," said Dr Mario Raviglione. "Without help to fill the US$ 2 billion funding gap for TB care and control in 2010, the most vulnerable people will continue to miss the benefits so many others have seen."

The new report provides the most accurate information on the global burden of tuberculosis. It also features updates about the work of the Global Laboratory Initiative, the WHO Global Task Force on TB Impact Measurement, and describes the success of a new initiative in 2009 in which global TB data collection went online.

Michel Sidibé met with clinic staff including the counsellors, doctors and nurses as well as the Administration and Dean of the Medical school.
Credit: UNAIDS

Concluding his official visit to India yesterday, UNAIDS Executive Director Michel Sidibé visited the HIV treatment centre at Bowring & Lady Curzon Hospitals in Bangalore. The government run centre is the largest and oldest in Karnataka and has the highest rate of integrated HIV and TB services in India. The treatment centre is also one of the few sites able to both evaluate, with a viral load test, when first line treatment is failing, and provide access and establish people on second line treatment.

Mr Sidibé praised the work of Karnataka in leading the integration of HIV/TB services at the same facility and also for making access to second line treatment available to patients in need.

According to Mr Sidibé, "This clinic is a model, showing that access to 1st and 2nd line ART drugs made in India are being scaled-up for Indians in need of treatment." He said it represented an example of what could be possible in the future for Africa.

The HIV treatment centre at Bowring & Lady Curzon Hospitals in Bangalore able to establish people on second line treatment as needed.
Credit: UNAIDS

The UNAIDS Head had an opportunity to meet with patients and their families who shared personal testimonies of how treatment has given them back their lives and health, even enabling them to return to work. He also met with clinic staff including the counsellors, doctors and nurses as well as the Administration and Dean of the Medical school.

Mr Sidibé’s visit to Bangalore also included his participation in a civil society event in Bangalore, where he met with representatives of civil society and spoke with women living openly with HIV.

UNAIDS Executive Director first official visit to India also included events and meetings in New Delhi and Mumbai.

Dr Jorge Sampaio, the UN Secretary General’s Special Envoy to Stop TB and UNAIDS Executive Director Michel Sidibé together witnessed, first-hand, delivery of integrated HIV and TB services during a visit to the Socio-Medical Centre in Biryogo.

"It is gratifying to be at this clinic, which has intensified TB case finding in people living with HIV through TB screening and transferring confirmed cases to a TB clinic. In addition patients who enrol at the health centre with tuberculosis are also tested for HIV and those found to be HIV positive are given integrated care and support. It is a programme that reflects Rwanda's impressive progress nationwide on coordinating TB and HIV services," said Dr Jorge Sampaio, the UN Secretary-General's Special Envoy to Stop TB.

Mr Sidibé highlighted the progress Rwanda has made in improving the outcome of TB and HIV co-infection through better collaboration and the use of innovative diagnostic technology and underlined the UN’s commitment to effectively tackling the dual epidemics.

“I am pleased to see that Rwanda is leading Africa and the world in taking an integrated approach to dealing with the interlinked epidemics of TB and HIV. Rwanda’s bold leadership is achieving impressive results that show the rest of Africa what can be achieved," said Mr Sidibé said.

Mr Sidibé emphasize that tackling TB and HIV jointly is a priority for UNAIDS and, as stated in the UNAIDS Outcome Framework 2009-2011, it is one of the nine key areas for achieving results with the final goal being that no person living with HIV should die of TB.

Dr Sampaio and Mr Sidibé proceeded to another joint visit to Rwanda's National Reference Laboratory in Kigali, where they saw evidence of the country's major investment in laboratory services.

Rwanda has been tackling a thorny issue -- the difficulty of diagnosing TB among people living with HIV. TB diagnosis requires visualization under a microscope of the bacteria that cause the disease, obtained via sputum samples. Among people living with HIV, often few bacteria are present in the sputum and they are therefore not detectable through conventional diagnosis, even if the person has serious TB disease. Consequently the diagnosis is often missed.

The sensitivity of a TB diagnosis can be improved by incubating the samples to multiply the TB bacteria; but this process can take weeks or even months using conventional methods. To increase speed and accuracy of TB diagnosis, fast liquid culture (MGIT) will be introduced and rolled out soon in Rwanda. The National Reference Laboratory is also studying more efficient microscopes and staining techniques to improve speed of TB diagnosis.

Since 2004 Rwanda has had the capacity to test for drug-resistant TB. The National Reference Laboratory and the other main laboratories in the country are also currently developing their capacity to diagnose cases of XDR-TB (although none have been detected in Rwanda to date).

Dr Sampaio and Mr Sidibé congratulated the laboratory staff on their excellent work and recognized the key role they play in reducing deaths from TB among people living with HIV.

They highlighted the need for much greater investment in strengthening laboratory services and committed to advocating for increased investment in research for a faster, simpler and more accurate TB test.

Credit: WHO

Tuberculosis is one of the commonest causes of illness and death among people living with HIV globally. One of the major problems is that TB is particularly difficult to diagnose in people living with HIV. We have to rely on an outdated, inaccurate test that is over one hundred years old and is especially insensitive in people living with HIV.

A new web site, Evidence-Based Tuberculosis Diagnosis, has been launched that aims to provide the most comprehensive single source of evidence synthesis, policies, guidelines and research agendas on TB diagnosis. It is also a source for complete up-to-date information on the current TB diagnostics pipeline. Standard operating procedures and package inserts for several tests also are available.

‘This is an essential resource for HIV implementers, activists and civil society alike that will keep them updated on the latest developments in TB diagnosis’, says Alasdair Reid, HIV/TB Adviser at UNAIDS. ‘Without a faster, simpler, more accurate TB test we will really struggle to stop people living with HIV from dying of TB’.

The website has been established by the Stop TB Partnership's New Diagnostics Working Group in collaboration with the Foundation for Innovative New Diagnostics, the Special Programme for Research and Training in Tropical Diseases, the Global Laboratory Initiative and the Public Health Agency of Canada.

18 month old baby in Baragwanath Hospital, Soweto, South Africa
Credit: UNAIDS/L. Gubb

Bacille Calmette-Guérin, or BCG, is one of the most widely given vaccines globally and is safe in people with healthy immune systems. WHO recently published further research on the finding that this standard tuberculosis vaccine has a higher risk of causing death in babies living with HIV.

Given the severity of these risks, WHO recommends not vaccinating babies with HIV and delaying vaccination for those whose HIV status is unknown but who have signs or symptoms consistent with HIV infection.

This recommendation came in 2007 and poses several challenges to weak health systems around the world.

It underscores the need for more widespread testing of HIV in babies and pregnant mothers. Clinical symptoms of HIV infection typically occur after 3 months of age but in some countries babies are routinely vaccinated with BCG at birth.

UNAIDS calls for scaling up access to and use of quality services for the prevention of mother-to-child transmission as well as integrated delivery of services for HIV and tuberculosis.

“A selective BCG vaccination policy in HIV-exposed infants will require high uptake of maternal HIV testing, strengthened prevention of mother-to-child transmission services, and better integration of TB and HIV programmes,” said Dr Catherine Hankins, UNAIDS Chief Scientific Adviser in HIV this Week scientific blog.

The results of a three-year study in South Africa were published in the July edition of the journal Bulletin of the WHO. They confirm earlier research which led WHO in 2007 to change BCG vaccination policy for babies. The WHO Global Advisory Committee on Vaccine Safety and the Strategic Advisory Group of Experts TB and HIV experts then published Revised BCG vaccination guidelines for infants at risk for HIV infection.

“This paper gives better information on the risk of generalized BCG infection in HIV infected children and strongly reinforces the need to find better ways to prevent TB in infants (who are most at risk of dying from TB) and for diagnosing HIV in infants,” said Dr Alasdair Reid, UNAIDS TB Adviser.

In response to the urgent need to accelerate the discovery and development of new drugs to fight tuberculosis (TB), a landmark collaboration between the Global Alliance for TB Drug Development (TB Alliance), a non-profit, product development partnership, and Tibotec Inc., (Tibotec), a global pharmaceutical company, was announced at the Pacific Health Summit. 

The two organizations have agreed to share their expertise and resources in the development of “TMC207”, an anti-tuberculosis drug with a new mechanism of action.

Welcoming the news of the collaboration, Dr Alasdair Reid HIV/TB advisor to UNAIDS said, “If the encouraging results of early studies are confirmed, TMC207 will represent the first new class of TB drugs we have had in 40 years, offering hope to people living with HIV who are at increased risk of developing TB disease and especially drug-resistant TB.”

“The rise of multidrug resistant TB and the lack of new drugs to date are among the biggest threats to TB control and the HIV response,” Dr Reid noted.

The interim data from an ongoing Phase II study of TMC207 were recently published in the New England Journal of Medicine. In the placebo-controlled study of 47 patients with multidrug-resistant TB (MDR-TB), it was found that 48% of patients receiving TMC207 in combination with standard treatment converted to negative sputum culture after eight weeks compared with 9% of those who received placebo and standard treatment.

People living with HIV are susceptible to developing TB and are also particularly vulnerable to MDR-TB which has a higher mortality rate, and is significantly more difficult and costly to treat. In 2008–2009, the highest number yet of MDR-TB cases were reported to WHO, with an estimated half a million new MDR-TB cases emerging annually. Simpler and more effective ways to prevent, diagnose and treat TB in people living with HIV are urgently needed.

The TB Alliance aims to accelerate the discovery and development of new TB drugs that will shorten treatment, be effective against resistant strains, and be compatible with antiretroviral therapies for people living with HIV who have TB.

Integrated HIV and TB services

In Joint Action for Results: UNAIDS Outcome Framework 2009-2011, the UNAIDS Secretariat and Cosponsors recommend effective integrated delivery of services for HIV and tuberculosis in order to prevent people living with HIV from dying of tuberculosis.

UNAIDS Executive Director Michel Sidibé is committed to mobilizing leadership in confronting the interlinked epidemics of TB and HIV and to bring the AIDS and TB movements closer together. Earlier this year while participating at the 3rd Stop TB Partners Forum, Mr Sidibé met with TB Programme Managers and TB civil society and stressed that the epidemics of TB and HIV can no longer be addressed in isolation. “We need to ensure that people living with HIV do not die of TB,” Mr Sidibé said.

TB is among the leading causes of death among people living with HIV, and accounts for an estimated 23% of AIDS deaths worldwide.

The comic book Luis Figo and the World Tuberculosis Cup seeks to teach children and teens about tuberculosis, its relationship with HIV, and how to prevent it.

International football icon and Stop TB Ambassador Luis Figo is the main character of an educational comic book that provides key information on tuberculosis (TB). Luis Figo and the World Tuberculosis Cup was produced by the Stop TB Partnership, an international health partnership whose secretariat is housed by the World Health Organization (WHO) in Geneva, with support from UNAIDS.

The comic book features Figo as the captain of a team of teen-aged girls and boys. Together they win a football match against a squad of tuberculosis germs. The comic book seeks to teach children and teens about tuberculosis, its relationship with HIV, and how to prevent it.

In a statement released on the occasion of the launch Figo urged young people everywhere to take the comic book's messages seriously. "Tuberculosis is a killer, and I want all of you to stay safe from it. I am passing the ball to you -- you can help reach the goal of stopping tuberculosis," he said.

The book is available in Arabic, Chinese, English, French, Khmer, Kiswaili, Hindi, Portuguese, Russian, and Spanish and is being distributed in several countries in collaboration with local partners. An estimated number of 70 000 comic books have been so far distributed through country-based events. The comic book is also available for download at www.stoptb.org/figo

An international competition for comic artists to design the educational book was launched in 2008. A jury of cartoon experts from worldwide organizations together with representatives from UN organizations selected the winning proposal which was presented in Lisbon on 24 July 2008.

HIV and TB are so closely connected that they are often referred to as co-epidemics or dual epidemics.

The comic book has now become an animated cartoon that will be launched in Geneva on 13 June during the All Stars '09, a charity match organized by the Luis Figo Foundation. The animated cartoon version of Luìs Figo and the World Tuberculosis Cup will be shown in its French-language version at the gala match. It will soon also be available in Arabic, English, Portuguese, Russian and Spanish and broadcast widely around the world.

The fundraising game will take place at the Stade de Genève and will also feature current and former soccer stars and trainers including Mourinho, Chistian Chivu, Ronaldinho, Clarence Seedorf, Fabio Capello, Giovanni Trapattoni and Giga Popescu.

Tuberculosis and HIV

TB is the leading causes of death among people living with HIV, and accounts for an estimated 23% of AIDS deaths worldwide. HIV and TB are so closely connected that they are often referred to as co-epidemics or dual epidemics. The epidemics drive and reinforce one another: HIV activates dormant TB in a person, who then becomes infectious and able to spread the TB bacillus to others.

Untreated, someone with active tuberculosis will infect an estimated 10 to 15 people per year. The Stop TB Strategy is the internationally recommended standard for preventing, diagnosing and treating TB and includes recommendations for managing TB in people living with HIV.

Recently a new TB strain, extensively drug resistant TB (XDR TB), has emerged, which is particularly dangerous for people living with HIV in whom it is frequently fatal. Preventing the development and spread of drug resistant TB through greater investment in TB services, improved community case finding and adherence support, and more effective infection control are essential.

UNAIDS, the Stop TB Partnership and the World Health Organization (WHO) are together encouraging a concerted, coordinated global effort to control TB in people living with HIV. In addition, the Stop TB Partnership has formed the TB/HIV Working Group, which develops global policy on the control of HIV-related TB and advises on how those fighting against TB and HIV can work together.

These partnerships have led to the creation of policies and guidelines to deal with HIV-related TB, and countries and organizations have taken important steps towards integrating their HIV and TB responses.