SAfAIDS statement on World TB Day

Southern Africa HIV and AIDS Information Dissemination Service (SAfAIDS) recent statement commemorating World TB Day [24 March 2006]. SAFAIDS is a partner to the AIDS-Care-Watch campaign
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"We cannot fight AIDS unless we do much more to fight TB", Nelson Mandela. International AIDS Conference. Bangkok, 2004

Today, Friday, 24th March 2006, marks World Tuberculosis Day and Nelson Mandela’s statement is even more true today two years later. This year the world will commemorate the day under the theme, "Actions for Life: Towards a World Free of TB".

With over 2 million people dying from Tuberculosis every year, actions to counter TB are urgently needed to save lives. Despite the fact that Tuberculosis (TB) is a curable and preventable disease it is still infecting and killing millions of people throughout the world.

However some regions, more than others are bearing the brunt of the disease.

For example, Sub-Saharan Africa has approximately 10% of the world’s population and yet nine of the sub-Saharan countries are among the world’s 22 TB high-burden countries. In Namibia, 751 out of every 100 000 people are infected with TB every year. In Botswana, the situation is equally as serious, with 657 new TB cases for every 100 000 people every year.[1]

While TB is curable, its occurrence in people whose immune systems are compromised can be lethal. The combination of TB and HIV has to many deaths in the southern African region. In Malawi, 77% of TB patients are HIV positive, while in Zambia, 62% of TB patients are HIV positive. In Mozambique over half of the all the new TB cases are associated with HIV, making it one of the highest rates of TB/HIV co-infection in Southern Africa[2].

The factors that fuel the HIV and AIDS pandemic, are also driving the TB epidemic, particularly in Southern Africa. Poverty, malnutrition, non-availability of proper health care facilities, shortages of drugs and lack of information among others all contribute to the growing incidenceof TB.

It is encouraging to note that at local level, countries are beginning to take the initiative to address TB and HIV and AIDS as linked epidemics. In Malawi, the recognition of the HIV and TB co-infection has forced the long-established TB Control Programme to replan and redevelop TB control strategies to ensure collaborative TB/HIV activities.

South Africa is demonstrating some of the best practices emerging from the region, in addressing the joint TB/HIV epidemic. A national TB/HIV coordinating body has been established to oversee collaborative activities. A similar approach has been taken in Zimbabwe.

At a recent discussion forum hosted by SAfAIDS Dr. O. Mugurungi of Zimbabwe’s AIDS and TB Unit said, "universal access [to treatment] as a holistic package, has to do with appropriate and adequate nutrition, prevention and management of opportunistic infections including TB".

There are however many challenges to overcome in order to take action and save lives.

As SAfAIDS, we can only endorse what Dr Tim France, the Managing Director of Health and Development Networks (HDN), and an advisor to the AIDSCareWatch (ACW) campaign said in a statement to commemorate World Tuberculosis day, "The two worst global health problems have combined forces well. But the institutions addressing them have not".

We need to have a joint approach towards these co-pandemics and the lead must be taken by the three main actors responsible for controlling the two diseases - the World Health Organisation (WHO), the Joint United Nations Programme on HIV/AIDS (UNAIDS), and the international Stop-TB Partnership.

Dr Peter Piot has issued the call, "we are not in competition. We are as intimately allied as are the human immunodeficiency virus and the TB Bacillus. We must work together. If we are serious bout our missions to stop TB and HIV, finding new realistic pathways to the future is imperative."

The drive for universal access to treatment has of necessity to include both TB and HIV. One cannot be addressed without the other. Countries in the region must therefore heed the call made by the Ministers of Health to urgently implement strategies to rationalise their plans for the two epidemics. Communities and Individuals need to be provided with adequate information and capacity to play a role in mitigating the impact of TB and HIV.

We recognise the role played by major players like the Global Fund in the fight against HIV in the world's worst affected countries. However more efforts are needed to address the increasing incidence of TB and HIV in many southern African countries. Advocacy efforts need to encourage governments and international funding agencies to develop appropriate responses to urgently address the co-pandemics.

At community level, programmes should focus on mobilizing communities to also adopt health-seeking behaviour in relation to TB as well as HIV prevention, care treatment and support.

As we commemorate World TB Day, it is time for all the players in this fight to take stock and re-evaluate our strategies so that we combine our collective energies to effectively fight Tuberculosis and HIV and AIDS.

Source: AF-ADS eForum

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[1] Integrating HIV/AIDS and AIDS Efforts: The Challenge for the Presidential Fund. Report by the Network of Public Health Programs and Open Society Institute.2004
[2] ibid

Fighting TB in Kenya's community clinics

By HDN Key Correspondent, Kenya

KENYA--For the last four months, Amina, 15, has religiously escorted her mother to the nearby tuberculosis clinic in Eastleigh North, Nairobi. According to Amina, her mother, Fatuma 48, is lucky to be alive.

She attributes this to the clinic’s nurse in charge of TB, Mrs Magdaline Apiyo.

Apiyo is just one of the many nurses charged with providing treatment and care for TB patients in the numerous local clinics in Kenya, as part of a government strategy that has seen TB services decentralised to the community level.

Working under strenuous conditions that include sparse funding from the Treasury, lack of protective working gear for frontline staff, shortages of personnel, an unreliable drug supply and poor buildings in the name of clinics, it takes personal initiatives by nurses like Apiyo to make the programme a success, in a country classified by the WHO as tenth out of the 22 countries with the highest TB burden.

The clinic is housed in an old building, squeezed into a corner that would best suited for a home's food store. There are no benches outside on which sick patients could sit as they wait for their turn, and for a hospital receiving 600 TB patients a week, in this densely populated estate, the waiting is no fun at all.

Fatuma herself is in the queue, waiting for her turn, somewhere in the shade of the hedge around the hospital.

Showing the enthusiasm with which the brave Kenyan medics have embraced the decentralisation of the TB programme, Apiyo dedicatedly begins her work with what she calls 'health education', where she teaches both the sick and the carers who bring them to the clinic, like Amina, about management of the disease.

Amina says that through the health education, she and three of her other siblings have been taught how to live with their sick mother in their ten square metre room. Amina says that Apiyo has taught them to always have their room's one window open, allowing sunlight to penetrate the room and not to share utensils with their sickly mother.

Apiyo has also emphasised the need for them to ensure that their mother gets to the clinic daily for directly observed treatment (DOTS), a WHO strategy to ensure adherence to treatment that currently runs for eight months in Kenya. They have also learned to make sure that their mother is fed some fruit to balance her diet.

Compounding Apiyo's problems is the fact that Eastleigh is an estate in Nairobi populated with people from all over Eastern African, including Eritrea, Ethiopia, Sudan, Somalia, Uganda and Tanzania, few of whom can comprehend and communicate in either English or Kiswahili, Kenya's national languages.

To get around these obstacles, Apiyo makes use of the carers and community elders to translate her health lessons into as many languages as are spoken in the area.

In a programme that has won global accolades, Kenya's TB programme has now been decentralised to the community from referral hospitals in a bid to stop a disease that was considered finished in the 1980's.

Thanks to the HIV/AIDS epidemic, TB has re-emerged in a fury and is now considered the most deadly of the opportunistic infections that actually kill people whose immunity has been compromised by HIV.

In Kenya, Dr J. Sitienei, the National TB-HIV Coordinator says a third of all AIDS-related deaths are due to TB. Together, TB and HIV have combined to create a deadly challenge to health care services in what Dr Sitienei calls an 'unholy marriage'.

Thanks to decentralisation, Nairobi province alone now has a combined 135 diagnostic and treatment centres set aside to manage TB. This is a much improved scenario from the days when the entire 3 million Nairobi residents had only Mbagathi Infectious Disease Hospital for TB treatment. In addition, thanks to the Stop TB partnership that brings together over 400 partners, TB treatment is now free countrywide.

Eastleigh North, Apiyo's clinic, typifies the Stop TB Partnership's call to bring everyone to work together in putting into action the plan to stop TB - one of the oldest and most lethal diseases known to humanity.

Source: Partners-Zimbabwe eForum

The chasm between HIV and TB

24 March 2006, By Dr Tim France, Health & Development Networks (HDN)

The two worst global health problems have combined forces well. But the institutions addressing them have not

THE CHASM BETWEEN HIV AND TB

A quiet shift took place a few years ago in the impact of global infectious diseases: The Human Immunodeficiency Virus (HIV) epidemic surpassed that of age-old tuberculosis (TB).

In the past five years annual spending on HIV programmes increased 16-fold – from USD 500 million to around USD 8 billion per year. The same period saw a paltry 70% increase in funding for anti-TB efforts. The cost to humanity? HIV kills around three million people every year. TB kills two million.

The point, however, is not to tally up marks for a macabre competition; it is precisely the opposite: We need to stop thinking of the two diseases in separate bodies, because a third of the 40 million people living with HIV today are also co-infected with TB.

In 2006 and for at least the next decade, HIV’s biggest challenge is TB.

One in every three people harbours the TB bacteria in their body. That’s two billion people. TB stays inactive, but transforms into active TB disease in about nine million of us every year.

Crucially, people with HIV are about 30 times more likely to develop active TB than those without HIV- fuelling a resurgence of TB in sub-Saharan Africa and some states of the former Soviet Union. East and South Asian countries are next in line.

Imagine the two diseases in one body. Jolting enough to be told you have TB – then to be called back to hear your HIV test was also positive. The doctor is fully aware that TB progresses faster in HIV-infected people, and that TB in those who also have HIV is more likely to be fatal. Their task now is to explain to you that the two diseases often cannot be treated at the same time; the two sets of drugs can interfere with one another.

Sadly, the ease with which the two diseases intensify one another is not mirrored by the groups of people and institutions working to fight them. Despite years of knowing how TB and HIV interact with one another, and how programmes to address them should also work together, this is how they continue to think about HIV and TB Separately.

It is astounding to find that the heads of three of the main actors responsible for controlling the two diseases – the World Health Organization (WHO), the Joint United Nations Programme on HIV/AIDS (UNAIDS), and the international Stop-TB Partnership – do little more than nominally reflect each other’s experience and advice. All the more surprising when you consider that the offices of the three men are no more than a kilometer apart in Geneva.

Each programme continues to eye the others from across the car park and in the process, lose vital lessons in political strategy, resource mobilisation and clearing of service delivery bottlenecks.

The solution is absurdly simple: Break down the walls of established thought between the two diseases and you hold out the biggest promise for saving million of lives.

There is much that the relatively new HIV world has to learn from the old guard. TB has been around for centuries and is one of the areas of public health where we know the most. It is a curable disease with available medicines, and a long demonstrated track record of success. The doctors, the detection and treatment centres, the drugs – much is already in place.

Since it was set up in 2001, for example, the TB Global Drug Facility – aimed at increasing access to high quality TB drugs – has delivered over 4.5 million TB patient treatments.

Something that the WHO-supported ‘3 by 5’ anti-HIV drug initiative has been trying to emulate, as yet incompletely.

TB is not only curable, it is preventable. The failure to effectively deliver TB diagnosis, treatment and prevention to people with HIV means that many are dying needlessly.

The most frequently used method for detecting active and infectious TB is a microscopic analysis of a patient’s sputum. The trouble is that the test is antiquated and unreliable in people with HIV. The test result may be negative even though a person has active TB, making reliable TB diagnosis impossible.

Commonly-used TB drug treatments are also outdated, with patients often required to take large numbers of tablets every day for up to eight months.

These technical obstacles are far from new; they have been written about and discussed for years now. Less often highlighted are some of the divisions between TB and HIV/AIDS established thinking that prevent synergy.

The TB world can learn from some of the accepted tactics of the movement against HIV. These include obvious lessons on how to raise more money as well as a loyalty to community- and rights-based approaches.

For example, the mainstay of the WHO gold standard policy and treatment package for TB control – known as Directly Observed Treatment, Shortcourse (or DOTS) – is a standard drug treatment for all confirmed cases.

This originally meant health workers literally watched patients take their drugs (hence ‘directly-observed’) to ensure the drugs were, in fact, ingested.

"That, for me, is unacceptable because it limits the autonomy and dignity of every person," commented Zackie Achmat, one of the founders of the South African Treatment Action Campaign, at a recent TB conference.

The HIV/AIDS sector sees clinical care as necessary but not sufficient for the best results.

People have to make changes in their lifestyles, develop new skills, and must learn to interact with health care providers to successfully manage their conditions. Similarly, people with TB can no longer can be viewed, nor see themselves, as passive recipients of health care services.

These issues are dealt with in a newly published TB ‘Patient’s Charter’, which aims to empower people with TB and their communities by highlighting their rights and responsibilities, and need to be put into practice widely and immediately.

Connecting with the expertise of community groups has been embraced to extreme degrees by responses to TB and HIV. TB services rarely integrate community resources into the care of patients to the same degree as HIV/AIDS services, leaving a broad array of consumer groups, patient advocates, and nongovernmental organisations (NGOs) virtually untapped.

On the other hand, HIV/AIDS NGOs fill many service gaps to greatly enhance the care of people living with HIV and help to meet goals for service coverage and treatment outcomes.

A new global plan to address TB head-on over the next decade was recently launched by the Stop TB Partnership. Actions for Life – Towards a World Free of Tuberculosis proposes some bold shifts towards empowerment of TB patients and communities, and asks governments and foundations to foot the bill. They should, despite the ten-year, USD 56 billion price tag.

Some demonstrated behaviour change will probably be required to convince donors. If they can learn to speak the same language, leaders of local and international organisations, NGOs and community-based support groups are perfectly positioned to raise awareness about the two conditions simultaneously. Community leaders are positioned to sensitise the public about TB and HIV, and reduce the stigma associated with them.

Foremost though, is the need for greater cooperation and coherence at the level of international institutions and agencies that help governments to set policies, priorities and good practices in dealing with HIV and TB.

In 2000, at the launch of the Stop-TB Partnership, Peter Piot, still the head of UNAIDS today, may have foreseen today’s organisational stalemate quite clearly: "We are not in competition.

We are as intimately allied as are the human immunodeficiency virus and the TB bacillus," he explained. "We must work together. If we are serious about our missions to stop TB and stop HIV, finding new realistic pathways to the future is imperative."

Six years on, we have waited too long to see their coherent joint actions on TB and HIV. The first step is simple: Someone gets Drs Piot, Raviglione and Espinal to match their schedules and talk.

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Dr Tim France (tfran@hdnet.org) is the Director of Health and Development Networks (HDN), and an advisor to the AIDSCareWatch (ACW) campaign. With 350 partners in Asia and Africa, ACW advocates for a comprehensive care package for people living with HIV/AIDS.[AIDSCareWatch: www.aidscarewatch.org]

Tuberculosis and HIV: The unholy marriage

Guardian - Dar es Salaam,United Republic of Tanzania, By MATILDA KASANGA, February 12, 2006

In recent years, the number of people with active Tuberculosis has increased where there is a large population of people infected with HIV. Experts say TB and HIV are like twins more especially when the duo affect one person. MATILDA KASANGA explains the symbiotic relationship between the two diseases and methods of treatment.

`I have been living with HIV for the past 10 years but I am now on ARVs and my CD 4 is 432.

It was a great challenge when I got to know that I had TB of the chest, knee and lymph nodes in the year 2000. Time seemed no longer to be on my side then. Coupled with weight loss, loss of appetite and night sweats, it was my worst time when they were not able to diagnose my TB.

My doctor then decided that I start my ARVs with my TB treatment - my CD4 count was 30 at this point in time. This led to a paradoxical reaction that complicated my recovery and I ended up staying in hospital for a period of seven months` says Lucy Chesire a TB/HIV advocate from Kenya.

Chesire continues: `During the same time, I was able to undergo three operations : one on the neck and two on my left leg. When I got out of hospital, I weighed about 48 kilos and I had to use crutches for a period of three months. It wasn’t easy.`

`I was able to recover and today my experience with TB has given me an opportunity to make my voice audible and advocate for TB and more so for the combination of TB and HIV programmes so that at the end of the day, since we are dealing with two diseases in one patient, we can be able to decrease the burden and give the person living with HIV a chance to get better treatment.`

The case of Selina illustrates that although she is infected with HIV, her TB has been cured.

Selina , a 30 year old mother of four who lives in Makambako, is a living example of proof that TB treatment is remarkably effective in people living with HIV.

‘I was married at the age of 16, but left my husband after giving birth to my second child because of his alcohol problem. I was afraid of him so I came to stay with my mum. Life was so hard and I had no other way to earn a living other than selling sex. ` When her baby was only four months old, Selina started to become sick with a cough , headache fever and chest pains,

She was taken to the hospital where she was diagnosed with TB. She returned home and was treated as part of the home-care services conducted by health workers and many volunteers offering support to People Living with HIV/AIDS. The health workers from the home- based team counselled her on the need to go for HIV testing.

She was found HIV positive but she says she was not entirely shocked as she knew her background quite well. People told her that there was no point in her having TB treatment because she would die of AIDS anyway, But Selina did complete her treatment and made a full recovery like Ms Chesire.

She even put on weight, and it is more than four years since she was diagnosed HIV positive and she is still leading a full and economically productive life. Chesire and Selina’s cases are just the tip of the iceberg. There are millions of women, men and children dying of TB worldwide, while the disease is preventable and curable.

There are nearly 42 million men, women and children living with HIV in the world today, more that 95 percent of whom are in the developing world where the highest rates of TB infection are found. More than 11 million are dual infected with TB and HIV.

It is an indisputable fact that the number of people with active TB has been observed to increase where there is a large number population of people infected with HIV. According to Dr Sitienei, the Kenyan TB-HIV National Coordinator, this increase in the numbers of TB cases can mainly be attributed to the HIV epidemic.

It is thought that HIV promotes the development of active TB in those with both previously and recently acquired tuberculosis infection. According to Dr. Sitienei, HIV destroys the cells that protect the body from getting infected with the TB bacillus which consequently attacks the body without hindrance. TB cases reported in Kenya have doubled over the years.

A study conducted on TB patients in 1994 showed that 40-60 percent of TB patients also had HIV. In some areas, the HIV sero prevalence in TB patients is as high as 92 percent. He says HIV also increases the risk of recurrent TB in those who have received recommended TB treatment regimes and been cured. This in turn increases the risk of TB transmission to the general community, Dr Sitenei says.

Although Kenya is facing a high TB burden, which is fuelled by the concurrent HIV epidemic, the majority of TB patients are not offered HIV diagnostic and testing and counselling and are therefore not aware of their HIV status. Similarly, many people living with HIV/AIDS have no access to an essential package of care and screening for TB and TB preventive therapy where appropriate.

He says an HIV positive person has a 50 percent chance of developing TB in his lifetime.

Impact of HIV on TB

The impact of HIV on TB is huge. It increases TB burden, morbidity and mortality. Dual stigma for both TB and HIV is common. Many suspected TB patients are reluctant to present themselves for screening because they fear that they will be labeled as having HIV/AIDS if found with TB.

Of further importance, says Dr Sitinei, the growing numbers of TB cases are due to the worsening socio-economic conditions, increasing urbanization with deteriorating urban infrastructure. HIV is the most significant cause of the dramatic rise in TB from the mid 1980s onwards.

Today TB is the single biggest killer of people infected with HIV. `The presence of TB greatly reduced the quality of life and ability to live, among people who are HIV positive. If their TB is not effectively treated, they have a high likelihood of dying within a few months,` says Dr Sitinei.

In Kenya, it is estimated that over the last ten years, there has been a ten-fold increase of TB cases which may be attributed to HIV/AIDS. In Kenya, since last year, the country has introduced a policy whereby every person who comes for TB diagnosis is also advised to undergo an HIV test in order to facilitate easy treatment in case he tests positive.

If I have TB does it mean that I have HIV/AIDS? Over the last ten years, many people have been asking this question simply because they suspect that once one has TB, one is automatically infected with HIV.

`If you have TB it doesn’t mean you have HIV/AIDS, ` says Dr. Vicent Ombeka, the Nairobi Provincial Tuberculosis’s and Leprosy Coordinator. He says it is not always that a person with HIV/ AIDS has TB.

Dr. Ombeka says there is a need for HIV/AIDS and TB programmes to work together. A collaborative program will decrease the burden of tuberculosis amongst people living with HIV/AIDS and decrease the burden of HIV amongst TB patients.

The collaboration is also geared towards creating a formal working relationship between the TB and HIV/AIDS programs at every level that supports effective referral and sharing of information. It will also promote TB screening among all HIV positive people and promote HIV counselling and testing for all TB patients.

With the increased burden of TB among HIV/AIDS patients, Dr Ombeka says there are challenges facing the health practitioners as well as the sector as a whole. There is an increased workload for health workers, shortage of staff and staff motivation and limited infrastructure to offer testing.

The TB/HIV activist, Ms Chesire, concludes, `TB has become the major killer among people living with HIV/AIDS. This is the time that we have to conduct treatment literacy among the people affected, so that at the end of the day we may decrease the burden of TB among people living with HIV. TB is manageable, preventable and curable. Together we stand to fight TB`

* SOURCE: IPP Media