Zimbabwe : TB leading cause of death among Aids patients

AFRICA NEWS NETWORK, MAY 21, 2006

ZIMBABWE--THE Aids epidemic has seen the re-emergence of tuberculosis (TB) in many parts of the world and now infects about one third of the world’s population.

Some countries currently face HIV and TB epidemics simultaneously. In sub-Saharan Africa, up to 70 percent of TB patients are infected with HIV.

Aids and TB interact destructively, each hastening the progression of the other.

TB is a leading cause of death among people with HIV and is responsible for an estimated 13 percent of Aids deaths. Most people infected with TB, but not HIV, remain healthy; only five percent to 10 percent will develop active case of TB.

HIV, however, triggers the active and infectious form of TB.

A person with an active case of pulmonary can infect an average of 10 to 15 people every year with TB if he or she does not receive treatment.

HIV infection also makes TB more difficult to diagnose. People with HIV or Aids often develop multi-drug resistant TB, detectable only through special laboratory tests often not available in low-income countries.

Tuberculosis is curable in HIV infected individuals, but treatment is much more expensive and typically requires a strict regimen of drugs for about six months.

Strict adherence to treatment often is difficult for residents in developing countries, where access to health care is limited.

Kenya: Combating TB, poverty and HIV at the Blue House

May 5, 2006, IRIN Plus News

KENYA--Blue House, a clinic run by Médecins Sans Frontières (MSF) in Mathare, one of the most populous slums in the Kenyan capital, Nairobi, means salvation to thousands of people infected with tuberculosis and HIV.

In the yard of the large, windowless building, where high walls and a thick iron gate keep the surrounding bars, shops and homes at bay, several dozen patients, many of them mothers with babies, sit on benches in the open air, but conversations are scarce.

"We opened Blue House [in 2001] because at our existing dispensary in Mathare we were detecting lots of TB and HIV cases, and it was difficult to refer patients to the [state-run] Kenyatta National Hospital because proper care for TB and HIV did not exist there at the time," said Christine Genevier, MSF head of mission in Kenya.

Mathare is home to an estimated 250 000 Kenyans and refugees who have fled strife in neighbouring countries. Families are crammed into single rooms in tightly packed shacks and market stalls line the congested dirt alleys, creating an ideal environment for spreading highly contagious TB.

The Ministry of Health has noted a sharp rise in cases and estimates that TB linked to poverty, malnutrition and HIV, which weakens resistance to infection, claims the lives of 200 Kenyans daily.

"Most people in Mathare, before they can think about treatment or anything else, must think about finding something to eat every day - we have so many destitute people there," Genevier said.Because TB so often occurs with HIV, Blue House is dedicated to the treatment of both diseases.

Genevier thought around 70 percent of TB patients in Mathare were also HIV positive, part of an Aids pandemic that caused the death of 70 000 people in 2005."Once diagnosed, the patient is administered generic drugs, approved by the [UN] World Health Organization, made in India and bought by us," she said.

The medication must be taken at regular, designated intervals for a period of up to eight months. Consistency is crucial; not only does interrupting the treatment - even briefly - cancel its effectiveness, it can cause the disease to become resistant to the drugs."Mathare has the problem of social instability, where patients are mobile - their stay in the area depends on their income, and they often move up-country from the slums, where we cannot reach them," said Genevier.

"We have a large structure of social workers and community assistants in Mathare tracking the patients for follow-up." Each patient is allocated a box containing their medication, which stays in Blue House, where they have to come to take it. Keeping the medicine in the clinic ensures that it is not sold to provide for other needs, and that patients make regular trips to the clinic, allowing medical workers to monitor their status.

Blue House treated 3 500 TB patients in 2005.The stigma associated with both TB and HIV prevents many people from seeking treatment for fear of being seen visiting the centre. "Most patients come to us as discreetly as possible - some even get here before dawn, when it's still dark, so that neighbours don't recognise them," said a nurse at Blue House, who preferred anonymity.

MSF has started education programmes encouraging people to come for treatment and adhere to their medication. In Mathare the organisation has moved away from the traditional Directly Observed Treatment System (Dots) for treating TB, where patients report to the clinic daily for their pills, to a 'light Dots', in which the patients fetch their TB medication weekly or monthly and get their antiretroviral drugs for combating Aids at the same time.

According to Genevier, "In order to ensure compliance with the drugs, we try to have a very strong education system, and ensure tight and heavy follow-up of the patients."

Source: Kaiser Family Foundation

Treating HIV and TB at the same time does not compromise outcome for either infection

AidsMap, Michael Carter, May 05, 2006

Taking anti-tuberculosis treatment at the same time as antiretroviral therapy does not reduce the virological success rate of anti-HIV treatment, a retrospective study published in the May 15th edition of The Journal of Infectious Diseases has found.

The investigators, from London, also found that patients who took anti-tuberculosis and anti-HIV therapy at the same time had a similar rate of tuberculosis (TB) recurrence to that of HIV-negative patients treated for tuberculosis.

Tuberculosis is the major cause of illness and death in HIV-positive individuals around the world and one of the two most common AIDS-defining illnesses in the United Kingdom. Practical problems combining treatment for tuberculosis and HIV include an inflammatory response, overlapping side-effects, a high pill burden, and poor drug absorption.

These factors could mean that anti-HIV therapy is less likely to achieve an undetectable viral load in patients taking concurrent tuberculosis and HIV therapy. Doctors from the North Middlesex Hospital, the Royal Free Hospital, London, and University College Hospital in London hypothesized that the specialist care provided by a team skilled in both the treatment of HIV and tuberculosis would improve the effectiveness of both anti-HIV therapy and tuberculosis treatment in their patients.

They therefore designed a retrospective study involving patients who received concurrent anti-tuberculosis and antiretroviral therapy at their centres between 1997 and 2003. They compared the virological and immunological outcome of these patients to match HIV-positive patients who did not have tuberculosis and who were treated with anti-HIV drugs.

To determine if the concurrent use of antiretroviral treatment compromised the potency of tuberculosis therapy, treatment outcome and relapse rates of the HIV-positive tuberculosis patients were also compared with individuals who only had tuberculosis.

A total of 156 HIV-positive/tuberculosis patients were included in the investigators' analysis. Their median age was 35, 52% were men and 77% were of African origin. The median CD4 cell count at the time of tuberculosis diagnosis indicated advanced immune suppression and was 77 cells/mm3, and median viral load was 125,000 copies/ml.

A total of 29 patients were already taking anti-HIV therapy when their tuberculosis was diagnosed, and 15 of these patients already had a viral load below 50 copies/ml prior to treatment for tuberculosis being initiated. All 15 of these individuals still had a viral load below 50 copies/ml on the completion of tuberculosis therapy along with an additional eleven individuals who were already taking antiretrovirals.

Of the remaining 82 patients, anti-HIV treatment was commenced a median of two months after tuberculosis therapy was initiated. Of these 82 patients, 68 (83%) had a viral load below 50 copies/ml after six months of HIV treatment. CD4 cell counts increased in 71 patients who started HIV treatment after tuberculosis therapy (median increase at six months, 108 cells/mm3).

No difference in virological response was seen between the HIV/tuberculosis patients and 111 HIV-positive controls without tuberculosis who received HIV therapy. A total of 13% of HIV/tuberculosis patients failed to achieve a viral load below 400 copies/ml after six months of antiretroviral therapy, as did 13% of patients who only received HIV therapy.

CD4 cell count increased by a median of 97 cells/mm3 in HIV/tuberculosis-treated patients after six months compared to 89 cells/mm3 in patients who were only treated for HIV. The outcome of tuberculosis treatment in the HIV-positive patients was then compared to that of a population of 156 HIV-negative patients who were treated for tuberculosis.

Similar proportions of HIV-positive (6%) and HIV-negative (4%) patients took less than their planned course of tuberculosis therapy. Tuberculosis recurred in 3% of HIV-positive patients compared to 1% of HIV-negative individuals, a non-significant difference.

“These data suggest that persons coinfected with HIV and M. tuberculosis may be treated, with good outcomes for both conditions”, write the investigators. Reference Breen RAM et al. Virological response to highly active antiretroviral therapy is unaffected by antituberculosis therapy.

J Infect Dis 193: 1437 – 1440, 2006.