I was treating a woman named Cindy who had just immigrated to the United Kingdom from a country where tuberculosis (TB) is endemic. She had started her first job as a nanny for two children. She came to me coughing up blood, experiencing chest pain and with a high fever. We diagnosed her with TB. She also tested HIV positive.
When her employers found out, they fired her and, at the same time, her boyfriend left her. Within weeks, Cindy’s whole life was turned upside down – she had no money, no job and nowhere to live.
Cindy is one of hundreds of patients I have treated with similar stories. In 2017, approximately 300,000 people living with HIV died of TB. TB remains the leading cause of death among people living with HIV, with 80% of these deaths occurring in just eight countries (seven of which are in sub-Saharan Africa). In 2016, only 39% of people living with HIV who developed TB received treatment for both HIV and TB. And only 42% of people newly enrolled in HIV care received TB preventive therapy. In some countries, where both HIV and TB are important public health concerns, adequate diagnosis, treatment, care and support are being provided. However, in other countries, much more needs to be done.
If we are determined to stop TB among people living with HIV, there are specific steps we can take to do more this year to ensure that people like Cindy receive the quality of care they are entitled to:
- Scaling up integrated HIV and TB services: HIV and TB services must go together and should be delivered together as a package. Although international treatment guidelines have long recognized the value of fully integrated HIV and TB services, the reality is that service integration remains all too rare. Instead of treating the whole person, services often only address a portion of the individual’s needs. This can lead to undiagnosed or late diagnosis of TB and/or HIV, which can have a detrimental effect in terms of health, as well as the effectiveness of treatment for the individual. We need to scale up integration and ensure that new tools, including rapid diagnostic tools such as Xpert MTB/RIF and TB-LAM, are used. We need to consider and invest in differentiated service delivery models that foster community resilience in response to TB and HIV, and learn from positive examples. These models must respond to evidence-based practices in providing care and support for the diverse and specific needs of different groups, and address their individual circumstances. Among them are children and adolescents or people living with HIV who are on treatment for drug-resistant TB.
- Reach all in need for treatment of latent TB: We need to redouble efforts to improve the reach, quality and effectiveness of TB prevention services. Urgent efforts are needed to scale up treatment for people with latent TB infection, which will require strengthened screening services. Despite the fact that 1 million people living with HIV started TB prevention with isoniazid in 2017, only half of the countries with the highest incidence of HIV-associated TB did not report initiating TB prevention among people attending HIV care. The innovations in this field are encouraging as newer and more friendly formulations are becoming a reality; isoniazid and rifapentine (HP) combinations can be used with the existing pool of HIV treatments. But now is the time to scale innovations up in countries while also striving to increase access to generic medications.
- Avail the best treatments for drug-resistant TB to people: We need to ensure that programmes are offering the best TB treatment options – preferred, safer, all-oral treatment regimens and new medicines, such as bedaquiline and delamanid. There are advances in making pretomanid available as it is entering priority review by the United States Food and Drug Administration. These advances represent a unique opportunity in providing shorter, easier and less toxic treatments in these harder-to-treat forms of TB for the first time in 50 years.
- Prioritize the search for a safe and more effective TB vaccine: This quest can potentially change the game, and we call for more investment and inclusion of people living with HIV in trials as safety in this population will be key for reaching the global goals of reducing the TB burden in high HIV-prevalence settings.
- Get to the heart of TB and HIV stigma: We need to do everything we can to ensure empathy when treating people with TB and HIV. It starts with how healthcare facilities treat people who have TB and HIV. We cannot let stigma be the barrier to welcoming people like Cindy into care, but instead ensure that each person is supported in accessing the best and most comprehensive services that they need, at the time they need it.
We have opportunities to advocate and advance these tangled steps to address these linked epidemics. In the coming months, the HIV/TB 2019 symposium will take place prior to the 10th IAS Conference on HIV Science (IAS 2019) in Mexico City focusing on a new era in TB prevention and implications for people living with HIV. This meeting will bring together researchers and practitioners across TB and HIV fields to exchange knowledge and generate solutions that will enable all those in need to access holistic, people-centred treatment. Later, the three-year replenishment of the Global Fund to Fight AIDS, Tuberculosis and Malaria will serve as the primary source of funding for TB services.
One of the most important things we can do to advance the health and well-being of people living with HIV is to conquer TB. We need to leverage these two moments in 2019 to advocate for the political and financial support needed to make this a priority of the global health and development agenda.
Today, Cindy is fully treated for TB and taking regular treatment for HIV. She is married and has a good job. We were able to put her in touch with social and other support services. Her case should not be the exception, but rather the norm. It’s time to join forces and ensure that human rights are not jeopardized for people like Cindy in the context of both TB and HIV. It is time.
By Anton Pozniak, IAS President