We know that nearly one third of the 35 million people living with HIV (PLHIV) have tuberculosis (TB), and 13% of 8.6 million new TB cases every year are HIV positive. Also 1 in 5 HIV associated deaths are due to TB. Moreover PLHIV are 21-34 times more likely to develop active TB disease than persons without HIV. So it becomes imperative to establish an effective collaboration between two vertical programmes and provide point-of-care services for both the infections through policies that promote effective screening for HIV among TB patients and provide early antiretroviral therapy (ART) to those who are confirmed to be HIV positive.
Some Asian countries shared their national responses to deal with both epidemics around the 20th International AIDS Conference (AIDS 2014) held in Melbourne. Citizen News Service (CNS) spoke with national TB programme officers as well who were not attending AIDS 2014 to include their perspectives.
Dr Mean Chhi Vun, National Centre for HIV/AIDS, Dermatology and STD, Cambodia, informed that prevalence of HIV in TB patients in Cambodia is 6.3% (2009). Dr Vun shared some successes of rolling out TB and HIV collaborative activities in Cambodia. He said that there has been integration of HIV testing in TB services and TB screening in HIV services. HIV screening for TB patients is done at all point-of-care centres and TB screening of all HIV-positive patients is done in all pre-ART and ART sites. He added that for TB and HIV co-infected patients ART is started immediately after two weeks of TB treatment regardless of CD4 count, and for other PLHIV it is started when CD4 count drops below 350.
Dr Vun also shared challenges faced while implementing TB and HIV collaborative activities in Cambodia. He said that as of now there is no provision of isoniazid preventive therapy (IPT) for HIV infected children. According to the World Health Organization (WHO), PLHIV who do not have active TB disease (and only have latent TB) should receive at least 6 months of IPT as part of a comprehensive package of HIV care. So provision of IPT to children living with HIV is missing in Cambodia. Poor followup of TB-HIV coinfected patients to access ART and anti TB treatment is another challenge. Dr Vun said that limited capacity of diagnosis and treatment of multidrug-resistant TB (MDR-TB) is a stumbling block as well. People in Cambodia have limited access to TB rapid diagnostics like GeneXpert.
Speaking about next steps to address TB and HIV co-infection in Cambodia, Dr Vun called for introduction of IPT in HIV infected children. He also said that IPT should be scaled up for PLHIV who are receiving ART. Scaling up implementation of advocacy and community mobilisation initiatives to reduce lost to followup within and between cascade of HIV and TB services is another priority ahead. We also need to monitor and evaluate the performance of IPT, ART and TB treatment in TB-HIV coinfected patients. We need to better integrate infection control in the general healthcare system and not just in TB and or HIV services separately.
According to Dr Nguyen Hoang Long, Vietnam Administration of HIV/AIDS Control, the estimated TB burden is 130,000, with 256000 PLHIV, out of which HIV associated TB burden is estimated to be 9300. As of 2013 HIV co-infection rate in TB patients was 4.27%.
Enumerating the successful HIV TB interventions, Dr Long said that there are three major steps to prevent TB in PLHIV in Vietnam:
(i) by expanding ART coverage to PLHIV with CD4 count less than 350, by integrating HIV testing into TB, antenatal clinics (ANCs) and methadone maintenance treatment (MMT), and decentralizing HIV testing to PHC level;
(ii) reducing late ART initiation: PLHIV initiated on ART at CD4 count less than 100 have decreased from 63% in 2009 to 37% in 2013;
(iii) TB screening in PLHIV to rule out active TB, and providing IPT to those without contraindications.
IPT in Vietnam was started in 2009 and now nearly 20,000 PLHIV are treated with IPT. Intensified TB case finding in HIV care settings by screening PLHIV for TB at every visit to HIV clinic and referring suspected cases to TB clinic for further investigation has also helped a lot. There are 32 GeneXpert machines that have been rolled out in Vietnam as of 2014 and around 60%-70% of TB patients have received provider-initiated HIV counselling and Testing (PICT) services in TB settings.
Speaking about ART and TB treatment for HIV-TB co-infected people, Dr Long said that about 60% of co-infected people are on ART and TB treatment which is higher as compared to previous years but still short of the 100% target. Government subsidy for travel costs for the poor people and ethnic minorities, from home to healthcare facilities and food subsidy during hospitalization has also been instrumental in shaping the response.
Dr Long said that one of the challenges that needs to be addressed ahead is to provide ART and TB treatment to remaining 40% TB-HIV co-infected people in Vietnam. He said that TB and HIV services should be integrated in the existing healthcare system and decentralised to the PHC level. He stressed on increasing the number of districts providing PICT, ART, MMT needle/syringe and TB DOTS at one stop. There is a need for clear and specific guidelines to lead coordination and have good linkages between TB and HIV settings to improve provision of timely ART for coinfected patients. Also joint monitoring and evaluation of TB-HIV collaborative activities will further help programme outcomes.