The key to overcoming the dual burden of TB and HIV

Tuberculosis is the leading cause of death among people with HIV, so better integrating care for the two diseases is seen as crucial to ending TB.

The dual risk has been on the global health community’s mind in recent decades, with acknowledgment that the two diseases need to be tackled together: The provision of antiretroviral therapy, or ART, to people living with HIV and diagnosed with TB averted an estimated 74 million deaths between 2000 and 2021.

Missing diagnoses

“One hundred percent, the two diseases have to be in people’s heads together,” said Helen Bygrave, a chronic disease adviser at Médecins Sans Frontières who focuses on sub-Saharan Africa. “The integration of services has been a key element programmatically for MSF’s work. The idea is to make sure everybody we’re diagnosing with HIV is properly screened for TB and, likewise, anybody diagnosed with TB is tested for HIV and then appropriately started on ART.”

Having these facilities in the same place is crucial, said Bygrave, adding that this has improved over time. “Before we integrated care, what we saw is that people would just get lost in the system,” she said. “That happens as soon as you have to refer somebody to another clinic room, another building or a different hospital.”

But despite these efforts, almost half of people with HIV who developed TB in 2021 were not diagnosed or reported to have TB, while coverage of TB preventive therapy, or TPT, among eligible HIV-positive people stands at only 42%.

Meanwhile, last year, MSF highlighted concerning signs of a reversal in progress in combating the two diseases, compounded by COVID-19 and global economic difficulties. Even before the pandemic, the organization had identified a crucial funding gap for HIV and TB response.

“There’s full recognition of the dual issue by donors, but implementation could still be better,” said Bygrave. “Investment in treatment literacy needs funding too, with counseling in the clinic and education about people’s diseases being areas of care that can always be done better.”

Push for change

Bygrave spoke of the promise in Africa of TB LAM tests, which use a urine sample at the point of care without the need for a sputum sample. “It’s a big piece of the puzzle, but the scale-up of TB LAM for the specific diagnosis of TB in people with advanced HIV has been very slow,” she said. She pointed out, however, that the onset of the COVID-19 pandemic has not helped the adoption of these tests.

Another key push that Bygrave cited is the “Time for $5” campaign coordinated by MSF. Under this initiative, MSF and more than 150 civil society organizations have called on U.S. diagnostics corporation Cepheid and its parent company Danaher to cut the price of its molecular GeneXpert tests to $5. Some movement was seen in September when it dropped the price for the main drug-resistant TB test by 20% to below $8 in high-TB-burden countries.

However, test prices were not cut for extensively drug-resistant TB or other diseases including HIV, hepatitis, COVID-19, and Ebola, which remain at $15 to $20 per cartridge. “It’s a move in the right direction, so it is a big deal,” said Bygrave. “But we feel it could be bigger and it could certainly be across more disease cartridges.”

Ease of diagnostic testing is a priority for people with lived experience. Timur Abdullaev, a TB activist and consultant for the Stop TB Partnership in Uzbekistan, has first-hand experience with both diseases — living with HIV and having had TB twice.

He pointed to the AIDS center he attends now having a digital X-ray machine that can test for TB. “It wasn’t there 10 years ago and it’s amazing that they have it now,” he said. “As a person with HIV, I love that I don’t need to go to another place to do the X-ray.”

He also cited the Stop TB Partnership’s Global Plan to end TB by 2030, which refers extensively to the impact of HIV and calls for the provision of TPT to 100% of people living with HIV by the end of the decade.

Ground-level challenge

But Abdullaev believes there is an urgent need for a refocus if the world is to get back on track to end TB by 2030, with a lack of willingness to change traditional methods and stigma around both diseases hampering the implementation of national strategies to combat the dual issue.

“At a global level, the TB community is perfectly aware that we cannot do things in silos and that we need to work with the other health communities,” said Abdullaev. “It’s really when it comes down to the level where everything happens on the ground that things become a bit tricky. So is there a lot of good stuff happening? Yes. Is it enough? No.”

He believes the resources are out there but require redistribution. He highlighted the TB33% campaign, under which community and civil society organizations are pushing for a reallocation of financing by the Global Fund to Fight AIDS, Tuberculosis and Malaria to at least a third for TB.

The Global Fund allocates 50% of its funds to HIV, 32% to malaria, and only 18% to TB, despite TB accounting for more than 60% of deaths among the three diseases. The proportion was, however, increased to 25% for TB for country allocations above $12 billion in the 2023 to 2025 period.

“In HIV, we’re not only turning off the tap, we’re looking at whether the plumbing is good. In TB, we can’t even turn off the tap,” said Abdullaev, referring to the level of detail and attention each disease gets. He highlighted a need from both the TB and HIV communities to improve efficiency and integration, alongside better, more transparent reporting systems.

Karin Hatzold, global director for HIV, tuberculosis, and hepatitis at nonprofit global health organization Population Services International, or PSI, agreed that big hurdles remain.

“Health care workers are not necessarily offering HIV testing to TB patients because of the high burden to the health delivery system,” she said. “Educating or training them to do this has been challenging. Coverage of TPT amongst HIV-positive patients should likewise be routine.”

Going forward

Hatzold said the tools and technologies are there to tackle the issue, adding that partnerships and community-led interventions are key to doing so.

She cited Zimbabwe as a country where such strategies had worked effectively for PSI. There, the incidence rate of TB fell from 242 to 199 per 100,000 between 2015 and 2019, with over 90% coverage of HIV testing among TB patients.

In supporting the country’s Ministry of Health and Child Care, PSI and its independent Zimbabwean partner Population Solutions for Health are working with private clinics, general practitioners, and pharmacies to complement HIV and TB service delivery in the public sector. “We’re providing public-sector services with public-sector-funded drugs in private-sector clinics,” said Hatzold.

“In an attempt to extend access and coverage of HIV and TB services for diagnosis, prevention, care, and treatment, especially for people who might have difficulties accessing public health care facilities, we are working through these public-private partnership clinics providing these services as an annex to the public sector. With these partnerships, we have been able to improve diagnosis through screening, laboratory services, and adequate treatment and surveillance of people.”

Integrated services, active TB case finding, community-led interventions, and mobile clinics have also aided the cause.

Myanmar, meanwhile, which has a high burden of TB and TB-HIV, was the only country in WHO’s Southeast Asia region to achieve the sustainable development goal of a 20% reduction in TB incidence from the 2015 baseline by 2020.

There, PSI similarly collaborates with private-sector entities such as pharmacies and community networks. The organization is also carrying out integrated and targeted screening among key vulnerable populations such as women who are sex workers and men who have sex with men. “We also do advocacy, counseling and social mobilization at the community level to raise awareness,” said Nandi U, head of TB in Myanmar at PSI.

But there is much room for further improvement, with 13% of people with TB in Myanmar being HIV-infected and only 78% of HIV-positive people with new or relapsed TB being started on ART in 2019. COVID-19 has also seriously impacted progress, with case notifications falling.

PSI is playing its part in seeking to improve the situation. “We are planning to expand HIV-TB integrated services and support, and we’re now engaging more with multiple stakeholders to fill the service gap,” said U.

Despite all the challenges, Abdullaev is optimistic that efforts can still be accelerated on the dual health issue in a way that will help achieve the world’s 2030 target for ending TB.

“If you look at the [Stop TB Partnership] Global Plan, you’ll see solutions there and they are all evidence-based,” he said. “We do still have six years and things have evolved really fast over the past 10 years. I wouldn’t be doing what I do if I didn’t believe we can and will end TB by 2030.”

Source: Devex