Elsevier

Tuberculosis

Volume 83, Issues 1–3, February 2003, Pages 68-76
Tuberculosis

Can we control tuberculosis in high HIV prevalence settings?

https://doi.org/10.1016/S1472-9792(02)00083-5Get rights and content

Abstract

The overlap between the epidemiology of HIV and tuberculosis and consequent rapid rise in numbers of patients with tuberculosis in many African countries has put a huge burden on health systems. The stigma of HIV has increased the existing stigma surrounding tuberculosis. There are three mechanisms by which we may reduce the number of cases of tuberculosis in a community: reducing transmission of tuberculosis, reducing reactivation of latent tuberculosis infection and reducing HIV transmission. Reinforcing the existing health service to find more cases, active case-finding in communities or enhanced case-finding in specific groups will reduce transmission of tuberculosis. However, health services that find it difficult to find cases efficiently will also find it difficult to support patients throughout treatment to achieve a cure. Partnership with traditional healers, community-based organizations and private practitioners could reduce this burden. Reactivation of tuberculosis among people living with HIV can be reduced by tuberculosis preventive therapy or by antiretroviral therapy. Programmes that identify people living with HIV can also implement enhanced tuberculosis case-finding increasing the benefits of the programme. However, the impact of widespread use of antiretroviral therapy may be to increase the number of people in a community who are mildly immunocompromised and the incidence of tuberculosis at a community level might rise. Any strategy that successfully reduces HIV transmission will benefit tuberculosis control, since around a third of all HIV-positive individuals will develop tuberculosis before they die. To control tuberculosis in high HIV prevalence settings, we must strengthen health systems to include not only expansion of the DOTS strategy but also full-blooded implementation of voluntary counselling and testing, enhanced and active tuberculosis case-finding, preventive therapy and better care for people living with HIV including antiretroviral therapy. The approach needed to control tuberculosis needs also to be integrated into broader development and poverty reduction goals.

Section snippets

Can we control tuberculosis in high HIV prevalence settings?

HIV is the greatest risk factor for tuberculosis ever known. Infection with HIV leads to both greatly increased rate of reactivation of latent tuberculosis infection1 and a greatly enhanced susceptibility to progression to active tuberculosis following new infection.2., 3., 4., 5. Current strategies for the control of tuberculosis are not sufficient in these dually burdened areas and we need to identify additional strategies and new approaches to control tuberculosis in high HIV prevalence

Epidemiology of the dual epidemic of tuberculosis and HIV

Before the advent of HIV, 10% of those infected with tuberculosis would be expected to progress to active tuberculosis disease over their lifetime, of whom about one-half would have infectious, usually sputum smear positive, disease.6 It follows that if one infectious case of tuberculosis successfully infected 20 other people, one was likely to develop smear positive or infectious tuberculosis and the disease would be maintained at a stable level in the community. When HIV is added into the

Impact of HIV on tuberculosis control

Increasing the numbers of tuberculosis cases puts an increased burden on a health system that is often already pushed to its limits. Tuberculosis control requires direct observation of therapy for at least the intensive phase of therapy and in many countries health services are becoming swamped. This added burden is not the only way in which HIV impacts on tuberculosis control. In communities with high prevalence of HIV the diagnosis of tuberculosis is more challenging. More individuals have

How can we control tuberculosis?

To control tuberculosis we need to reconsider all the options available and think more broadly than has been previously the case. The existing strategy for tuberculosis control is DOTS. This strategy relies on detecting the most infectious cases as they pass through the existing health infrastructure and ensuring that adequate treatment with a short course rifampicin-containing regimen is taken. This strategy is succeeding in reducing both mortality and prevalence of tuberculosis in areas with

DOTS

The DOTS strategy reduces transmission of tuberculosis by catching infectious patients as they present to existing health facilities and rendering them non-infectious by efficient anti-tuberculosis chemotherapy. A series of studies from Kenya prior to the HIV era demonstrated that the large majority of those in a community who have sputum smear positive tuberculosis have indeed passed through the government health services, often several times without a diagnosis being made.39., 40., 41. With

Reducing the risk of reactivation

In areas of high tuberculosis incidence, up to 80% of the population may be latently infected with tuberculosis. Treatment of latent infection with tuberculosis preventive therapy has been demonstrated to reduce tuberculosis in both HIV-negative63 and HIV-positive individuals.64 Current WHO recommendations are that in settings with such a high prevalence of dual infection, all HIV-infected individuals should be offered tuberculosis preventive therapy if they can undergo adequate screening to

Reduction in HIV transmission

Many strategies have been proposed or even proven to reduce HIV transmission in various situations. Any strategy that successfully reduces HIV transmission will benefit tuberculosis control, since around a third of all HIV-positive individuals will develop tuberculosis before they die. However, in the context of the combined epidemics of tuberculosis and HIV, two strategies require specific discussion, implementation of antiretroviral drugs and voluntary HIV testing. As discussed above,

Operationalizing tuberculosis/HIV activities

How do we put all of these activities together? The ProTEST project has been one example of the operationalization of the combined tuberculosis/HIV reduction activities that have been mentioned.82 ProTEST uses enhanced VCT as an entry point for a series of activities that aim to reduce HIV transmission and tuberculosis incidence. The provision of services for people living with HIV acts as an incentive for more of the community to access VCT. HIV-negative individuals can receive education,

The way forward—can we control tuberculosis in high HIV prevalence settings?

The recent commission on macroeconomics and health has emphasized the huge gains that might be made to improve the health outcomes of the poor if a rather limited set of interventions was scaled up and sufficient investment provided to strengthen the health system to deliver them.84 To control tuberculosis in high HIV prevalence settings, we must strengthen health systems to include not only expansion of the DOTS strategy but also full-blooded implementation of voluntary counselling and

References (86)

  • A.D. Harries

    High death rates in health care workers and teachers in Malawi

    Trans R Soc Trop Med Hyg

    (2002)
  • E. Johansson

    Staff and patient attitudes to tuberculosis and compliance with treatmentan exploratory study in a district in Vietnam

    Tuber Lung Dis

    (1996)
  • P. Farmer

    Social scientists and the new tuberculosis

    Soc Sci Med

    (1997)
  • D.M. Needham et al.

    Economic barriers for tuberculosis patients in Zambia

    Lancet

    (1996)
  • J.A. Aluoch

    A second study of the use of community leaders in case-finding for pulmonary tuberculosis in Kenya

    Tubercle

    (1978)
  • H. Nsanzumuhire

    A third study of case-finding methods for pulmonary tuberculosis in Kenya, including the use of community leaders

    Tubercle

    (1981)
  • J.A. Aluoch

    A fourth study of case-finding methods for pulmonary tuberculosis in Kenya

    Trans R Soc Trop Med Hyg

    (1982)
  • P. Godfrey-Faussett

    Tuberculosis control and molecular epidemiology in a South African gold-mining community

    Lancet

    (2000)
  • P. Nunn

    The effect of human immunodeficiency virus type-1 on the infectiousness of tuberculosis

    Tuber Lung Dis

    (1994)
  • M.D. Badri et al.

    Effect of highly active antiretroviral therapy on incidence of tuberculosis in South Africaa cohort study

    Lancet

    (2002)
  • M. Sweat

    Cost-effectiveness of voluntary HIV-1 counselling and testing in reducing sexual transmission of HIV-1 in Kenya and Tanzania

    Lancet

    (2000)
  • P.A. Selwyn

    A prospective study of the risk of tuberculosis among intravenous drug users with human immunodeficiency virus infection

    N Engl J Med

    (1989)
  • C.L. Daley

    An outbreak of tuberculosis with accelerated progression among persons infected with the human immunodeficiency virus. An analysis using restriction-fragment-length polymorphisms

    N Engl J Med

    (1992)
  • G. Di Perri

    Risk of reactivation of tuberculosis in the course of human immunodeficiency virus infection

    Eur J Med

    (1993)
  • K.M. De Cock

    Tuberculosis and HIV infection in sub-Saharan Africa

    J Am Med Assoc

    (1992)
  • A.M. Elliott et al.

    The changing pattern of clinical tuberculosis in the AIDS erathe role for preventive therapy

    Baillieres Clinics Infect Dis

    (1997)
  • WHO. Global tuberculosis control. WHO Report 2001. Geneva: World Health Organization,...
  • UNAIDS. Report on the Global HIV/AIDS epidemic. Geneva: UNAIDS,...
  • T. van der Werf

    Sero-diagnosis of tuberculosis with A60 antigen enzyme-linked immunosorbent assayfailure in HIV-infected individuals in Ghana

    Med Microbiol Immunol (Berl)

    (1992)
  • W.J. Burman et al.

    Treatment of HIV-related tuberculosis in the era of effective antiretroviral therapy

    Am J Respir Crit Care Med

    (2001)
  • A. PablosMendez

    Global surveillance for antituberculosis-drug resistance, 1994-1997

    N Engl J Med

    (1998)
  • R.J. Kent

    Transmission of tuberculosis in British centre for patients infected with HIV

    BMJ

    (1994)
  • S. Valway

    Outbreak of multi-drug-resistant tuberculosis in a New York State prison, 1991

    Am J Epidemiol

    (1994)
  • Y.D. Mukadi et al.

    Tuberculosis case fatality rates in high HIV prevalence populations in sub-Saharan Africa

    AIDS

    (2001)
  • J.A. Grange et al.

    Tuberculosis in disadvantaged groups

    Curr Opin Pulm Med

    (2001)
  • A.J. Rubel et al.

    Social and cultural factors in the successful control of tuberculosis

    Public Health Rep

    (1992)
  • J.A. Ngamvithayapong et al.

    High AIDS awareness may cause tuberculosis patient delayresults from an HIV epidemic area Thailand

    AIDS

    (2000)
  • J. Grange et al.

    Tuberculosis and the poverty-disease cycle

    J R Soc Med

    (1999)
  • J.D. Porter

    Mycobacteriosis and HIV infectionthe new public health challenge

    J Antimicrob Chemother

    (1996)
  • P. Kamolratanakul

    Economic impact of tuberculosis at the household level

    Int J Tuberc Lung Dis

    (1999)
  • J. Ogden

    Shifting the paradigm in tuberculosis controlillustrations from India

    Int J Tuberc Lung Dis

    (1999)
  • P.G. Suarez

    The dynamics of tuberculosis in response to 10 years of intensive control effort in Peru

    J Infect Dis

    (2001)
  • China Tuberculosis Control Collaboration. Results of directly observed short-course chemotherapy in 112,842 Chinese...

    • Cited by (52)

    • Time series cross-correlation analysis of HIV seropositivity and pulmonary tuberculosis among migrants entering Kuwait

      2012, International Journal of Mycobacteriology
      Citation Excerpt :

      In particular, HIV infection seemed to have played a significant role in the re-activation of latent infection with M. tuberculosis in this population. This positive linear relationship between the proportions of HIV seropositive and TB cases among migrants demonstrates that the rapid spread of HIV may lead to an increasing burden of TB as suggested previously [28]. The increasing burden of co-infection with HIV and M. tuberculosis is a crucial issue for public health authorities in the countries of origin of these migrants, which needs to be addressed and made a priority.

    • Status of tuberculosis/HIV coinfection in the municipality of Armenia (Colombia): Ten years experience

      2012, Infectio

    • Stigma matters in ending tuberculosis: Nationwide survey of stigma in Ethiopia

      2020, BMC Public Health

    • Factors influencing active tuberculosis case-finding policy development and implementation: A scoping review

      2019, BMJ Open

    • Knowledge, beliefs, and perceptions of tuberculosis among community members in Ntcheu district, Malawi

      2018, Journal of Multidisciplinary Healthcare

    • Does antiretroviral treatment increase the infectiousness of smear-positive pulmonary tuberculosis?

      2017, International Journal of Tuberculosis and Lung Disease
    View all citing articles on Scopus
    View full text
    Copyright © 2003 Elsevier Science Ltd. All rights reserved.