TB and AIDS Becomes Joint African Epidemic

by Wilson Johwa

(IPS) -- Fuelled by a burgeoning AIDS problem, tuberculosis is resurging in southern Africa where health officials are beginning to talk of integrating programs to fight the two diseases.

In the last decade, there has been a four-fold increase in the number of tuberculosis (TB) cases in the sub-region, the present global epicenter of HIV/AIDS. Although it accounts for 30 percent of Africa's population, southern Africa has 70 percent of the continent's TB cases.

In Zimbabwe, one of the 22 countries most affected by TB in the world, there are now 462 new cases for every 100,000 people per year, a seven-fold increase since 1982, according to the World Health Organization (WHO). By comparison, Western Europe and Northern America report less than 20 cases per 100,000 people.

"HIV is the single most important factor for the resurgence of TB in Africa," says Dr Robert Makombe, a medical officer at the Harare-based WHO regional office for Africa. TB is also the biggest killer among people with HIV/AIDS.

WHO has spearheaded efforts to link TB and HIV care, holding workshops and conferences, particularly in sub-Saharan Africa. The organization has also developed guidelines and recommendations about linking TB and HIV/AIDS care.

"There was a time when everybody parted themselves on the back and said 'TB's under control in Zimbabwe'. Unfortunately, that was the time when HIV was surfacing," says Ellen Ndimande, the national coordinator of 'The Rehabilitation and Prevention of Tuberculosis' (RAPT), a non-governmental organization (NGO) which has fought TB for half a century.

Based in Bulawayo, Zimbabwe's second city, RAPT built convalescence centers (when TB patients were still isolated), recreational centers and laboratory that assisted in the containment of TB since the organization's founding by concerned citizens in 1954.

Quoting various studies, Ndimande says up to 80 percent of TB patients have HIV. As a result, RAPT's core focus is now disseminating information on the two diseases.

"We realize that for us to conquer the current TB epidemic, we have to address the issues relating to HIV/AIDS," she says. "We cannot talk about TB on its own; we have to talk about both, TB and HIV, because the current TB epidemic is a result of HIV infection."

Makombe says there is also scope to treat the two diseases together since TB and HIV are intricately linked biologically.

Effective national TB programs, says Makombe, are well-placed in identifying those TB patients who are HIV-infected and, those eligible for anti-retroviral therapy.

However, despite such scope for combining TB and AIDS programs, many countries continue to run separate control programs for the two diseases.

Shortcomings for collaborative care include inadequate drugs, logistics as well as human and financial resource constraints. In addition, health institutions are already overwhelmed by HIV-related diseases while national TB programs battle to cope with increased TB cases.

However, shortcomings in collaboration are not for lack of understanding of the correlation. At the policy level, the fight against TB and HIV/AIDS is integrated in Zimbabwe, beginning with the joint 'AIDS and TB Unit', the government department responsible for fighting the two conditions. Despite the government establishing opportunistic infections clinics in the major urban centers, where TB is the most common ailment among people with HIV/AIDS, full integration still lags behind.

"You'll find that in a health department there's an STI (sexually transmitted infection) co-ordinator and there is a TB coordinator," Ndimande says. "So, for the two to really integrate at grassroot level, there are still problems here and there."

Such separation, says Dr Zanele Hwalima, the health director in Bulawayo, also became apparent with the National AIDS Council showing reluctance to fund activities to mark World Tuberculosis Day on Mar. 24.

Dr Milton Chemhuru, who is in charge of TB in the ministry of health, describes Zimbabwe's TB program as well-developed, with TB coordinators working right down to village level. He says the focus now is to also increase their capacity in dealing with HIV/AIDS. "There is that integration," he says. "However, we are trying to scale up and that's not an easy thing."

But the health authority in Bulawayo seems to be more geared for the collaborative treatment. Through its network of clinics, it has just commenced giving anti-retroviral treatment which, for the time being, is limited to patients who've been treated for tuberculosis.

Even Botswana, until recently the worst affected by HIV/AIDS with a prevalence of 37.5 percent, recognises the kinship of TB and HIV/AIDS. "For us we believe they (TB and HIV/AIDS) affect a person at the same time, they must be look at holistically," Dr Patson Mazonde, the deputy permanent secretary in the Ministry of health, told IPS.

"If someone has TB we ask if they are HIV-positive, and if one has HIV or AIDS, we put them on preventive therapy," Mazonde said. He added the Ministry of Health is being restructured to reflect such realities. "The current structure was developed when HIV-AIDS was not a factor."

Makombe says collaborative treatment has tended to be mainly at the home-based care level, since many do not have access to life-prolonging anti-retroviral drugs (ARVs) that often lead to a treatment separate regimen.

The WHO doctor says across the region, some TB and HIV/AIDS control programs are now headed by the same person, and share most of their planning and other activities. For instance, in Malawi there's a well-established TB and HIV/AIDS joint care program in most districts.

Evidence proving the effectiveness of joint TB-HIV action is mounting, says the Global TB-HIV working group, set up in 1998 as part of the international 'Stop TB Partnership'. It says collaboration has modified risky sexual behaviour in Malawi and achieved a six-fold increase in the number of people getting HIV test results in projects across southern Africa.

The group adds even more encouraging is the discovery that TB-HIV collaboration can help in reaching the "3 by 5" target ' WHO's goal of putting three million people living with HIV/AIDS on antiretroviral treatment by 2005.

It says more than 300,000 people with HIV are diagnosed with TB each year in Africa alone; while an estimated 400,000 more cases are not yet identified or notified by national programs.

"If all these patients were offered HIV testing and counselling they would, without doubt, constitute the largest single group eligible for anti-retroviral therapy," says the group through its web page.