MSF at the IAC
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Running in Place:Too Many Patients Still in Urgent Need of HIV/AIDS TreatmentHIV-TB co-infection: Integrated programs, comprehensive care
Cambodia, 2007 © Dieter Telemans Tuberculosis (TB) accelerates the progression of HIV-related immune suppression and is one of the leading causes of death among PLWHA. Diagnosis of TB in HIV-positive individuals is difficult, often leading to delays in treatment, which in turn contributes to increased death rates. Nearly a quarter of a million PLWHA died of TB in 2006. People living with HIV/AIDS are up to 50 times more likely to develop active TB in a given year compared with HIV-negative individuals, and roughly a third of the 33 million PLWHA worldwide are infected with latent TB. In the past 15 years, new TB cases have tripled in countries with high HIV prevalence, but <1% of PLWHA were screened for TB in 2006. Increases in multidrug-resistant (MDR) and extensively drug-resistant (XDR) cases of TB add another dimension of complexity to the diagnosis and treatment of HIV-TB co-infection. In HIV/AIDS patients co-infected with XDR-TB, case fatality rates surpass 90%.18 Despite the recognized need for combined care of HIV and TB, the drugs and diagnostics currently available are not appropriate for managing co-infection. Drug interactions when treating both diseases make managing co-infection difficult. Rifampicin, one of the key drugs in TB treatment, can reduce the levels of ARVs in the blood. For the most commonly used FDC of 3TC/d4T/NVP, interactions with rifampicin result in lower than acceptable levels of NVP, making a change in ARVs necessary. Efavirenz (EFV) does not share this degree of drug interaction and can be used as an alternative, but this EFV-based combination is not available in a FDC, resulting in patients having to take a more complicated cocktail of medications. This is further complicated if the patient is a young child since no dosage guidelines for EFV are available for children under 3 years of age. HIV-TB co-infection thus poses a vital challenge for MSF. In response, MSF has reorganized certain of its HIV and TB programs, combining treatment and integrating care for both diseases. MSF runs or has operated integrated HIV-TB programs in several countries, including Cambodia, China, Kenya, Lesotho, Malawi, Myanmar (Burma), South Africa, Uganda, and Zambia. In the MSF-supported program in Khayelitsha, South Africa, a comprehensive model of care for HIV-TB has been in place since 2003, through a collaboration between MSF and the provincial and city departments of health. Through June 2008, over 9,000 patients are on ART, and the HIV-TB co-infection rate is 70%. Over 150 MDR- and XDR-TB cases were detected in 2005-2006. In December 2007, MSF and the city health department launched a pilot project for community-based management of drug-resistant TB, taking advantage of existing resources and networks previously developed for the community-based ART program. In Homa Bay, Kenya, MSF, in collaboration with the national TB program (NTP), merged the HIV and TB treatment clinics in 2006. After implementing this joint treatment program, 80% of the TB patients were tested for HIV, and 88% (313/354) were found to be positive for HIV. At the end of TB treatment, 40% of patients were also on ART, with 57% cured or completed treatment, 13% dead, and 12% defaulted. In Nanning, China, MSF has provided ART since December 2003, and over 700 patients are currently on ART. Approximately 10% of the HIV-infected patients in this program develop active TB each year. Of these TB infections, less than a quarter are easily diagnosed with the most commonly used TB diagnostic test, sputum smear microscopy. Furthermore, less than half are successfully diagnosed after a significant delay because their initial sputum tests are negative. Increasing and improving care for HIV-TB co-infection requires:
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