Explaining TB-HIV integration

Tuberculosis and HIV are two separate infections. One is a bacterial organism that has been around for many, many years and the other is a virus that was discovered less than 30 years ago. If untreated, both can induce untold suffering and death. Now what’€™s worse is that over the last decade or so, HIV clinicians have observed that many of their patients develop TB over time. As a result, the two are now known as ‘€œthe deadly twins’€.

‘€œWe know we can’€™t separate TB and HIV’€, says Annetjie Pretorius of the Centres for Disease Control in Pretoria.  

It’€™s a simple statement, but its meaning is very significant. In South Africa, it’€™s very common for one person to be infected with both HIV and TB simultaneously. This is a phenomenon throughout the country. Mpumalanga province is an example.

‘€œThe co-infection rate in the province is around 70% where you’€™ve got both TB and HIV living in one host’€, says the head of the provincial TB unit, Dr Thokozani Mhlongo.

The 70% co-infection rate in Mpumalanga is very close to the national estimate. Observations show that about 80% of South Africans living with HIV will develop TB. An HIV-positive person is 50 times more likely to develop active TB than an HIV-negative individual. In most cases, TB is also the first disease that a person with HIV gets before they even know their HIV status. As a result, clinicians and policy makers argue that guidelines for the treatment of both infections should be merged.

 ‘€œAll of us must realise that if I’€™m having a TB patient that I must counsel or we must motivate that person to go for testing and counseling. The same’€¦ if I’€™m working with HIV-positive people those people must be symptom-screened with each visit’€, says the Centres for Disease Control’€™s Annetjie Pretorius.

In Mpumalanga the TB burden is already high. About 612 people out of every 100 000 have Tuberculosis. TB is also known as the number one killer in the province. The epidemic has had a knock-on effect on the HIV prevalence in the region, says provincial TB Unit Director, Dr Mhlongo.

‘€œWe have moved from 32% to 35.5%. That puts us just after KZN (KwaZulu-Natal). And in terms of the size of the province we are the second smallest, but we are competing with the largest province when it comes to HIV. That is very worrisome for us. The TB/HIV co-infection’€¦ is where the problem is’€, she says.

Many people in the province and, indeed, in South Africa have TB, but they don’€™t know it. In other words, they don’€™t have symptoms that show disease and live for many years without getting ill. This is called latent TB infection.

In fact, a third of the world’€™s population or two billion people globally, is estimated to have latent TB. HIV infection is one of the factors that could trigger active disease, says Dr Bavesh Kana, a researcher at the National Health Laboratory Service, in Johannesburg.    

‘€œIt’€™s not very well known the exact environmental stresses that trigger a latent infection to develop into an active one, but one of the most obvious things is when the immune system is compromised. So, those patients that are HIV-infected have a very high risk of developing Tuberculosis if they are carrying TB around in a latent form. That would significantly explain why we have such a high rate of HIV-TB co-infection in South Africa. Also, it’€™s important to remember that there is a lot of TB in the environment since we have a rampant epidemic in the country. Also, those individuals that don’€™t carry any TB around, but become HIV-compromised, are predisposed because we live in a society that has a lot of Tuberculosis’€, Kana explains.

Dr Mhlongo agrees and says the situation calls for extra-ordinary measures.  

‘€œWe have a challenge because of the increased pool of TB floating around. Now we are getting to a point whereby at VCT, whether a person is HIV-positive or negative we now have to screen for TB’€, Mhlongo says.  

Doctors say that, if untreated, TB can kill a person with HIV/AIDS in a matter of weeks. With TB treatment, life can be extended by years. The integration of TB and HIV services now means that HIV counseling, testing and access to treatment is readily available and co-infection can be dealt with effectively, thus sparing lives.   Early diagnosis of HIV will also help people access prophylaxis to prevent TB infection in those who test negative for Tuberculosis.      


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