TB Co-infection

© Brendan Bannon

“When I started taking ARVs, I felt good.  But then I started coughing up blood again, the chest pains were back and my joints began to hurt. I was getting weaker and I had to stop working.” Monica Juma is co-infected with MDR-TB and HIV and received treatment from MSF in Nairobi's Mathare slum.
 

“I am fine now. I had some tough times, but I survived. When I meet other patients that are reluctant to take a TB or HIV test, I always try to convince them. I give myself as an example. I was once also very sick, but now I am as strong as a horse. I would like to say to co-infected patients that life is worth living, you should get treatment.” Masautso, 37 years old, a Voluntary Community Worker, Zambia, who is co-infected with TB and HIV. He helps to detect and take care of TB and HIV patients.

HIV/AIDS and Tuberculosis (TB): the twin epidemics
TB remains the main killer of people with AIDS. Because people with living with HIV/AIDS have suppressed immunity, they are up to 20 times more likely to develop TB than those who are not infected with the virus. It’s estimated that around 11 million people are currently infected with both HIV and TB.

TB-HIV co-infection presents MSF with extremely difficult medical challenges. And the challenges are constantly growing as TB infection rates skyrocket among people living with HIV, primarily in sub-Saharan Africa.

“These patients have to take between 13 and 16 pills a day. Also, there are interactions between AIDS and TB treatment which cause side effects like liver problems or allergies.” Dr. Gilles Van Cutsem, MSF in South Africa.

Diagnostic and treatment options are not equal to the task
Both diagnosis and treatment of TB in HIV patients is much more difficult: HIV patients are much less likely to be able to produce enough sputum for the standard TB microscopy test, which leads to a ‘false’ negative result and them not getting treatment. The clinical symptoms for TB are not easily distinguished from those of other ‘opportunistic infections’ that affect people with HIV/AIDS. Many more drugs have to be taken by co-infected patients, and the drugs used to treat TB interact with antiretrovirals (ARVs) and lessen their efficacy.

Drug interactions and high daily pill count hamper treatment
Some of the commonly used ARVs, such as nevirapine, cannot be taken together with rifampicin, a vital part of TB treatment. In poor countries, the alternatives to rifampicin are too expensive, and efavirenz (an alternative ARV to nevirapine) is more expensive and cannot be taken in early pregnancy.

In addition, the number of tablets a co-infected patient needs to take each day is high, making it harder for them to stick to their treatment properly. They also tend to suffer from more side-effects from the drugs, which again makes it especially tough for co-infected patients to adhere to the treatment regimen.

TB-HIV co-infected children particularly neglected

“In 1994 we started TB treatment for undernourished children. Young children do not produce sputum and the diagnosis had to be entirely based on clinical judgment.” Dr. Frank Smithuis, MSF Head of Mission and Medical Coordinator, Myanmar

The most neglected of all those suffering from TB and/or HIV are children. HIV cannot be diagnosed in infants without expensive and complex medical equipment. Even when they do not have HIV, the problems of diagnosing TB are greater in children than in adults. It is rare to achieve a definitive diagnosis of TB in co-infected children without equipment that, for most, is out of reach.

Children with TB and HIV develop disease more quickly and die more quickly. The drugs needed to treat both TB and HIV are not available in child-friendly palatable liquid forms, nor are tablets small enough for young children to swallow. When drugs are available they are often very expensive.

MSF is increasingly focused on getting children with HIV and TB onto treatment but globally far too little is being done. Many National Treatment Programmes neglect children, or leave them until adults are treated. Drug companies see no profit in researching better diagnostic tools or drugs for children in poor countries.

What needs to happen:

  • We need to push for more sensitive, simple and affordable TB diagnostic tests for people with HIV that can be carried out in remote settings.
  • We need TB drugs that don’t interfere with ARVs used to treat people with HIV/AIDS.

 

MSF activities with HIV TB co-infected patients

"TB systems are usually vertical organized systems. In every town or district you will have a TB system. Next to it there might be another vertical organized system for AIDS. You go for your AIDS infection to the AIDS doctors and for your TB to the TB doctor. This is of course an extra burden for the patient and poor medical practice. In MSF’s Myanmar programme we don’t have that problem because in our clinic we treat both. There is not an AIDS doctor and a TB doctor. We have a doctor who treats patients whatever you have." Dr. Frank Smithius, Head of Mission and Medical Coordinator, Myanmar.

There has been little cooperation between TB and HIV programmes despite clear statements from the WHO and others on the importance of integration and cooperation. Instead treatment usually happens in different places at different times, which places additional burdens on the patient.

To address the challenges of TB-HIV co-infection, MSF provides TB treatment in the context of its AIDS programmes in several countries including South Africa, China, Cambodia, Kenya, Malawi, and Zambia. MSF staff involved in the care of HIV patients is trained to regularly look for signs of TB, and programmes have begun to offer routine HIV counseling for all TB patients.

Read more 

TB and HIV. The Failure to Act

Dr. Pheello Lethola's experience in treating TB and HIV/AIDS co-infection in Lesotho

MSF and HIV/AIDS

Children and HIV/AIDS

Registration Barriers

Push for Better Tools

Promoting Generic Competition

Pushing Prices Down

Patent Barriers

Need for Newer Drugs

What Needs to Happen