The final day of the 12th ICASA in Burkina Faso heard a plenary presentation from Dr Joseph Odhiambo, from Nairobi, Kenya, on tuberculosis and HIV.
After a brief global overview he focussed on Africa, where between a third and a half of all adults have been exposed to TB and have latent (or active) infection.
The interaction with HIV is of major importance, as one third or more of people dying with AIDS die from TB. The other way round, a majority of people with active TB are now HIV positive. On a whole population basis, TB rates have risen three to six times from what they were. In Nairobi, between one and two percent of the population is now getting active TB each year, placing massive strain on health systems. The problem cannot be ignored; he said that each person with smear positive TB in their lungs can infect 10 to 15 others.
While the WHO DOTS control strategy, which he outlined, remains valid as a minimum response to TB, and while the same treatment for TB applies regardless of HIV status, he also said that TB with HIV is essentially a different disease from TB without HIV and called for additional measures to control it.
These strategies needed to include the targeted use of prophylaxis (isoniazid) in people who tested positive for TB but did not have active disease - although there were limitations to this, in the screening systems and in adherence to the treatment. Further work was needed, for example, on whether chest x-rays were really needed.
Results with cotrimoxazole prophylaxis in coinfected people varied between trials in different countries but this was still a more readily implemented treatment strategy than HAART, which could be scaled up rapidly where it stood a chance of working.
All TB patients in Africa should be counselled on HIV and offered testing and HIV prevention information and support.
In Brazil and in the USA it had been shown that HAART reduces TB risk; this could be a way to reduce the risk in Africa. In Malawi and in Haiti, TB healthcare infrastructure had been used successfully on an pilot basis to deliver antiretroviral treatment to people with HIV.
"Ultimately the control of TB in Africa will require control of the HIV epidemic."
A new syndrome emerges
In the following session, Dr Bahoura Balaka from Lomé in Togo reported 8 cases of TB in newborn babies, seen in one centre during less than a year. All had been born to HIV positive mothers whose active TB infection had not been recognised when they were admitted to hospital, posing risks to healthcare staff as well as to their babies.
One case was a baby boy born with breathing difficulty and nodules: he died aged 40 days despite TB treatment having been started at 38 days old. His mother was then diagnosed with TB.
Another case was a small girl with skin TB at day 30 and whose chest x-ray showed TB. Again, her mother had TB, in her genital region and in her lungs, and a male relative was also diagnosed with TB.
A third case was a small boy with respiratory difficulties shortly after birth. After 7 days he was started on TB treatment and his condition improved, although it emerged that the baby was HIV positive along with his mother and father who both also had TB.
A fourth case was a small girl admitted at 3 months old, but with illness that had started earlier. She had severe malnutrition, bronchopneumonia and nodules from which M. tuberculosis could be detected.
In each case, diagnosis was difficult and depended on biological tests. Treatment was also difficult for lack of access to suitable formulations of the TB drugs: adult versions had been used at reduced doses. The main message was the importance of diagnosing women with active TB during pregnancy and getting early treatment for newborns in this "emergent disease".
Reference
Balaka B, Redah D. Tuberculose du nouveau-né et de la mère VIH-seropositive. Abstract 13BT3-1, 12th ICASA, Ouagadougou, 2001.