Tuberculosis is still killing more than 4000 people with HIV every day worldwide, the World Health Organization reported this week. Despite progress over the past few years, more needs to be done to identify and treat HIV in TB patients, and to prevent TB in people with HIV.
The new tuberculosis control data from the World Health Organization show that, despite modest progress in 2009, the majority of people with HIV and TB worldwide are still not receiving antiretroviral therapy or isoniazid preventive therapy.
Nevertheless the findings, released this week ahead of the 41st Union World Lung Health conference in Berlin, do show substantial improvement in rates of HIV testing among TB patients.
The survey, compiled by WHO from official returns submitted by all national TB control programmes, shows that in 16 countries in sub-Saharan Africa, three-quarters of people diagnosed with TB were tested for HIV in 2009, including many of those countries worst affected by HIV.
Across sub-Saharan Africa, just over half (53%) of TB cases were tested for HIV in 2009. This compares to 22% in 2006 and 38% in 2007, suggesting that vigorous efforts to promote integration of HIV and TB activities is beginning to have a substantial impact in sub-Saharan Africa.
Forty-six per cent of TB patients tested for HIV had a positive result in 2009 in sub-Saharan Africa.
However a number of important interventions that have the potential to improve the health of people with HIV and TB, or to prevent the development of TB in people with HIV, still have limited coverage.
Cotrimoxazole as an adjunct to TB treatment reduces the risk of death in people with HIV. It is recommended in WHO and national guidelines as a prophylactic measure against opportunistic infections in people with HIV, but the TB control survey shows that one-quarter of people with HIV and TB did not receive cotrimoxazole in 2009.
The proportion who received cotrimoxazole in sub-Saharan Africa (76%) has remained almost unchanged since 2006.
Antiretroviral therapy, recommended in WHO guidelines issued at the end of 2009 for all people with TB/HIV coinfection regardless of CD4 count, was received by only 36% of people with coinfection in sub-Saharan Africa in 2009, and by 37% worldwide. The finding indicates not only a shortcoming in TB/HIV integration, but also the huge gap that remains between available treatment and the number of people in need.
A course of isoniazid preventive therapy (IPT), although not recommended universally in national guidelines, is proven to reduce the risk of developing TB in people with HIV. Sixty thousand people in Africa (15% of those eligible) and a further 25,000 people in other regions of the world received IPT in 2009, up from 50,000 in 2008. Almost all the increase was accounted for by patients with HIV who received IPT in sub-Saharan Africa and Europe.
In South-East Asia just 467 people with HIV were reported to have received IPT in 2009 – around 1% of all TB cases diagnosed with HIV.
The Global Plan to Stop TB aims to achieve 100% access to each of these interventions by 2015.
Progress towards TB targets shows improvement
Global progress towards overall TB control targets was positive in 2009.
The global incidence of TB fell slightly in 2009, to 137 cases per 100,000 people, indicating that the peak of global TB incidence was probably reached in 2004 at 142 cases per 100,000 people. There were around 9.4 million cases of TB worldwide in 2009, WHO estimates.
Approximately 11 to 13% of incident TB cases occurred in people with HIV, WHO estimates. Eighty per cent of these cases occurred in Africa.
The global death rate from TB has fallen by 35% since 1990. In 2009 1.7 million people died from TB worldwide, including 380,000 people with HIV.
Global treatment success rates have also reached their highest level. Eight-six per cent of people treated for TB were cured in 2009, and two countries with a high burden of HIV and TB coinfection, Tanzania and Kenya, achieved an 85% cure rate in their national TB programmes in 2009, indicating that even with the additional burden of HIV-related TB, a high level of performance is possible.
Across Africa as a whole the treatment success rate was 80%.
WHO says that 13 of the 22 countries with the highest burden of TB are on track to reach the 2015 Millennium Development Goal target of halting and reversing the rise in TB incidence, and 12 countries are likely to halve the incidence of TB by 2015.