Combating TB Is Central to the Fight Against HIV, WHO Doctor Warns

Dr. Marcos Espinal, executive secretary of the World Health Organization's Stop TB Partnership, in a September 28 talk at UCLA reported important strides in the global fight against the great respiratory killer, tuberculosis, but warned that infection rates are still going up in much of the developing world in a close linkage to HIV/AIDS. He outlined crucial steps that still need to be taken to halt the epidemic. Asking his audience to guess at the prevalence of TB, no one came even close: 2 billion human beings, one third of all those alive today, carry the infection in their bodies. The point Espinal hammered home in his address was not just the scope of the infection, but its close association with HIV/AIDS and its role as one of the leading causes of death for those whose immune systems have been compromised. Dr. Espinal's meeting at UCLA was sponsored by the International Institute's Globalization Research Center - Africa.

Espinal traced the World Health Organization's growing concern with the renewed spread of TB, including drug resistant varieties, to a meeting in London in 1998 of an ad hoc committee of specialists. Out of that gathering the Stop TB Partnership was born. "One of our aims," Espinal said, "is to reduce the inequitable social and economic toll of TB."

There are almost 9 million new active cases of TB each year, Espinal said, and 2 million people a year die of it, 98% in the developing world. Worst hit is Sub-Saharan Africa, where TB infection rates are running above 300 per 100,000 population. The countries of the former Soviet Union, as well as China, India, Indonesia, Peru, and Bolivia are close behind, with rates of 100-299 per 100,000. In contrast, most of Western Europe has 10 to 24 cases and the United States fewer than 10 cases per year per 100,000 people. A large percentage of those who die also have HIV. About one third of the people infected with HIV also have TB. "Women especially and the poor are disproportionately denied treatment," he added.

The treatment favored by WHO and the Stop TB Partnership is DOTS (Directly Observed Treatment, Short-course). This is highly effective even in cases of drug resistant tuberculosis. Under DOTS, drugs for TB patients are free, and program staff must observe the patient taking every single dose of medicine for the first two of their six to eight months of treatment.

"The WHO set as its goal to detect 70% of world TB cases by 2005 and to cure 85% of the discovered cases," Dr. Espinal said. "Today we are detecting only 37% of the cases, and curing 82% of those." He complained that far too little attention is paid to TB by governments and the media. "We hear about Sharon Stone and Richard Gere talking about HIV, but not about TB."

Impressive Expansion of DOTS

On the positive side, Espinal showed a graph of the growing number of countries that have committed to using the DOTS health care management system. DOTS was begun in 1993 in 19 countries. It became a global initiative in 1995 with an expansion to 73 countries, and by 2002 was in use in 180 countries.

Another positive development he reported is that there are two new anti-tuberculosis vaccines now in clinical trials, after almost a century in which there has been little change in the pharmaceuticals available to combat this killer.

The bad news is that TB has had a worldwide resurgence "that is directly proportional to the increase in HIV." Dr. Espinal pointed out that TB fatalities in Sub-Saharan Africa are 3.5 times higher among people who are HIV positive than those who do not carry the immune-destroying virus. For the many who carry the TB bacteria but where it is dormant, reinfection rates are astronomically higher for the HIV positive. For those free of HIV, the risk of reinfection is 10% in a lifetime. "For the HIV positive, it is 13% each year."

What Needs to Be Done?

Dr. Espinal outlined the proposals of the Stop TB Partnership and the World Health Organization to push back the TB epidemic. He called for "establishing mechanisms for collaboration between TB and HIV/AIDS programs." Specifically he proposed creation of an international coordinating body for all TB/HIV activities that would operate in all countries at all levels. He proposed the routine surveillance of tuberculosis patients for HIV. And he proposed changes in how DOTS makes contact with patients. "DOTS is usually passive," Espinal said. It is triggered by a doctor's diagnosis of TB. "DOTS needs to go for active case finding  among the HIV positive population."

He added that "TB is a stigma disease. Like AIDS, people are afraid to admit that they have it. We need to convince people that the need to work together is even more important than the stigma."

Finally, Dr. Espinal said that both HIV/AIDS and TB have become diseases of poverty. "We need to find good cost-effective poverty reduction strategies. This has to be solved in context of health system strengthening."

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Dr. Marcos Espinal holds an MD from the University of Santo Domingo, Dominican Republic. He holds a PhD in Public Health from the University of California, Berkeley. He was awarded the scientific prize of the International Union against Tuberculosis and Lung Disease in 1996. In 1997 he joined the staff of the World Health Organization in Geneva, where he led the Global Project on Drug Resistance Surveillance. In 2000 he was put in charge of the newly established DOTS-Plus initiative for the management of multidrug-resistant tuberculosis, including its Stop TB Working Group. He is the executive secretary of the WHO-hosted Stop TB Partnership.