Management of TB/HIV Coinfection - Preventing TB

Authors: Neal Martinson, MBBCh, DCH, MFGP, MPH; Martie van der Walt, PhD, MBA
Editor In Chief: Richard E. Chaisson, MD (More Info)

Last Reviewed: July 8, 2016 (What's New)

Credit Information

inPractice® Africa’s Continuing Education Unit (CEU) provider, the South African Medical Association, offers physicians 3 CPD points on a 70% pass rate for completing this individual module. Nonphysicians who successfully complete the module will receive a participation certificate. To learn more on CPD credits and participation certificates, click here.

Introduction: Tuberculosis in Persons Living With HIV

With an estimated annual incidence of 834 tuberculosis (TB) cases per 100,000 individuals in 2014 and fuelled by the HIV coepidemic, South Africa has one of the highest rates of TB in the world.[WHO TB Fact Sheet ZA 2016] Approximately 60% of TB cases in South Africa occur among HIV-infected persons.[WHO TB Fact Sheet ZA 2016] The complexity of the South African TB epidemic is further compounded by high rates of multidrug-resistant TB and, more recently, extensively drug–resistant TB.

Progress in combatting TB and HIV in South Africa has been mixed. Cure rates for new smear-positive and/or culture-positive cases have risen in the last decade to approximately 80%, but HIV prevalence in incident TB cases is 61% in 2015 which translates to a high rate of TB mortality.[WHO Global TB 2015] The TB defaulter rate has dropped from 13% in 2000 to approximately 7% in 2009 (Management Guidelines).[SANAC NSP 2012]

Tremendous strides have been made in integrating TB- and HIV-related interventions, particularly with respect to testing TB patients for HIV and screening HIV-infected persons for symptoms of TB. Moreover, the widespread introduction of the Xpert MTB/Rif test has also facilitated diagnosis, but evidence of a beneficial effect on mortality and morbidity of this rapid diagnostic has been disappointing. However, delays in initiation of antiretroviral therapy among TB patients with HIV and poor uptake of isoniazid preventive therapy to reduce the risk of active TB among HIV-infected persons have hampered efforts to reduce the incidence of TB and mortality due to TB and HIV. There are hints that this is having an effect on the number of new cases diagnosed each year.

The South Africa National Strategic Plan on HIV, STIs and TB, 2012-2016, builds on the country’s past successes—including the rapid scale-up of accelerated diagnosis of TB and multidrug-resistant TB, interventions to address the socioeconomic drivers of the TB and HIV epidemics, and efforts to reduce prices of antiretroviral and TB drugs and other key commodities—to now address prevention of TB transmission and both latent TB infection and active TB disease.[SANAC NSP 2012]

For an overview from inPractice Africa on TB, click here.

South African Targets in the National Strategic Plan

The South Africa National Strategic Plan on HIV, STIs and TB, 2012-2016 (NSP) (Management Guidelines)sanac nsp sets ambitious tuberculosis (TB) and HIV control targets for the country, including “the three zeros” advocated by the Joint United Nations Programme on HIV and AIDS: “Zero new HIV infections. Zero discrimination. Zero AIDS-related deaths.”[UNAIDS 2011] Within the next 20 years, South Africa aims to achieve “zero new HIV and TB infections, zero new infections due to vertical transmission, zero preventable deaths associated with HIV and TB, and zero discrimination associated with HIV and TB.”[SANAC NSP 2012]

To accelerate the nation’s progress toward this final goal, the NSP has set progressively higher interim targets for HIV and TB prevention and treatment indicators.[SANAC NSP 2012] By the end of 2016, the NSP calls for cutting the incidence of new HIV infections by half from 2012 levels. Likewise, it directs the health sector to increase the proportion of South Africa’s eligible HIV-infected patients initiated on antiretroviral therapy to 80%, with a goal of keeping at least 70% of these patients alive and on treatment 5 years after initiation of antiretroviral therapy. Regarding TB, the NSP calls for a 50% reduction in the number of new TB infections and TB-related deaths by the end of 2016. Finally, the NSP has called for a 50% reduction in self-reported stigma and discrimination related to HIV and TB and an enabling, accessible, legal framework that promotes and protects human rights.

For an overview from inPractice on TB, click here.

Scale of the Challenge

Even if the South Africa National Strategic Plan were focusing only on preventing active tuberculosis (TB) disease, the undertaking would be formidable. In 2014, the incidence of active TB was 834 per 100,000 (or an estimated 450,000 out of ~ 45 million South Africans).[WHO TB Fact Sheet ZA 2016] Much of the increased incidence in active TB has been fuelled by the HIV epidemic; the proportion of incident TB cases who were coinfected with HIV increased from 57% to 61% between 2001 and 2014.

It is estimated that up to 80% of South Africans are latently infected with Mycobacterium tuberculosis (Management Guidelines).[SANAC NSP 2012] One cross-sectional study conducted in the townships of Cape Town found that the prevalence of latent TB infection ranged from 28% among 5-10 year olds to 88% among 31-35 year olds and then dropped to 60% among 36-40 year olds; the overall prevalence of latent TB infection was 45% among participants 5-40 years old.[Wood 2010]

For an overview from inPractice on TB, click here.

Many Drivers Requiring a Multisectoral Response

Recognising that a variety of factors are contributing to South Africa’s HIV-related tuberculosis (TB) epidemic, the South Africa National Strategic Plan calls for an unprecedented multisectoral response that includes essential biomedical and behavioural TB prevention interventions as well as social and structural interventions to tackle the drivers of the epidemic. The elements of this combination TB prevention strategy are described in Table 1.

Table 1. Combined TB Prevention Strategy[SANAC NSP 2012; WHO TB/HIV 2012]

Methods

Interventions

Details

Biomedical interventions

 

The “Three I’s” for prevention of TB among HIV-infected (and other) persons

 

  • Intensified and active TB case-finding paired with HIV testing and high-quality anti-TB treatment
  • [underline; ">Isoniazid] preventive therapy (and initiating antiretroviral therapy for HIV-coinfected patients)
  • Infection control in healthcare facilities and congregate settings

The fourth “I”: Initiation of antiretroviral therapy

  • Widespread early initiation of ART in all HIV-infected individuals

Prevention of and monitoring for drug-resistant TB

  • Rapid scale-up of accelerated diagnosis of multidrug-resistant TB

TB vaccines

  • Accelerated development of a safer, more effective TB vaccine that can be given to children to prevent TB

Behavioural interventions

Combatting smoking and alcohol abuse

  • Implementation of educational campaigns and programmes in schools and tertiary institutions

Reducing TB- and HIV-related stigma

  • Stigma Mitigation Framework to reduce stigma

National communication strategy to increase demand and uptake of services and to address norms and behaviours that put people at risk for HIV and TB

  • Improved education on behavioural modifications to reduce risk of transmitting TB to others

Social and structural interventions

Mainstreaming HIV and TB into the mandates of all core government departments

  • National, provincial, and municipal levels of the South African government responsible for addressing social, economic, and structural drivers of HIV and TB

Re-engineering public healthcare to maximise opportunities for testing and screening

  • Universal HIV testing
  • Annual TB screening

 

Workplace and occupational health policies on TB and HIV

  • Upholding the human rights of persons living with HIV or TB
  • Providing legal services for those whose human rights have been violated
  • Employers to reduce the risk of HIV and TB transmission in work environments

Prompt linkage to, retention in, and adherence with care and treatment

  • Increasing appropriate referral for clinical and laboratory investigations, as well as linkage to care and treatment

Increased access to care for infants, children, and adolescents

  • Decentralised community-based services
  • Implementation of school health services and linkage to facility-base services
  • Enacting child-specific monitoring and evaluation indicators for TB and HIV
  • Promoting the socioeconomic stability of child-headed households

Eliminating system-level barriers to accessing care

 

  • Integration of TB and HIV services
  • Expanding operating hours of service delivery sites
  • Providing a continuum of care at service delivery sites
  • Delivery of testing and screening services in diverse settings, including homes, workplaces, schools, tertiary institutions, social grant distribution points, and correctional facilities

Establishment of ward-based public healthcare teams

  • Implementation of contact tracing
  • Provision of linkage to facility-based services

Increased access to high-quality drugs

  • Ensuring reliable supply of drugs, including paediatric formulations
  • Implementing pooled procurement, negotiated price reductions, improved systems for regulatory approval, and strengthened supply chain management

These interventions and the evidence for them will be described in greater detail in this chapter. Activities targeting behavioural, social, and structural drivers of TB transmission and incidence are particularly important because existing biomedical approaches have proved insufficient for controlling TB.

Key Populations at Higher Risk for Tuberculosis

The South Africa National Strategic Plan has identified certain key populations who are at higher risk for tuberculosis (TB) infection, progression from latent to active TB, and/or poor access to health services; these key populations should be prioritised in the delivery of TB services (Table 2).

Table 2. Key Populations for Priority Delivery of TB Services[SANAC NSP 2012]

Population

Persons Included in Specific Population

Persons in potential contact with individuals with infectious, active TB
  • Household contacts of confirmed TB cases, including infants and young children
  • Healthcare workers, mine workers, corrections services staff, and inmates
  • Persons living or working in poorly ventilated and/or overcrowded environments, including residents of informal settlements

Persons with potential comorbidities

  • HIV-exposed infants
  • HIV-infected infants, children, adolescents, and adults
  • Persons with diabetes
  • Undernourished persons
  • Smokers and those abusing alcohol and/or drugs

Persons from disadvantaged populations

  • Mobile, migrant, and refugee populations
  • Persons with disabilities